Narrow Results Clear All
- Communication Improvement 8
- Culture of Safety 12
- Education and Training 11
Error Reporting and Analysis
- Error Reporting 16
- Human Factors Engineering 4
- Legal and Policy Approaches 11
- Logistical Approaches 2
- Policies and Operations 2
- Quality Improvement Strategies 23
- Research Directions 1
- Specialization of Care 2
- Teamwork 2
- Technologic Approaches 4
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 3
- Drug shortages 2
- Failure to rescue 1
- Identification Errors 1
- Medical Complications 2
- Medication Safety 8
- Nonsurgical Procedural Complications 2
- Overtreatment 1
- Psychological and Social Complications 6
- Surgical Complications 4
- Transfusion Complications 1
- Family Members and Caregivers 2
- Health Care Executives and Administrators 63
Health Care Providers
- Nurses 2
- Non-Health Care Professionals 30
- Patients 4
Search results for "Europe"
NHS Improvement. July 2, 2019.
The United Kingdom National Health Service (NHS) has been at the forefront of patient safety innovation. This strategy seeks to further implement approaches that explore and optimize the intersection of systems and human behaviors to support safe care at the NHS. The framework builds upon the perspectives of patients, staff, and organizations to achieve whole system improvement and sustain those changes through effective intervention and program design.
Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2019. ISBN: 978926474260.
The overprescribing of prescription opioids heightens the likelihood of opioid dependence and harm. This report shares data from 25 countries to provide a baseline for the current crisis. The publication illustrates the complexity of the opioid epidemic and suggests that system-focused multisector strategies are required to address the problem.
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.
Tingle J, O'Neill C, Shimwell M. New York, NY: Routledge; 2019. ISBN: 9781138052789.
Improving patient safety is a global goal. This book covers error reduction methods used in developing and transitioning countries and synthesizes the concepts and theories with those from developed countries. Contributors examine strategies to transfer successes across a range of national environments and policy situations.
London, UK: Royal College of Surgeons of England; 2019.
Physical demands and technical complexities can affect surgical safety. This resource is designed to capture frontline perceptions of surgeons in the United Kingdom regarding concerning behaviors exhibited by their peers during practice to facilitate awareness of problems, motivate improvement, and enable learning.
London, UK: Royal College of Surgeons of England; 2019.
Introducing innovations in practice involves taking calculated risks. To ensure patient safety, new techniques should be accompanied by training, oversight, and heightened awareness of the learning curve. This book provides a framework to guide the design and introduction of new surgical procedures into regular practice. It includes recommendations for auditing, cost assessment, and effectiveness review.
Newcastle upon Tyne, UK: Care Quality Commission; December 2018.
The term never events was originally coined to describe rare, devastating, and preventable events. This report provides an analysis of National Health Service (NHS) efforts to optimize use of alerts, guidance, and recommendations to prevent never events. The investigation found that NHS staff feel unsupported by training, challenged by complex processes of care to practice safely, and uncertainty regarding improvement roles at the system level.
Executive Board EB144/29 144th session. Geneva, Switzerland: World Health Organization; December 12, 2018.
This guidance summarizes the current status of global patient safety, highlights World Health Organization efforts to address the problem, and provides direction for WHO leadership and policy makers to achieve improvements in safety. Recommendations include universal health coverage, coordination of efforts, and dissemination of effective practices.
Pedersen KZ. London, United Kingdom: Palgrave Macmillan; 2018. ISBN: 9781137537850.
The book suggests that though a systems orientation to safety improvement is the correct approach, it can be complex and difficult to operationalize. The author explores the unintended influences of blame-free methodologies, challenges the belief that fixing the system will prevent all error, and cautions health care to moderate patient engagement efforts.
Watts E, Rayman G. Diabetes UK. London, UK; 2018.
Chronic disease management can add complexity to inpatient care regimens. Researchers worked with patients, system leaders, and clinicians to examine areas of risk for hospitalized patients with diabetes and determine solutions such as specialized teams, clinical leadership, and improved use of technology. A WebM&M commentary illustrated safety challenges associated with providing care for hospitalized patients with diabetes.
Patient Safety Learning: London, UK; September 2018.
This paper provides an analysis of the current status of patient safety in the United Kingdom. The report outlines existing challenges and strategies to drive system improvement, including leadership engagement, shared learning, patient safety data optimization, and building on expertise from other high-risk industries.
Smithson R, Richardson E, Roberts J, et al. The King's Fund, Alliance Manchester Business School; September 2018. ISBN: 9781909029880.
Regulation and accreditation programs are controversial approaches to improve safety. This report provides a framework developed to analyze the quality improvement inspection process in the United Kingdom. Investigators applied eight factors to examine how regulation can result in care delivery changes. They found that the regulation process can help engage staff in identifying areas of concern and uncover issues like poor performance.
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.
Mannion R, Blenkinsopp J, Powell M, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2018.
Staff willingness to speak up about safety and process concerns enables organization and practice improvements that prevent patient harm. This review explores challenges to raising concerns in the National Health Service and discusses policies that support whistleblowers. Further research is needed to examine organizational failures when concerns are reported.
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.
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.
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.
Slawomirski L, Auraaen A, Klazinga N. Paris, France: Organisation for Economic Co-operation and Development; 2018.
The global economic impact of medical error is substantial. This report expands on a 2017 analysis to address a gap in understanding about the impact of medical mistakes in ambulatory and primary care environments across 29 countries. The authors found iatrogenic harm and associated disease burden in outpatient care to be concerning and suggest the need for policy and leadership to design and implement improvement strategies.
Comptroller and Auditor General, Department of Health; London, UK: National Audit Office; 2017. ISBN: 9781786041395.
Applying evidence generated from complaints submitted to health care services has been promoted as a way to inform improvement. This report assesses management of claims against National Health Services trusts to determine the costs involved, ensure appropriate patient compensation, and control incidence of future claims through collaborative care improvement efforts.
Short-Life Working Group on Hospital Reports. Edinburgh, Scotland: Royal College of Surgeons of Edinburgh; July 31, 2017.
Surgical training is demanding and can result in burnout. This publication explores deficiencies in surgical training that can contribute to a stressful work environment and diminish the safety of care delivery. The report recommends changes to improve work climate and reduce the potential for error, including establishing a strong team culture and promoting human factors training.
Report of the Announced Inspection of Medication Safety at the Midland Regional Hospital Tullamore, County Offaly.
Dublin, Ireland: Health Information and Quality Authority; May 2017.
Investigation reports help health care organizations identify areas in need of improvement. This report highlights weaknesses in one hospital's medication safety processes and provides suggestions to enhance governance structure, effort prioritization, pharmacy leadership, and patient education to drive safe medication delivery.