Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study.

Sharon Mayor; Elizabeth Baines; Charles A. Vincent; Annette Lankshear; Adrian Edwards; Mansel Aylward; Helen Hogan; Paul Harper; Jan Davies; Ameet Mamtora; Emily Brockbank; Jonathon Gray

Book/Report

Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study.

April 19, 2017

Mayor S, Baines E, Vincent CA, et al. Southampton, UK: NIHR Journals Library; 2017.

View more articles from the same authors.

This publication compared the use of the Global Trigger Tool with a two-stage retrospective review process to design a method to monitor health care–associated harm in Welsh National Health Service hospitals. Analyzing results from 11 of the 13 system hospitals, investigators determined that a hybrid incident review approach that does not rely on physician involvement can return reliable data.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice.

October 12, 2016

Quality and Safety Between Ward and Board: a Biography of Artefacts Study.

August 29, 2018

Safer Delivery of Surgical Services: a Programme of Controlled Before-and-after Intervention Studies with Pre-planned Pooled Data Analysis.

January 25, 2017

Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm.

November 16, 2016

Patient Safety in Ambulance Services: A Scoping Review.

June 10, 2015

Improving care by using patient feedback.

February 12, 2020

Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews.

September 19, 2018

The Measurement and Monitoring of Safety.

May 8, 2013

Systems Analysis of Critical Incidents: the London Protocol.

December 19, 2007

Ignoring the Alarms: How NHS Eating Disorder Services Are Failing Patients.

March 28, 2018

Conceptual and practical challenges associated with understanding patient safety within community-based mental health services.

December 7, 2022

With Safety in Mind: Mental Health Services and Patient Safety.

September 6, 2006

Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study.

August 1, 2012

Effective Board Governance of Safe Care: A (Theoretically Underpinned) Cross-sectioned Examination of the Breadth and Depth of Relationships through National Quantitative Surveys and In-depth Qualitative Case Studies.

March 2, 2016

Patient Safety, 2nd edition.

August 4, 2010

Clinical Risk Management. Enhancing Patient Safety. 2nd ed.

March 27, 2005

Transformational improvement in quality care and health systems: the next decade.

November 25, 2020

Progress at the Intersection of Patient Safety and Medical Liability.

February 8, 2017

National Reporting and Learning System Research and Development.

April 13, 2016

Six major steps to make investigations of suicide valuable for learning and prevention.

November 2, 2022

Managing the Costs of Clinical Negligence in Trusts.

October 4, 2017

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

November 12, 2014

Relationship between preventable hospital deaths and other measures of safety: an exploratory study.

June 4, 2014

Understanding the factors influencing implementation of a new national patient safety policy in England: lessons from 'Learning from Deaths'.

May 18, 2022

How to do no harm: empowering local leaders to make care safer in low-resource settings.

March 3, 2021

Health Literacy Toolkit.

January 31, 2018

Mitigating the July effect.

July 7, 2021

Early diagnosis of cancer: systems approach to support clinicians in primary care.

April 5, 2023

Safer Clinical Systems: Evaluation Findings.

February 18, 2015

Registration errors among patients receiving blood transfusions: a national analysis from 2008 to 2017.

December 16, 2020

Embracing multiple aims in healthcare improvement and innovation.

March 23, 2022

Merry and McCall Smith's Errors, Medicine, and the Law. 2nd ed.

March 6, 2005

Complaints to the Parliamentary and Health Service Ombudsman.

October 23, 2023

Action on patient safety can reduce health inequalities.

April 13, 2022

Observer-based tools for non-technical skills assessment in simulated and real clinical environments in healthcare: a systematic review.

June 12, 2019

Measuring safety in older adult care homes: a scoping review of the international literature.

May 19, 2021

Fostering a just culture in healthcare organizations: experiences in practice.

August 31, 2022

Safety and Ethics in Healthcare: A Guide to Getting it Right.

October 10, 2007

Safer Healthcare: Strategies for the Real World.

February 24, 2016

Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings.

