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Journal Article > Study
Shaw R, Drever F, Hughes H, Osborn S, Williams S. Qual Saf Health Care. 2005;14:279-283.
This study evaluated the utility of a voluntary reporting system from several National Health Service trusts. Investigators collected, categorized, and analyzed anonymized data from nearly 29,000 incidents, with the largest proportion related to falls. Discussion includes detailed presentation of the frequency of events, their location of occurrence, and the low rate of incidents associated with a catastrophic outcome. The authors conclude that this type of reporting system can provide useful information on a national level but requires the development of information technology systems to support the efforts.
Scobie S, Minghella E, Dale C, Thomson R, Lelliott P, Hill K. London, UK: National Patient Safety Agency; July 2006.
This report, the second in a series from the United Kingdom's National Patient Safety Agency, analyzes nearly 45,000 patient safety incidents relating to mental health that were reported to a nationwide incident reporting system. The majority of reported incidents were from inpatient mental health facilities, primarily involving patient accidents (including falls), disruptive or aggressive behavior, self-harming behavior, and missing (absconding) patients. The report summarizes existing initiatives to improve patient safety in mental health, makes specific recommendations for mental health providers, and identifies priority areas for future research.
Journal Article > Review
Healey F, Oliver D, Milne A, Connelly JB. Age Ageing. 2008;37:368-378.
This review analyzed whether bedrails were inherently responsible for serious patient injury and found that outdated design and incorrect assembly, rather than bedrails themselves, contributed to such injuries.
Web Resource > Multi-use Website
This national program draws from other large collaborative efforts to engage health care organizations across Wales in reducing preventable harm.
Journal Article > Commentary
Fall risk and prevention agreement: engaging patients and families with a partnership for patient safety.
Vonnes C, Wolf D. BMJ Open Qual. 2017;6:e000038.
Journal Article > Study
Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame.
Armstrong N, Brewster L, Tarrant C, et al. Soc Sci Med. 2018;198:157-164.
Measuring patient safety is critical to improvement. This ethnographic study examined the implementation of a patient safety measurement program in the United Kingdom, the NHS Safety Thermometer, which measured incidence of pressure ulcers, harm from falls, catheter-associated urinary tract infection, and venous thromboembolism, with the goal of informing local improvement efforts. Investigators sought to examine how the measurement program was perceived by frontline staff. Despite the explicit emphasis on using the data for improvement, it was viewed as an external reporting requirement. The program was also viewed as a basis to compare organizations, especially because it included pay-for-performance incentives. The authors suggest that the intention of the program did not match the real-world considerations of participating health care systems and had the unintended consequence of creating potential for blame.