Infection prevention and control: lessons from acute care in England

December 23, 2015

Source:  The Health Foundation

Follow this link for item

Date of publication:  November 2015

Publication type:  Report

In a nutshell:  This learning report is based on the findings of a large research study that identified and consolidated published evidence about infection prevention and control initiatives. The researchers synthesised this with findings from qualitative case studies in two large NHS hospitals, including the perspectives of service users. The report considers what has been learned from the infection prevention and control work carried out over the last 15 years in hospitals in England. It looks at the lessons learned and outlines future directions for effective infection prevention and control.

Length of publication:  25 pages


Developing a ‘critical’ approach to patient and public involvement in patient safety in the NHS: learning lessons from other parts of the public sector?

December 24, 2012

Source: Health Expectations  Vol/Iss  15/4 pp.424-432.

Follow this link for abstract

Date of publication: December 2012

Publication type: Journal Article

In a nutshell: Over the last 10 years there has been a significant drive within the NHS to develop greater patient and public involvement (PPI). In patient safety, the initiative to increase involvement has increasingly been seen as an important way of building a safety culture. This paper analyses some of the key underlying drivers for involvement in the wider context of health and social care and makes some suggestions on what lessons can be learned for developing the PPI agenda in patient safety.

Length of publication: 9 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.


Improving safety in maternity services

May 28, 2012

Source:  The Kings Fund

Follow this link for summary

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


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

July 28, 2011

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

Follow this link for abstract

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

June 28, 2011

Source: Clinical Risk Volume 17 Issue 3

Follow this link for abstract

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

June 28, 2011

Source: Nursing Standard  Volume 25, Issue 34 p18

Follow this link for abstract

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

February 28, 2011

Source: Postgraduate Medical Journal

 Follow this link for abstract

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.