Patient safety and the problem of many hands

Source: BMJ Quality & Safety [Epub ahead of print]

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Date of publication: February 2016

Publication type:  Journal article

In a nutshell:  Healthcare worldwide is faced with a crisis of patient safety. Notwithstanding occasional successes in relation to specific harms, safety as a system characteristic has remained elusive. The authors of this article propose that one neglected reason why the safety problem has proved so stubborn is that healthcare suffers from a pathology known in the public administration literature as the problem of many hands. It is a problem that arises in contexts where multiple actors—organisations, individuals, groups—each contribute to effects seen at system level, but it remains difficult to hold any single actor responsible for these effects. This paper calls for recognition of the problem of many hands and for attention to be given to how it might most optimally be addressed in a healthcare context.

Length of publication:  5 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

The daily relationships between staffing, safety perceptions and personality in hospital nursing: a longitudinal on-line diary study

Source: International Journal of Nursing Studies 59 pp. 27–37

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Date of publication: March 2016

Publication type:  Journal article

In a nutshell:  The association between poor staffing conditions and negative patient safety consequences is well established within hospital nursing. However, many studies have been limited to nurse population level associations, and have used routine data to examine relationships. As a result, it is less clear how these relationships might be manifested at the individual nurse level on a day-to-day basis. Furthermore, personality may have direct and moderating roles in terms of work environment and patient safety associations, but limited research has explored personality in this context.

The findings elucidate the potential mechanisms by which patient safety risks arise within hospital nursing, and suggest that nurses may not respond to staffing conditions in the same way, dependent upon personality. Further understanding of these relationships will enable staff to be supported in terms of work environment conditions on an individual basis.

Length of publication:  11 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

 

Video transparency: a powerful tool for patient safety and quality improvement

Source:  BMJ Quality & Safety

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Date of publication:  February 2016

Publication type:  Journal article

In a nutshell: Video recording is taking centre stage in healthcare as technology increasingly allows it to be feasible and streamlined. Despite some fears that video will be used for the wrong purposes, we anticipate that a growing physician and public demand for accountability will reward hospitals and surgical centres that lead the way in advancing this highly effective tool. Leading academic centres will likely be the first to pioneer video transparency, and many have already started to do so. As the medical community continues to seek high-impact ways of advancing patient safety and quality, implementing videos with feedback represents the next great leap forward.

Length of publication:  1 webpage

Patient safety in ambulance services: a scoping review

Source:  Health Services and Delivery Research 3/21

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Date of publication:  May 2015

Publication type:  Journal article

In a nutshell:  The aim of this review was to identify and map available evidence relating to patient safety when using ambulance services. The authors concluded that patient safety needs to become a more prominent consideration for ambulance services. Development of new models of working must include adequate training and monitoring of clinical risks. Areas requiring further work include the safety surrounding discharging patients, patient accidents, equipment and treatment, delays in transfer/admission to hospital, and treatment and diagnosis, with a clear need for increased reliability and training for improving handover to hospital.

Length of Publication:  1 web page

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

DH backs shifting national safety functions to single body

Source:  Health Service Journal 11 February 2015

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Date of publication:  February 2015

Publication type:  News item

In a nutshell:  The Department of Health has said it “makes sense” to combine national patient safety functions into one organisation.

Length of Publication:  1 web page

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

Nurses in Scotland given list of ‘essential actions’

Source:  Nursing Times 27 August 2013

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Date of publication:  August 2013

Publication type:  Journal article

In a nutshell:  Ministers in Scotland have announced that a list of 10 patient safety “essentials” will be rolled out for use by all NHS staff in Scotland. Ten of the most successful elements of NHS Scotland’s patient safety programme, which are already being used extensively, are included in the list. The new list is intended to ensure all of the elements are now implemented by every member of staff, for every patient receiving hospital care.

Length of Publication:  1 web page

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.

Berwick review into patient safety

Source:  Department of Health

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Date of publication:  August 2013

Publication type:  Report

In a nutshell:  The main problems affecting patient safety in the NHS are highlighted in this report, by Professor Don Berwick, an international expert in patient safety, and there are recommendations made to address them. The report states that the health system must recognise the need for system wide change and insist on the primacy of working with patients and carers to achieve health care goals. It also says that the NHS needs to ensure that the responsibility for functions related to safety and improvement are established clearly and simply.

Length of Publication:  1 web page

New Online Patient Safety Resource Centre

Source:  The Health Foundation

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Date of publication:  June 2013

Publication type:  Website

In a nutshell: The Health Foundation has launched a new online patient safety resource centre. The website pulls together existing evidence and new resources to help deliver safe and reliable care. The new resource centre provides fast, reliable access to accurate, up-to-date patient safety information for managers and healthcare professionals and is suitable for all levels of practice.

Length of Publication:  1 web page

Building capacity and capability for patient safety education: a train-the-trainers programme for senior doctors.

Source: BMJ Qual Saf Epub ahead of print

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Date of publication:  March 2013

Publication type: Journal article

In a nutshell: The aim of this article was to develop, implement and assess a training programme for senior doctors to become faculty leaders for patient safety training. The article concludes that training senior doctors in patient safety is achievable, acceptable and effective as a means of building capacity and capability for delivering training in this quickly emerging field.

Length of publication: 8 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.

Design of a prospective cohort study to assess ethnic inequalities in patient safety in hospital care using mixed methods

Source:  BMC Health Services Research, vol/iss 12 450

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Date of publication:  December 2012

Publication type:  Journal article

In a nutshell:  This study aims to assess the risk of adverse events (AEs) for hospitalised patients of non-Western ethnic origin in comparison to ethnic Dutch patients. It looks at the patient-related determinants that may affect the risk of AEs and explores the mechanisms of patient-provider interactions that may increase the risk of AEs. It also explores possible strategies to prevent inequalities in patient safety.

Length of Publication:  20 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 patient safety

Source: Worcester News

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Date of publication: November 2012

Publication type: News item

In a nutshell: A team has been set up at Worcestershire Acute Hospitals NHS Trust to improve patient safety by eliminating blood clots, falls, bed sores and urinary catheter infections. The safe care team, launched in August, has been working across county hospitals, including Worcester. The scheme has already had some successes including Ward 11 at the Alexandra Hospital, Redditch, where there have now been 130 days without a patient developing a pressure ulcer.

Length of publication: 1 web page

A discussion of approaches to transforming care: contemporary strategies to improve patient safety

Source:  Journal of Advanced Nursing, vol. 67, iss. 11 pp 2488-2495

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Date of publication: November 2011

Publication type:  Journal article

In a nutshell:  This study looks at three modern methods of transforming care: at the Bedside, Releasing Time to Care: the Productive Ward and the work of the Studer Group. To affect improvements in patient safety multiple interventions need to be implemented at the same time.

Length of publication:  8 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