Source: Royal Pharmaceutical Society
Date of publication: July 2011
Publication type: Guidance
In a nutshell: This guidance looks at the one of the risks to patient care when the patient is transferred between health care providers. This risk is the miscommunication or unintended change to medications. The guidance looks at ways to reduce this risk and reduce preventable incidences.
Length of publication: 11 pages
Acknowledgements: Kings Fund blog
Leave a Comment » | 
Communication, Drug administration, harm reduction, Medication errors, Risk management, Volume 2 Issue 6 | Tagged: miscommunication, preventable adverse events (PAE) | 
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Posted by lynnallan
Source: BMJ Volume 342, d3447
Date of publication: June 2011
Publication type: Journal article
In a nutshell: While patient safety is on the forefront of health care worldwide there are still a high number of preventable adverse incidents causing patient harm. This article looks at four challenges to patient safety and the implementation of interventions – visibility; ambiguity; complexity and autonomy.
Length of publication: 1 web 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
Acknowledgements: NELM News service
Leave a Comment » | autonomy, complexity, visibiility, Volume 2 Issue 6 | Tagged: adverse events, ambiguity, patient harm, preventable adverse events (PAE) | Permalink
Posted by lynnallan
Source: Nursing Standard Volume 25, Issue 34 p18
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
Leave a Comment » | Patient safety, Uncategorized, Volume 2 Issue 5 | Tagged: learning lessons, lessons learned, never events, preventable adverse events (PAE), preventable incidents | Permalink
Posted by lynnallan
Source: International Journal of Health Care Quality Assurance Vol 28 Iss 8 p699-707
Date of publication: December 2010
Publication type: Journal article
In a nutshell: A literature review to increase understanding of healthcare checking procedures. Checking procedures are carried out many times during a patient’s stay in hospital. These procedures are both written (official guidance) and unwritten practices. The author states that more thorough checking in specific errors e.g. bedside checking, could prevent adverse events.
Length of publication: 8 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.
Acknowledgement: MEDLINE
Leave a Comment » | In patient procedures, Volume 2 Issue 1 | Tagged: adverse events, bedside checking, checking procedures, Patient care, preventable adverse events (PAE), process control, safety | Permalink
Posted by lynnallan
Source: Deutsches Ärzteblatt International. Vol. 107 Iss. 6DOI: 10.3238/artebl.2010.0092.
Date of publication: February 2010
Publication type: Journal article
In a nutshell: A literature review into how adverse events, which can harm patient safety, can be prevented in hospital and in outpatient settings in Germany.
Length of publication: 7 pages
Leave a Comment » | Errors, Germany, Patient safety, Preventive measures, Volume 1 Issue 1 | Tagged: adverse events, hospitals, outpatients, preventable adverse events (PAE) | Permalink
Posted by lynnallan
Patient Safety Horizon Scanning 