NHS Scotland learns from safest hospital in world

Source:  Wired-GOV.net

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Date of publication:  December 2013

Publication type:  News item

In a nutshell:  The NHS in Scotland is sharing learning about patient safety with Cincinnati Children’s Hospital in Ohio, USA, which is widely regarded as a world leader in patient safety. Cincinnati Children’s Hospital has influenced how the Scottish Patient Safety Programme is managed and it pioneered morning safety and flow huddles, which have now been adopted at Yorkhill Children’s Hospital in Glasgow. The Cincinnati hospital is also learning from the Scottish approach to ensuring children have the best start in life through the Early Years Collaborative, which is a programme set up to help make Scotland the best place to grow up.

Length of Publication:  1 web page

Safer Patients Network evaluation

Source:  The Health Foundation

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Date of publication:  April 2013

Publication type:  Report

In a nutshell:  The Health Foundation supported a safety improvement collaborative over five years. The Safer Patients Network was created as a platform for those taking part to continue engaging after the collaborative ended. The Network comprised a community of practice with access to virtual meetings and annual learning events. Evaluation of the Network examined the extent to which this approach helped to create a self-sustaining approach to continuous improvement.

Length of Publication:  84 pages

Using safety cases in industry and healthcare

Source: The Health Foundation

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Date of publication: December 2012

Publication type: Report

In a nutshell: The results of a study that reviewed the use of safety cases in six safety-critical industries, as well as the emerging use of safety cases in healthcare are presented in this report. The study aimed to describe safety case use in other industries, to make pragmatic recommendations for the adoption of safety cases in healthcare and to outline possible healthcare application scenarios.

Length of publication: 1 web page

Patient safety: learning from Europe

Source:  The Health Foundation

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Date of publication: May 2012

Publication type: Blog entry

In a nutshell:  This is a joint action looking at lessons that can be learned, and passed on, between the different countries in Europe.  An example of this would be the level of understanding and concern there is in the UK with healthcare acquired infection, while in Spain the high priority there is a high public awareness of medication errors and a need to reduce risk in this area.

Improving safety in maternity services

Source:  The Kings Fund

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Date of publication: March 2012

Publication type:  News item

In a nutshell:  In 2006 the inquiry ‘Safe Births: everybody’s business’ was published.  Further to this the ‘Safer Births Improvement Programme’ was published.  This programme supported 12 multidisciplinary maternity teams and the report shares their experiences and lessons learned.

Length of publication:  1 web page

A process for rapid learning: sharing experiences.

Source:  NHS Alliance

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Date of publication: November 2011

Publication type:  Report

In a nutshell:  This report looks at the positive impact of sharing experiences of things going wrong.  10 out of hours providers collaborated to share their experiences online with a view to developing accelerated learning.  10 years on this report looks at the benefits and future improvements.

Length of publication:  8 pages

Accountability, organisational learning and risks to patient safety in England: Conflict or compromise?

Source: Health, Risk & Society vol. 13 iss 4  pp327-346)

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Date of publication: June 2011

Publication type: journal article

In a nutshell: This article looks at 2 approaches to patient safety within the NHS – promoting accountability & promoting learning lessons from previous mistakes and near-misses.  These approaches can sometimes be conflicting however, the article looks at how these approaches can work together.

Length of publication: 19 pages

Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library.

Acknowledgements:  CINAHL

Keywords: 

Categories:  Volume 2 Issue 6;

Improving patient safety: how can the legal profession help

Source: Clinical Risk Volume 17 Issue 3

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Date of publication: May 2011

Publication type: Journal Article

In a nutshell: This article looks the legal profession and the lessons it can learn from adverse events.  It also calls for the NHSLA to audit the lessons to find correlations between the events, the professionals and the Trusts to find out the lessons that can be learned here.

Length of publication: 4 pages

Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library.

Learning from mistakes

Source: Nursing Standard  Volume 25, Issue 34 p18

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Date of publication: April 2011

Publication type: Journal article

In a nutshell: The article describes what a never event is, and why the Department of Health expanded the list from 8 to 25 in February 2011.  The main focus of the list is on acute.

Length of publication: 1 page

Some important notes: This article is available in full text to all NHS Staff using Athens, for more information about accessing full text follow this link to find your local NHS Library

Acknowledgement: HMIC

The quest to eliminate intrathecal vincristine errors: a 40-year journey

Source: Postgraduate Medical Journal

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Date of publication: January 2011

Publication type: Article

In a nutshell: This article looks at avoidable errors in the application of intrathecal vincristine.  It suggests that there are 5 major areas why these incidents continue to occur, where lessons need to be learned, and applied across the board in other areas of healthcare.  These are: 1. Failure to learn from adverse events; 2. Failure of international translation; 3. Failure to achieve compliance with safety guidelines; 4. Failure of investigations and enquiries; 5. Failure of solutions.

Length of publication: 3 pages

Some important information:  Please contact your local NHS Library for the full text of the article.  Follow this link to find your local NHS Library.

The role of theory in research to develop and evaluate the implementation of patient safety practices

Source: BMJ Quality & Safety Volume 20

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Date of publication: 11 February 2011

Publication type: Article

In a nutshell: This article suggests that theory should be added to interventions as they can provide a way of predicting or mitigating the effects of Patient Safety Practices (PSPs).  It further suggests that adding the theoretical basis to the PSPs will enable learning in different contexts.

Length of publication: 6 pages

Some important information:  This article is available in full text to all NHS Staff using Athens, for more information about accessing full text fllow this link to find your local NHS Library.  Follow this link to find your local NHS Library.

A wake up call – lessons from the first major improvement programme

Source: The Health Foundation

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Date of publication: 4 February 2011

Publication type: News item

In a nutshell: The Health Foundation looks at their ‘Safer Patient Initiative’,  evaluating the lessons learned from it.  It also looks at the success achieved on ward level, and raising awareness of these issues across the UK.  However, more lessons are to be learned if this is to have an impact at organisation level, and this article highlights some of the ways to achieve this.

Length of publication: 1 webpage