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Search results for "Policy Makers"

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Journal Article > Review

Patient safety in cataract surgery.

Kelly SP, Astbury NJ. Eye. 2006;20:275-282.

The authors evaluate patient safety issues involved with cataract surgery and provide several recommendations for safety improvement, including developing a culture of safety and reviewing critical incidents.

Book/Report

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.

Book/Report

Learning From Mistakes.

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.

Web Resource > Government Resource

NHS Improvement.

National Health Service England.

The National Health Service (NHS) has been a global leader in patient safety improvement since the publication of An Organization With a Memory in 2000. This government resource combines several NHS initiatives—such as the National Reporting and Learning System and the Advancing Change Team—to oversee and provide support for clinicians.

Book/Report

National Safety Standards for Invasive Procedures (NatSSIPs).

NHS England Patient Safety Domain, National Safety Standards for Invasive Procedures Group. London, UK: National Health Service; 2015.

Patients face risks when undergoing invasive procedures. This report provides recommendations developed by multidisciplinary consensus and outlines how organizations can implement the standards to improve safety of invasive procedures.

Book/Report

Complaints and Raising Concerns.

Fourth Report of Session 2014–15. House of Commons Health Committee. London, England: The Stationery Office; January 13, 2015. Publication HC 350.

Complaints are a proactive way to monitor and address recurring problems that may result in adverse events and system failures. This report discusses progress achieved through complaint response efforts in the United Kingdom and provides recommendations to augment how complaints are managed to develop further improvements.

Journal Article > Study

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

Ahmed M, Arora S, McKay J, et al. BMC Fam Pract. 2014;15:206.

There is a consensus that training in patient safety must be integrated into medical education, but less agreement on the core skills that students should be taught. A prior study used a consensus approach to identify the key attributes of a safe practitioner. In this study, a group of educational supervisors of primary care trainees in the United Kingdom were surveyed regarding how they perceived the importance of each of these skills. Clinicians identified many nontechnical skills as being essential for safe practice, including conscientiousness and situational awareness, and agreed that these abilities could be taught through formal curricula. The concepts explored in this study have been used to develop a patient safety curriculum that is being implemented widely in the United Kingdom.

Book/Report

Complaints About Acute Trusts 2013–14 and Q1 and Q2 2014–15.

London, UK: Parliamentary and Health Service Ombudsman; November 26, 2014.

The National Health Service broadly reports the results of system-level analyses and investigations into trust-specific failures. This publication is the first in a series that will provide information about complaints submitted to trusts (from 2013 to 2014 and in the first half of 2014 to 2015) to track complaints received and responded to, identify common themes, and uncover recurring problems in an effort to enable organizations to improve processes for managing complaints.

Audiovisual

Joshua’s Story.

Anderson-Wallace M, Denning R. Leeds, UK: Patient Stories; October 18, 2014.

Patient stories are a growing component of understanding the impact of medical errors on patients and uncovering underlying causes. This video features an in-depth interview with the father of an infant who died following delayed diagnosis and treatment for sepsis. The father's quest to understand what happened led to a comprehensive inquiry that revealed regulatory failures and systemic issues with transparency.

Book/Report

Mid Staffordshire NHS Foundation Trust Quality Report.

Newcastle Upon Tyne, UK: Care Quality Commission; October 9, 2014.

The Mid Staffordshire Trust has been under much scrutiny in recent years. This report highlights insights from staff about the trust's current ability to deliver safe care and whether these efforts can be sustained in the future, with a focus on staffing levels, organizational leadership, and attention to new approaches to achieving safety. The authors also note that staff at the trust were fatigued due to external and internal forces driving improvement.

Book/Report

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

London, UK: Frontier Economics Ltd; October 2014.

This report provides an overview of evidence on preventable adverse events in the National Health Service and estimates that health care–acquired patient harm results in £1 to £2.5 billion in extra costs annually.

