Learning from preventable deaths: exploring case record reviewers’ narratives using change analysis

November 26, 2014

Source: Journal of the Royal Society of Medicine 107/9 pp. 365-75.

Follow this link for item

Date of publication:  September 2014

Publication type:  Journal article

In a nutshell: The authors set out to determine if applying change analysis to the narrative reports made by reviewers of hospital deaths in acute NHS Trusts in 2009 increases the utility of this information in the systematic analysis of patient harm. The change analysis approach enabled explicit characterisation of multiple problems in care, both across the admission and also at the boundary between primary and secondary care, and illuminated how these problems accumulate to cause harm. The method was straightforward to apply to multiple records and achieved good inter-rater reliability. Analysis of case narratives using change analysis provided a richer picture of healthcare-related harm than the traditional approach.

Length of Publication:  11 pages


Retained surgical sponges, needles and instruments

May 29, 2013

Source:  Ann R Coll Surg Engl. Vol/iss 95/2 pp. 87-92

Follow this link for abstract

Date of publication:  March 2013

Publication type:  Journal article

In a nutshell:  Retained sponges and instruments (RSI) due to surgery are a recognised medical ‘never event’. The aim of this review was to reveal the extent of the problem of RSI and to detect preventative strategies. Vigilance among operating theatre personnel is paramount if RSI is to be prevented.

Length of Publication:  6 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.


Simple prompts on drug charts improve prevention.

March 27, 2013

Source: The Health Foundation

Follow this link for abstract

Date of publication:  February 2013

Publication type: Journal article

In a nutshell: Time constraints and other priorities may mean that hospital doctors do not always assess people for their risk of venous thromboembolic events or prescribe preventive measures. Attaching a simple prompting checklist to patients’ drug charts can increase risk assessment and preventive measures.

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.