January 10, 2018

Why is patient safety a challenge? Insights from the Professionalism Opinions of Medical Students' research.

November 2, 2022

The Future of NHS Patient Safety Investigation.

April 4, 2018

An Investigation into the Death of Baby J at University Hospitals Bristol and Weston NHS Foundation Trust.

November 3, 2021

An Avoidable Death of a Three-year-old Child from Sepsis.

July 16, 2014

Discharge from Mental Health Care: Making it Safe and Patient-centred.

April 17, 2024

Report 6: Managing Risk and Minimising Mistakes in Services to Children and Families.

October 5, 2005

Understanding teamwork in rapidly deployed interprofessional teams in intensive and acute care: a systematic review of reviews.

September 28, 2022

IHI Framework for Improving Joy in Work.

August 9, 2017

Patient Safety in the Home: Assessment of Issues, Challenges, and Opportunities.

September 6, 2017

A system-based approach to managing patient safety in ambulatory care (and beyond).

January 10, 2018

Patient Safety 2030.

April 6, 2016

The problem with 'My Five Moments for Hand Hygiene'.

August 25, 2021

Review into the Quality of Care and Treatment Provided by 14 Hospital Trusts in England: Overview Report.

August 7, 2013

Risks to Medication Delivery Using Ambulatory Infusion Pumps – Design and Usability in Inpatient Settings.

February 14, 2024

Unlocking Solutions in Imaging: Working Together to Learn from Failings in the NHS.

August 4, 2021

Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports.

April 16, 2024

Giving voice to quality and safety matters at board level: a qualitative study of the experiences of executive nurses working in England and Wales.

August 24, 2016

A systematic review of the effect of telepharmacy services in the community pharmacy setting on care quality and patient safety.

June 30, 2021

First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic.

October 4, 2017

Patient safety skills in primary care: a national survey of GP educators.

February 4, 2015

A Framework for Safe, Reliable, and Effective Care.

February 15, 2017

Task uncertainty and communication during nursing shift handovers.

September 12, 2012

Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety.

October 11, 2017

A Just Culture Guide.

April 18, 2018

Broken Trust: Making Patient Safety More than Just a Promise.

July 19, 2023

Dying for the weekend: a retrospective cohort study on the association between day of hospital presentation and the quality and safety of stroke care.

July 25, 2012

Patient involvement in patient safety: the health-care professional's perspective.

November 7, 2012

The problem with preventable deaths.

December 9, 2015

Factors associated with potentially missed acute deterioration in primary care: cohort study of UK general practices.

October 20, 2021

Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study.

October 5, 2016

Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: a retrospective clinical audit.

November 17, 2021

An assessment of the quality and impact of NPSA medication safety outputs issued to the NHS in England and Wales.

April 13, 2011

Measuring variation in use of the WHO surgical safety checklist in the operating room: a multicenter prospective cross-sectional study.

December 17, 2014

Learning From Mistakes.

August 31, 2016

Making Complaints Count: Supporting Complaints Handling in the NHS and UK Government Departments.

October 7, 2020

The key to reducing doctors' misdiagnoses.

September 20, 2017

HSJ Patient Safety Congress.

September 16, 2024 - September 17, 2024

Naming the "baby" or the "beast"? The importance of concepts and labels in healthcare safety investigation.

April 5, 2023

Moving beyond the weekend effect: how can we best target interventions to improve patient care?

June 30, 2021

Patient safety in community dementia services: what can we learn from the experiences of caregivers and healthcare professionals?

February 15, 2017

A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: lessons from the "Surgical Checklist Implementation Project."

August 20, 2014

Management and patient safety of complex elderly patients in primary care during the COVID-19 pandemic in the UK-Qualitative assessment.

April 14, 2021

Interventions to improve communication at hospital discharge and rates of readmission: a systematic review and meta-analysis.

September 29, 2021

Bad things can happen: are medical students aware of patient centered care and safety?

January 25, 2023

Multidisciplinary centres for safety and quality improvement: learning from climate change science.

