Narrow Results Clear All
- Communication Improvement 15
- Culture of Safety 16
- Education and Training 14
Error Reporting and Analysis
- Error Reporting 23
- Human Factors Engineering 4
- Legal and Policy Approaches 8
- Logistical Approaches 2
- Quality Improvement Strategies 25
- Teamwork 3
- Technologic Approaches 5
- Transparency and Accountability 1
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 4
- Failure to rescue 1
- Identification Errors 3
- Medical Complications 4
- Medication Errors/Preventable Adverse Drug Events 4
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 6
- Surgical Complications 3
- Transfusion Complications 1
- Family Members and Caregivers 3
- Health Care Executives and Administrators 51
- Health Care Providers 36
Non-Health Care Professionals
- Media 2
- Patients 11
Search results for "Government Resource"
- Government Resource
- United Kingdom
Cultural Issues Related to Allegations of Bullying and Harassment in NHS Highland: Independent Review Report.
Sturrock J. Edinburgh, Scotland: The Scottish Government; May 2019. ISBN: 9781787817760.
Disrespectful and unprofessional behaviors are a common problem in health care. The report examines cultural issues at a National Health Service trust that affected the transparency needed to report disruptive behaviors and that limited conversation needed to facilitate local actions and improvement. Recommendations for the leadership, organizational, and system levels are provided to enable constructive change.
Tools/Toolkit > Fact Sheet/FAQs
London, England: NHS Resolution; 2018.
Although victims of adverse events have clearly expressed their preferences for full error disclosure, most physicians remain uncomfortable with disclosing and apologizing for errors. This leaflet offers information to help clinicians understand the value of effective apologies along with tips for organizations to support open disclosure efforts.
London, UK: Royal College of Physicians; 2018. ISBN: 9781860167270.
Lack of appropriate staffing can diminish the safety and effectiveness of medical services. This report explored staffing levels in United Kingdom trusts for three tiers of expertise and found them to be inadequate across the system. The paper provides recommendations for staffing decisions for individual organizations and emphasizes the need for improved focus on care provision during routine working hours to support a healthy work force and safe patient care.
Williams N. Department of Health and Social Care. London, England: Crown Copyright; 2018.
Accountability for errors and organizational assessment of failures affect incident reporting. This policy review explores how potential legal ramifications stemming from investigations of negligence can hinder improvement efforts and outlines recommendations to support safety culture in health care.
Keen J, Nicklin E, Long A, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2018.
The National Health Service (NHS) is a global leader in patient safety improvement. This report reviews the results of a study that explored whether staff had access to information needed to prevent errors. Clinicians in four acute NHS hospitals were surveyed to assess how information is used by nurses, staff, and senior hospital managers. The report concluded that robust access to patient information improved care and proactive risk management activities.
Gosport Independent Panel. London, England: Crown Copyright; 2018. ISBN: 9781528604062.
Organizational culture influences how comfortable individuals are with raising awareness of conditions that diminish patient safety. This independent inquiry report provides case studies and a detailed analysis of conditions that hindered nurses and families from acquiring answers about care concerns. The analysis determined factors such as hierarchy and poor physician regard for nursing expertise as persistent challenges to safety in health care.
Tools/Toolkit > Government Resource
National Health Service.
Data surveillance and transparency are core to measuring and informing improvement efforts. This website provides detailed data that links ambulatory care prescribing activity to National Health Service hospitalizations in an effort to clarify potential adverse medication events. The dashboard launched tracking gastrointestinal bleeding as an indicator of a medication-related adverse result and will expand to other indicators and conditions over time.
NHS Improvement. London, UK: National Health Service; March 15, 2018.
Although focusing on system failure has been highlighted as key to improving patient safety, individual behaviors must also be recognized as contributors to risks. This guide provides tactics for managers to address concerns associated with practitioner performance that arise during incident investigations. The guide helps managers initiate constructive conversations with clinical staff when their performance creates conditions for unsafe care delivery.
NHS Improvement. London, UK: National Health Service.
Organizational processes to investigate adverse care incidents play an important part in generating the learning needed for improvements. This announcement sought multidisciplinary insights regarding how to revise the Serious Incident Framework (2015), currently used by the National Health Service, to enhance reporting and investigation processes.
