Patient Safety & Risk - UHL Evidence Update

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Patient Safety & Risk
Recently published guidance, policies, articles and reports

June-July 2016

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June 2016

Institute for Healthcare Improvement White Paper- Sustaining Improvement
"This white paper presents a framework that health care organizations can use to sustain improvements in the safety, effectiveness, and efficiency of patient care. The key to sustaining improvement is to focus on the daily work of frontline managers, supported by a high-performance management system that prescribes standard tasks and responsibilities for managers at all levels of the organization".

The Royal College of Paediatrics and Child Health’s have published situation awareness in hospitals. This free, online resource pack aims to improve communication, build a safety-based culture and deliver better health outcomes for children and young people. It includes informative presentations and useful tools with worked examples in six areas: quality improvement; patient safety culture; structured communication; recognising deterioration; The 'huddle', and evaluation and spread. The pack has been developed as part of the final phase of the College’s flagship quality improvement programme, Situation Awareness for Everyone (S.A.F.E).

The Professional Standards Authority has published Dishonest behaviour by health and care professionals: exploring the views of the general public and professionals. This research report undertaken by the independent research agency Policis used qualitative methods to explore responses to a number of scenarios based on real-life cases of professional dishonesty.

The Ministry of Justice has published its annual statistical bulletin on deaths reported to coroners across England and Wales - New statistics of deaths reported by coroners

The National Institute for Health Research has funded Understanding Children’s Heart Surgery Outcomes, an online tool that will help people make sense of published survival data about children’s heart surgery in the UK and Ireland.

IHI - Always Events Toolkit
The Always Events Toolkit provides specific guidance for health care leaders and point-of-care teams in partnering with patients and their care partners to co-design, reliably implement, and sustain and spread Always Events to dramatically improve the care experience.

BMJ Open - Strengthening leadership as a catalyst for enhanced patient safety culture: a repeated cross-sectional experimental study

Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) Tool
Efforts to advance patient safety have been hampered by the lack of high quality measures of adverse events (AEs). This study's objective was to develop and test the Global Assessment of Pediatric Patient Safety (GAPPS) trigger tool, which measures hospital-wide rates of AEs and preventable AEs.

July 2016

Care Quality Commission - Learning from serious incidents in NHS acute hospital. This briefing document discusses the need for a change in the way that serious incidents are investigated and managed in the NHS.

Royal College of Obstetricians & Gynaecologists release: New measures to prevent maternal deaths, including a video and poster entitled 'Three P's in a Pod'

NHS Improvement tools and shared learning -

A safe system framework for recognising and responding to children at risk of deterioration
A joint initiative with the Royal College of Paediatrics and Child Health to improve outcomes and reduce the incidence of deterioration in acutely ill children.

The adult patient who is deteriorating: sharing learning from literature, incident reports and root cause analysis investigations

Resources for the detection and management of deterioration in adult patients

NHS Employers - Raising concerns e-learning module now available

IHI - Two Countries, One Culture of Patient Safety A blog post by Kevin Rooney, 19th July 2016

Parliamentary and Health Service Ombudsman - Learning from mistakes: An investigation report by the Parliamentary and Health Service Ombudsman into how the NHS failed to properly investigate the death of a three-year old child. This case which ombudsman service investigated, found that the local NHS investigation processes were not fit for purpose, and not sufficiently independent, inquisitive, open or transparent, properly focused on learning, or able to span organisational and hierarchical barriers, and they excluded the family and junior staff in the process. The report provides a series of recommendations for NHS organisations.

Picker Institute Europe - NEW Policy briefing: The state of maternity services in England

Resources used:
Applied Ergnomics
BMJ Quality & Safety
Daily Health Bulletin
Department of Health
Journal of the Royal Society of Medicine Open
Monitor
NHS Employers
NHS Health Education England
NHS Improvement
NHS Trust Development Authority
Public Health England

Links checked: [03/08/2016]

View our other Evidence Updates

Our mailing address is: l ouise.hull@uhl-tr.nhs.uk

This document aims to highlight useful publications around patient safety and risk. Please send feedback to louise.hull@uhl-tr.nhs.uk on both the selected content and amount of detail, as this can be
amended to ensure it meets the needs of those using it.

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UHL Clinical Librarian Service · Education Centre · Glenfield Hospital · Leicester, LE3 9QP · United Kingdom