April 27, 2011

Just a Cup of Tea – an Introduction to the SEIPS Framework.

May 24, 2023

A qualitative exploration of patients' attitudes towards the 'Participate Inform Notice Know' (PINK) patient safety video.

April 17, 2013

An examination of opportunities for the active patient in improving patient safety.

February 22, 2012

Patient involvement in patient safety: what factors influence patient participation and engagement?

August 22, 2007

Communication patterns in a UK emergency department.

October 10, 2007

Identifying hot spots for harm and blind spots across the care pathway from patient complaints about general practice.

November 3, 2021

When disasters strike the emergency department: a case series and narrative review.

November 10, 2021

Investigating the association of alerts from a national mortality surveillance system with subsequent hospital mortality in England: an interrupted time series analysis.

May 16, 2018

NHS Safety Thermometer Reports.

January 27, 2016

Patient harm resulting from medication reconciliation process failures: a study of serious events reported by Pennsylvania hospitals.

March 24, 2021

Patient Safety in Private Hospitals: the Known and the Unknown Risk.

September 10, 2014

Process failures that increase the risk of infection through respiratory droplets: a study of patient safety events reported by hospitals across Pennsylvania.

October 7, 2020

Are personal health records (PHRs) facilitating patient safety? A scoping review.

June 15, 2022

Analysis of paediatric long-term ventilation incidents in the community

January 22, 2020

When bad things happen: training medical students to anticipate the aftermath of medical errors.

September 2, 2020

Related Resources

Roadmap to Health Care Safety for Massachusetts.

May 3, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Solutions from Professional Regulation and Beyond.

October 5, 2022

A Thematic Analysis of HSIB's First 22 Investigations.

September 29, 2021

Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020.

September 15, 2021

Medical Office Survey: 2020 User Database Report.

April 28, 2021

Never Events Analysis of HSIB's National Investigations Report.

February 3, 2021

Ockenden Report. Emerging Fndings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust.

January 13, 2021

Making Complaints Count: Supporting Complaints Handling in the NHS and UK Government Departments.

October 7, 2020

Covid-19: Assessing the Risk to Public Protection Posed by a Doctor as a Result of Concerns about their Practice during the Pandemic.

September 30, 2020

Beyond the Data: Understanding the Impact of COVID-19 on BAME Groups.

July 1, 2020

Medicare Part D Beneficiaries at Serious Risk of Opioid Misuse or Overdose: A Closer Look.

May 20, 2020

Quality and Safety Between Ward and Board: a Biography of Artefacts Study.

August 29, 2018

Actions Needed to Address Employee Misconduct Process and Ensure Accountability.

August 15, 2018

Guidance on Safe Medical Staffing: Report of a Working Party.

August 1, 2018

Gross Negligence Manslaughter in Healthcare: The Report of a Rapid Policy Review.

July 25, 2018

AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2016.

June 13, 2018

Medical Device Safety Action Plan: Protecting Patients, Promoting Public Health.

June 6, 2018

Quality Improvement Series.

June 6, 2018

AHRQ Health Information Technology Division's 2017 Annual Report.

May 30, 2018

Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame.

May 23, 2018

Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring of Required Follow-up.

May 16, 2018

Medical Office Survey on Patient Safety Culture: 2018 User Database Report.

May 2, 2018

Latent risk assessment tool for health care leaders.

April 25, 2018

A Just Culture Guide.

April 18, 2018

Hospital Survey on Patient Safety Culture: 2018 User Database Report.

April 4, 2018

The Future of NHS Patient Safety Investigation.

April 4, 2018

Ignoring the Alarms: How NHS Eating Disorder Services Are Failing Patients.

March 28, 2018

Adverse Drug Events in U.S. Hospitals, 2010 Versus 2014.

March 14, 2018

Prevalence and Economic Burden of Medication Errors in the NHS England.

March 14, 2018

See More About The Topic

Hospitals

Facility and Group Administrators

Medicine

Epidemiology of Errors and Adverse Events

Quality Improvement Strategies

Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site