Free access. Despite consensus that preventing patient safety events is important, measurement of safety events remains challenging. This is, in part, because they occur relatively infrequently and are not always preventable. There is also no consensus on the ‘best way‘ or the ‘best measure’ of patient safety. The purpose of all safety measures is to improve care and prevent safety events; this can be achieved by different means. If the overall goal of measuring patient safety is to capture the universe of safety events that occur, then broader measures encompassing large populations, such as those based on administrative data, may be preferable. Acknowledging the trade-off between comprehensiveness and accuracy, such measures may be better suited for surveillance and quality improvement (QI), rather than public reporting/reimbursement. Conversely, using measures for public reporting and pay-for-performance requires more narrowly focused measures that favour accuracy over comprehensiveness, such as those with restricted denominators or those based on medical record review.
Clinical negligence claims are costly events, both in terms of the harm caused and the expense that results. Helen Vernon, Chief Executive of NHS Resolution, discusses the importance of generating and sharing insight from the harm that can result in clinical negligence claims.
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The Secretary of State for Health and Social Care asked us to work with NHS Improvement to look at issues in NHS trusts that contribute to Never Events taking place.
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In a national report published today, the Care Quality Commission (CQC) found that too many people are being injured or suffering unnecessary harm because NHS staff are not supported by sufficient training, and because the complexity of the current patient safety system makes it difficult for staff to ensure that safety is an integral part of everything they do.
The commitment includes a proposal for some of the most important types of avoidable harm to patients to be halved over the next five years in areas such as medication errors and Never Events, alongside developing a ‘just culture’ for the NHS where frontline staff are supported to speak up when errors occur.
Free access. Incident reporting has been a mainstay of patient safety initiatives throughout the world, but its purpose and potential for stimulating safety improvements are still much debated. Record review studies of adverse events revealed the nature and scale of harm to patients, and it was initially hoped that incident reporting systems would capture these adverse events on an ongoing basis.1 2 This epidemiological dream was never realised; studies showed that incident reporting was actually very poor at identifying adverse events.3 Furthermore, incident reporting, record review and other systems such as pharmacy reports capture very different types of problems, which means that combining information sources can provide a more complete picture of safety issues.4 5
Open access. The Primary Care Patient Measure of Safety (PC PMOS) is designed to capture patient feedback about the contributing factors to patient safety incidents in primary care. It required further reliability and validity testing to produce a robust tool intended to improve safety in practice.
The Prevention of Hospital Infections by Intervention and Training (PROHIBIT) project included a cluster-randomised, stepped wedge, controlled study to evaluate multiple strategies to prevent catheter-related bloodstream infection. We report an in-depth investigation of the main barriers, facilitators and contextual factors relevant to successfully implementing these strategies in European acute care hospitals.
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Open access. Editorial. An enduring challenge for the improvement of healthcare quality is variation in the success of quality improvement (QI) interventions when implemented across settings.1 This is particularly true in the field of healthcare-associated infection (HAI) prevention. Some of the brightest success stories in QI have emerged from large-scale efforts to reduce HAIs such as central venous catheter-related bloodstream infections (CRBSIs)2 or catheter-associated urinary tract infections.3 The light dims, however, when efforts to export these interventions to other settings fail to meaningfully improve outcomes.4 5
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Open access. Healthcare organisations often fail to harvest and make use of the ‘soft intelligence’ about safety and quality concerns held by their own personnel. We aimed to examine the role of formal channels in encouraging or inhibiting employee voice about concerns.
Patient safety measurement remains a global challenge. Patients are an important but neglected source of learning; however, little is known about what patients can add to our understanding of safety. We sought to understand the incidence and nature of patient-reported safety concerns in hospital.. To read the full article, log in using your NHS OpenAthens details.
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