Mind the Implementation Gap. The Persistence of Avoidable Harm in the NHS.

Book/Report

Mind the Implementation Gap. The Persistence of Avoidable Harm in the NHS.

May 4, 2022

London UK: Patient Safety Learning: 2022.

Unsafe care affects a wide range of individuals and organizations physically, emotionally, and financially. This report examines large system failures in the UK National Health Service to suggest actions that support learning and improvement. The publication highlights how public investigations, government reports, legal actions, and patient complaints can provide information to support the systems approach required to arrive at safe care.

Free full text

Related Resources From the Same Author(s)

A Patient-Safe Future.

November 14, 2018

Never Events--Framework 2010-11.

March 4, 2010

Medical Error.

September 28, 2005

Patient Safety 2030.

April 6, 2016

National Reporting and Learning System Research and Development.

April 13, 2016

Safety in Doses.

September 16, 2009

Review of Patient Safety for Children and Young People.

July 1, 2009

Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety.

August 3, 2005

Safety First: a Report for Patients, Clinicians and Healthcare Managers.

January 17, 2007

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

September 6, 2006

Information Design for Patient Safety: A Guide to the Graphic Design of Medication Packaging. 2nd edition.

November 23, 2007

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

May 18, 2022

Zero: Eliminating Unnecessary Deaths in a Post-pandemic NHS.

June 22, 2022

Final Report of the Ockenden Review.

April 27, 2022

Systems Analysis of Critical Incidents: the London Protocol.

December 19, 2007

Exploring the Potential Use of Safety Cases in Health Care.

March 4, 2015

Deaths in Acute Hospitals: Caring to the End?

November 25, 2009

Leveraging a safety event management system to improve organizational learning and safety culture.

March 30, 2022

Positive approaches to safety: learning from what we do well.

August 31, 2022

Creating a learning health system for improving diagnostic safety: pragmatic insights from US health care organizations.

June 22, 2022

Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis.

January 12, 2022

Safety implications of remote assessments for suspected COVID-19: qualitative study in UK primary care.

March 23, 2022

Maternity Pre-arrival Instructions by 999 Call Handlers.

March 16, 2022

Weight-based Medication Errors in Children.

February 16, 2022

HSIB Education.

October 19, 2022

HSIB Maternity Investigation Programme Year in Review 2021/22. Summary of Highlights, Themes and Future Work.

September 21, 2022

Administering High-Strength Insulin from a Pen Device in Hospital.

September 14, 2022

Decontamination of Surgical Instruments.

June 8, 2022

A machine learning approach to reclassifying miscellaneous patient safety event reports.

July 29, 2020

Clinical supervision in general practice training: the interweaving of supervisor, trainee and patient entrustment with clinical oversight, patient safety and trainee learning.

May 5, 2021

The value of learning from near misses to improve patient safety: a scoping review.

January 25, 2023

Are the World Health Organization's patient safety learning objectives still up-to-date: a group concept mapping study.

December 21, 2022

Global State of Patient Safety 2023.

December 20, 2023

How Safe Is Your Hospital?

January 6, 2010

The International Forum on Quality and Safety in Healthcare.

April 10, 2024 - April 12, 2024

Designing Safer Rotas for Junior Doctors in the 48-Hour Week.

October 25, 2006

Unintended consequences of patient online access to health records: a qualitative study in UK primary care.

November 16, 2022

Making Hospitals Safe for People With Diabetes.

October 31, 2018

Health Literacy Toolkit.

January 31, 2018

Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety.

March 15, 2023

The fusion of incident learning and failure mode and effects analysis for data-driven patient safety improvements.

March 17, 2021

NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme.

July 21, 2021

Exploring patient safety outcomes for people with learning disabilities in acute hospital settings: a scoping review.

June 30, 2021

ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient Safety Collaborative.

November 18, 2020

Massive open online course (MOOC) learning builds capacity and improves competence for patient safety among global learners: a prospective cohort study.

September 8, 2021

Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement.

August 25, 2021

Medication safety in mental health hospitals: a mixed-methods analysis of incidents reported to the National Reporting and Learning System.

August 4, 2021

Patient safety and quality improvement: ethical principles for a regulatory approach to bias in healthcare machine learning.

July 22, 2020

Analysis of the interprofessional clinical learning environment for quality improvement and patient safety from perspectives of interprofessional teams.

March 16, 2022

Promoting patient and nurse safety: testing a behavioural health intervention in a learning healthcare system: results of the DEMEANOR pragmatic, cluster, cross-over trial.

March 2, 2022

Evaluating a patient safety learning laboratory to create an interdisciplinary ecosystem for health care innovation.

July 13, 2022

Indicators for implementation outcome monitoring of reporting and learning systems in hospitals: an underestimated need for patient safety.

May 4, 2022

Patient Safety Learning.

July 17, 2019

Quality improvement for patient safety: project-level versus program-level learning.

February 22, 2012

Learning and mindfulness: improving perioperative patient safety.

April 19, 2017

The Patient Safety Leadership Academy at the University of Pennsylvania: the first cohort's learning experience.

June 13, 2007

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

January 13, 2021

National Patient Safety Syllabus.

June 30, 2021

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

Noise: a Flaw in Human Judgement.

August 25, 2021

Improving Patient Safety Culture – A Practical Guide.

August 2, 2023

Sway: Unravelling Unconscious Bias

July 8, 2020

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

July 1, 2020

Please, write to me. Writing outpatient clinic letters to patients. Guidance.

