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Approach to Improving Safety
Safety Target
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 6
- Failure to rescue 1
- Identification Errors 5
-
Medical Complications
7
- Delirium 1
- Medication Safety 9
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 7
- Surgical Complications 6
- Transfusion Complications 1
Target Audience
Origin/Sponsor
-
Europe
- United Kingdom
Search results for "United Kingdom"
- Web Resource
- United Kingdom
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Book/Report
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.
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
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.
Book/Report
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.
Book/Report
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.
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.
Book/Report
PHSO Review: Quality of NHS Complaints Investigations.
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.
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 Reporting and Learning System Research and Development.
Mayer E, Flott K, Callahan R, Darzi A. London, UK: NIHR Imperial Patient Safety Translational Research Centre; 2016.
Incident reporting has achieved varying levels of success in encouraging transparency and facilitating system learning. This publication discusses reporting initiatives in the National Health Service and focuses on the importance of considering system purpose, user experience, data integrity, and feedback process to enhance reporting systems.
Book/Report
Effective board governance of safe care: a (theoretically underpinned) cross-sectioned examination of the breadth and depth of relationships through national quantitative surveys and in-depth qualitative case studies.
Mannion R, Freeman T, Millar R, Davies H. Health Serv Deliv Res. 2016;4:1-165.
This mixed-methods analysis of four trusts in the National Health Service (NHS) found that evident board commitment and behavior supporting safety encourages staff to raise concerns that can lead to improvements. The authors suggest their results should help to inform hospital board training and recruitment efforts across the NHS.
Book/Report
NHS Safety Thermometer Report: Patient Harms and Harm Free Care, November 2014–November 2015.
Leeds, UK: Clinical Support Audit Unit, Health and Social Care Information Centre. December 9, 2015. ISBN: 9781783865697.
The NHS Safety Thermometer is a tool developed by the National Health Service to facilitate staff participation in measuring patient harm in various care environments. This report explores the data collected on four types of health care–acquired conditions (pressure ulcers, falls, catheter–associated urinary tract infections, and venous thromboembolisms) in NHS patients over a 1-year period.
Tools/Toolkit > Multi-use Website
Patient Safety Toolkit for General Practice.
London, UK: Royal College of General Practitioners; 2015.
Although most patient safety efforts have focused on inpatient care, the majority of health care actually takes place in the ambulatory setting. This toolkit for general practitioners in the United Kingdom provides various instruments to help prevent and analyze safety problems. Materials include a trigger tool, medication reconciliation form, and significant event audit template.
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
Learning Not Blaming.
Department of Health. London, England: Crown Publishing; July 2015. ISBN: 9781474123716.
The National Health Service (NHS) has a history of sharing analyses of problems in its system. This publication contains the government response to three reports on system failures at the NHS: the Freedom to Speak Up review, the Investigating Clinical Incidents in the NHS report, and the Morecambe Bay Investigation. Common recommendations in the three reports included the need to support open discussions about what went wrong, learning from error, and a culture of safety.
Web Resource > Multi-use Website
Safer Clinical Systems.
London, UK: Health Foundation.
This Web site highlights the work of a United Kingdom initiative launched in 2008 to apply safety improvement tactics from high-risk industries to care services. The program engages teams to identify problems in care delivery, develop innovations, and then test and evaluate the new approaches. The site provides access to project reports, overall guidance, and analysis of what was learned.
Book/Report
Freedom to Speak Up: A Review of Whistleblowing in the NHS.
Francis R. London, UK: Freedom to Speak Up Review; February 2015.
Staff willingness to raise awareness of problems that could affect patient care is an important indicator of safety culture. This publication explores National Health Service (NHS) staff perceptions regarding raising concerns about health care safety. Barriers to speaking up were related to organizational culture, incident management, and legal protection for whistleblowers. The report also suggests measures for NHS organizations to use to help ensure that staff are comfortable raising awareness of patient safety concerns.
Audiovisual > Audiovisual Presentation
Raising Concerns: Speaking Up About Patient Safety.
Health Education England. London, England: National Health Service; February 2015.
Staff willingness to speak up when they are concerned about unsafe behaviors and conditions is a hallmark of a safety culture. This video uses vignettes to demonstrate challenges to speaking up in health care, how open communication can prevent errors, strategies to raise concerns on the frontline, and the value of checklist use in supporting conversation.
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.
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
Patient Safety Briefing Film.
Haelo. Harm Free Care. London, UK: National Health Service; 2014.
Styled after airline safety advisories, this video walks hospitalized patients through a series of actions that can help ensure their safety. Steps highlighted include reminding clinicians to wash their hands, asking questions when confused, and wearing skid-resistant socks to prevent falls.