Book/Report

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

Leys C, Toft B. London, UK: Centre for Health and the Public Interest; August 2014.

This report discusses issues with staffing, equipment, and documentation that contributed to patient harm in private hospitals in the United Kingdom from 2010 to 2014. The authors explain how limited reporting requirements and lack of reliable data hinders patients' ability to compare the care provided by private hospitals with National Health System hospitals. They also outline recommendations to augment data collection and transparency in private hospitals.

Journal Article

After Mid Staffordshire: from acknowledgement, through learning, to improvement.

Martin GP, Dixon-Woods M. BMJ Qual Saf. 2014;23:706-708.

This editorial introduces a series of seven peer-reviewed commentaries that explore the ethical, sociolegal, academic, and clinical avenues to understanding system failures identified in the Francis inquiry, along with methods to identify gaps in knowledge such as measurement and feedback to drive improvement.

Journal Article > Study

Patient-safety–related hospital deaths in England: thematic analysis of incidents reported to a national database, 2010–2012.

Donaldson LJ, Panesar SS, Darzi A. PLoS Med. 2014;11:e1001667.

This analysis of incidents involving inpatient mortality reported to the National Health Service in the United Kingdom revealed that the most common events included failure to recognize clinical deterioration, falls, health care–associated infections, perioperative mortality, and handoff problems. These well-recognized safety issues require multiple interventions to address them.

Journal Article > Study

Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatric Trigger Tool.

Chapman SM, Fitzsimons J, Davey N, Lachman P. BMJ Open. 2014;4:e005066.

Using a novel trigger tool to identify adverse events for hospitalized children, this retrospective chart review found that 14% of patients experienced at least one adverse event. A recent AHRQ WebM&M commentary discusses the emergence of trigger tools as a patient safety measure.

Journal Article > Study

Characterisations of adverse events detected in a university hospital: a 4-year study using the Global Trigger Tool method.

Rutberg H, Risberg MB, Sjödahl R, Nordqvist P, Valter, L, Nilsson L. BMJ Open. 2014;4:e004879.

Hospitals employ various methods to detect adverse events, each with their own advantages and drawbacks. In this study at an academic medical center, the Global Trigger Tool identified an adverse event rate of 20%, and only 6% of these cases were submitted to the voluntary reporting system.

Journal Article > Commentary

Disclosing medical errors: views from the United States and the United Kingdom.

Kachalia A, Bates DW, Youngson GG. Surgeon. 2014;12:64-72.

These companion commentaries describe the status of efforts to promote and improve error disclosure in the United States and the United Kingdom. Each piece reflects on what makes these programs effective given the legal and organizational climate in each country.

Journal Article > Study

The friends and family test: a qualitative study of concerns that influence the willingness of English National Health Service staff to recommend their organisation.

Dixon-Woods M, Minion JT, McKee L, Willars J, Martin G. J R Soc Med. 2014;107:318-325.

Asking clinical and managerial staff across the National Health Service what concerns they would have if a friend or relative was treated at their organization provided vital insights into quality of care. Qualitative interviews using similar questions could be an effective method for uncovering detailed accounts of institutional safety problems.

Journal Article > Commentary

Early warnings, weak signals and learning from healthcare disasters.

Macrae C. BMJ Qual Saf. 2014;23;440-445.

This commentary examines how minor risks, when propagated and not addressed, may result in organizational disasters, as evidenced in the Francis report. The author advocates for early detection of workarounds and routine investigations into system causes of errors to reveal latent safety hazards in health care.

Journal Article > Review

How can the criminal law support the provision of quality in healthcare?

Yeung K, Horder J. BMJ Qual Saf. 2014;23:519-524.

This narrative review examines how principles from English criminal and civil law can be applied to health care situations where recognized care standards are not met. The authors recommend that a criminal offense be established to assign accountability for willfully neglectful or harmful provider behavior without disrupting transparent learning from the events.

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