September 26, 2018

Patient Safety Culture: Theory, Methods and Application.

January 21, 2015

Exploring the Costs of Unsafe Care in the NHS: A Report Prepared for the Department of Health.

November 5, 2014

Safer Clinical Systems.

May 13, 2015

The Report of the Morecambe Bay Investigation.

April 29, 2015

Safer Clinical Systems: Evaluation Findings.

February 18, 2015

The Habits of an Improver. Thinking About Learning for Improvement in Health Care.

December 16, 2015

Continuous Improvement of Patient Safety: The Case for Change in the NHS.

November 25, 2015

National Safety Standards for Invasive Procedures (NatSSIPs2).

February 7, 2023

BMJ Open Quality.

September 17, 2014

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

September 10, 2014

Safely Home: What Happens When People Leave Hospital Care Settings?

August 26, 2015

Openness and Honesty When Things Go Wrong: the Professional Duty of Candour.

July 15, 2015

Freedom to Speak Up: A Review of Whistleblowing in the NHS.

May 27, 2015

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

July 16, 2014

Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer.

June 4, 2014

Standardise, Educate, Harmonise: Commissioning the Conditions for Safer Surgery.

April 23, 2014

Learning From Invited Reviews.

April 10, 2019

Surgical Innovation, New Techniques and Technologies: A Guide to Good Practice.

May 29, 2019

Standing Up for Doctors, Speaking Out for Patients. Final Report.

June 2, 2010

Managing Patients' Medicines after Discharge from Hospital.

November 11, 2009

Building a Culture of Candour: a Review of the Threshold for the Duty of Candour and of the Incentives for Care Organisations to Be Candid.

April 2, 2014

The Francis Report: One Year On.

February 26, 2014

Staff Care: How to Engage Staff in the NHS and Why It Matters.

February 5, 2014

Patient Safety and Managing Risk in Nursing.

January 15, 2014

National Training Survey 2013: Concerns about Patient Safety.

January 8, 2014

Identifying Risks and Monitoring Safety: the Role of Patients and Citizens.

November 6, 2013

Acting on Concerns: Your Professional Responsibility.

March 6, 2013

Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry.

February 20, 2013

Using Safety Cases in Industry and Healthcare.

February 13, 2013

Involving Patients in Improving Safety.

January 30, 2013

The Measurement and Monitoring of Safety.

May 8, 2013

Investigating the Prevalence and Causes of Prescribing Errors in General Practice: The PRACtICe Study.

May 16, 2012

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

August 7, 2013

Standing Up for Doctors, Speaking Out for Patients. Final Report.

June 2, 2010

Non-technical Skills and the Future of Teamwork in Healthcare Settings.

July 10, 2013

Improving Safety in Maternity Services: a Toolkit for Teams.

April 25, 2012

Related Resources

Making Healthcare Safer IV: A Continuous Updating of Patient Safety Harms and Practices.

April 22, 2024

Perspective

Cybersecurity and How to Maintain Patient Safety

March 27, 2024

Interview

In Conversation with...Barbara Pelletreau and John Riggi about Cybersecurity

March 27, 2024

Interview

In Conversation With...Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0

February 28, 2024

Perspective

Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training

February 28, 2024

Harm Caused by Delays in Transferring Patients to the Right Place of Care.

September 6, 2023

Drugmakers are abandoning cheap generics, and now US cancer patients can’t get meds.

July 5, 2023

Government Response to the Investigation into the Death of Elizabeth Dixon.

June 14, 2023

Underreporting of quality measures and associated facility characteristics and racial disparities in US nursing home ratings.

June 7, 2023

Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs Decision.

June 7, 2023

A national safety board made transportation safer and could do the same for health care, advocates say.

June 7, 2023

Hospitals in two states denied an abortion to a miscarrying patient. Investigators say they broke federal law.

May 31, 2023

Why do so many Black women die in pregnancy? One reason: doctors don't take them seriously.

May 31, 2023

Clinical Investigation Booking Systems Failures: Written Communications in Community Languages.

May 31, 2023

Structural racism in behavioral health presentation and management.

May 17, 2023

Laura Levis' death outside ER has changed hospital signage, lighting in Mass.

May 10, 2023

Cancer drug shortages are creating dire circumstances for some patients.

April 26, 2023

Preventable harm in the Canadian organ donation and transplantation system: a descriptive study of missed organ donor identification and referral.

April 26, 2023

Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.

April 19, 2023

Care Delivery within Community Mental Health Teams.

April 5, 2023

Crisis in the Lakeshore Hospital ER.

March 8, 2023

NHS staff cried in safety interviews, says watchdog.

March 8, 2023

Access to Clinical Information at the Bedside.

March 1, 2023

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.

March 1, 2023

An infrastructure to provide safer, higher quality, and more equitable telehealth.

March 1, 2023

Is anybody 'Learning' from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017-2020.

February 22, 2023

Maternal and Infant Health Inequality: New Evidence from Linked Administrative Data.

February 22, 2023

A systems analysis of work-related violence in hospitals: stakeholders, contributory factors, and leverage points.

February 22, 2023

'Reading the Signals' : Maternity and Neonatal Services in East Kent – the Report of the Independent Investigation.

November 16, 2022

Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021.

November 16, 2022

See More About The Topic

General Public

Health Care Providers

Policy Makers

Epidemiology of Errors and Adverse Events

Latent Errors

Mind the Implementation Gap. The Persistence of Avoidable Harm in the NHS.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Mind the Implementation Gap. The Persistence of Avoidable Harm in the NHS.

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