Web Resource > Government Resource
2nd Floor, 151 Buckingham Palace Road, London, SW1W 9SZ.
The National Health Service (NHS) is a global leader in patient safety improvement. This website coalesces information and activities generated by three NHS improvement efforts: patient compensation, performance assessment, and fair resolution of appeals between the NHS and primary care contractors.
Department of Health and Social Care. London, England: Crown Publishing; February 2018.
Medication errors are a prominent challenge for health care systems worldwide. This report provides recommendations that align with the World Health Organization medication safety improvement effort to address medication failures in the National Health Service. The authors suggest an emphasis on technology, teamwork, and safety culture to enable sustained improvements across the system.
Tools/Toolkit > Government Resource
Leeds, UK: Health Education England, Public Health England, NHS England and Community Health and Learning Foundation; December 11, 2017.
Limits in patients' ability to understand health instructions and information affects the safety of their care. This toolkit provides resources related to health literacy including a business case for interventions, educational materials, and guides for engaging patients in discussions about low health literacy.
London, UK: Parliamentary and Health Service Ombudsman; 2017. ISBN: 9781528601344.
Patients with mental health conditions face particular safety challenges. This report describes incidents involving patients with eating disorders who experienced harm while receiving care in National Health Service organizations. Factors that contributed to the failures included poor care coordination, premature discharge, and lack of monitoring. The report discusses gaps in the investigations of these patient deaths and outlines areas of improvement.
Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study.
Mayor S, Baines E, Vincent C, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2017.
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.
Learning, Candour and Accountability. A Review of the Way NHS Trusts Review and Investigate the Deaths of Patients in England.
Newcastle Upon Tyne, UK: Care Quality Commission; December 2016. CQC-356-122016.
Patients and families can contribute to improvement when they are treated with respect and openness. This report explored the extent to which those characteristics are present in National Health Service (NHS) investigations regarding patient deaths and found them to be lacking, particularly in cases involving patients with mental health conditions or learning disabilities. The authors recommend a framework to guide behaviors consistently across the NHS to improve the timeliness and quality of investigations and ensure system-level learning.
Safer delivery of surgical services: a programme of controlled before-and-after intervention studies with pre-planned pooled data analysis.
McCulloch P, Morgan L, Flynn L, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2016.
This publication reports five British hospitals' experiences with teamwork interventions in surgical teams. Although teamwork training alone improved how teams functioned, it did not always enhance clinical performance. The investigators found that integrated training that combines technical and social improvements, such as Lean, resulted in more effective improvements.
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.
Wright J, Lawton R, O'Hara J, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2016.
Hospitals and health care providers are developing new ways to involve patients and families in safety efforts. This report discusses a National Health Service program designed to enhance feedback opportunities from consumers and assess these initiatives. Although the investigators found no direct care improvements associated with the interventions, the approaches they used to test patient engagement strategies (such as the ability to raise concerns) were successful.
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.
Carson-Stevens A, Hibbert P, Williams H, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2016.
Management and analysis of incident reporting data must be enhanced in order to realize the potential for learning and improvement from reporting activities. This publication explored primary care incidents reported in England and Wales over an 8-year period. Investigators found inconsistencies and gaps in information collected, including a lack of defined reasons explaining why incidents occurred. Despite weaknesses in the data, they were able to categorize the types of incidents and prioritize system improvements needed to optimize incident reporting as a patient safety improvement strategy.
London, UK: Parliamentary and Health Service Ombudsman; July 18, 2016. ISBN: 9781474135764.
The National Health Service (NHS) has a history of sharing analyses of problems in its system. Summarizing an NHS investigation into the death of a 3-year-old boy, this report highlights the need to improve organizational culture, complaint follow-up, and transparency to reduce opportunities for similar incidents.
First Report of Session 2016–17 Report. House of Commons Public Administration and Constitutional Affairs Committee. London, England: The Stationery Office; May 24, 2016. Publication HC 94.
Complaint investigations must be conducted in a consistent manner with a goal of learning from each incident to prevent similar occurrences. This government report summarizes an inquiry into the United Kingdom National Health Service complaint reporting system and suggests that support and training for staff must improve in order to address complaints effectively.