Learn: Learn

“It's like two worlds apart”: an analysis of vulnerable patient handover practices at discharge from hospital (October 2012)

Wed, 01 Jan 2020 15:45:00 +0000

Beyond metrics? Utilizing ‘soft intelligence’ for healthcare quality and safety (October 2015)

Wed, 01 Jan 2020 15:44:00 +0000

Key findings:

There are calls for greater use of ‘soft’ intelligence around quality and safety.
Little research examines the challenges and opportunities soft data present.
This study in the English NHS found clinicians and managers saw utility in soft data.
Dominant approaches to interpretation risked obscuring their greatest value.
Soft data might better be used to disrupt understanding and challenge consensus.

Developing a hospital-wide quality and safety dashboard: a qualitative research study (June 2018)

Wed, 01 Jan 2020 15:42:00 +0000

Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis (August 2016)

Wed, 01 Jan 2020 15:34:00 +0000

Putting out fires: a qualitative study exploring the use of patient complaints to drive improvement at three academic hospitals (May 2019)

Wed, 01 Jan 2020 15:31:00 +0000

BMJ Open: Systematic review of approaches to using patient experience data for quality improvement in healthcare settings (August 2016)

Wed, 01 Jan 2020 15:24:00 +0000

Findings suggest there is no single best way to collect or use PREM data for QI, but they do suggest some key points to consider when planning such an approach. For instance, formal training is recommended, as a lack of expertise in QI and confidence in interpreting patient experience data effectively may continue to be a barrier to a successful shift towards a more patient-centred healthcare service. In the context of QI, more attention is required on how patient experience data will be used to inform changes to practice and, in turn, measure any impact these changes may have on patient experience.

BMJ Open: A systematic review of evidence on the links between patient experience and clinical safety and effectiveness

Wed, 01 Jan 2020 15:09:00 +0000

The National Adult Inpatient Survey conducted in the English National Health Service from 2002 to 2009: how have the data been used and what do we know as a result?

Wed, 01 Jan 2020 15:02:00 +0000

Emotional harm from disrespect: the neglected preventable harm (June 2015)

Wed, 01 Jan 2020 14:45:00 +0000

Responding effectively to adult mental health patient feedback in an online environment: A coproduced framework (April 2018)

Wed, 01 Jan 2020 14:39:00 +0000

Using a machine learning system to identify and prevent medication prescribing errors: A clinical and cost analysis evaluation

Tue, 31 Dec 2019 10:22:00 +0000

The study analysed whether the system generated clinically valid alerts and its estimated cost savings associated with potentially prevented adverse events. These alerts were compared to alerts in the CDS system, using a random sample of 300 alerts selected for medical record review.

Findings showed a total of 10,668 alerts during the five-year period. Overall, 68.2% of the alerts would not have been generated by the existing CDS system. Ninety-two percent of a random sample of the chart-reviewed alerts were accurate based on structured data available in the record, and 80% were clinically valid. The estimated cost of adverse events potentially prevented in an outpatient setting was more than $60 per drug alert and $1.3 million when extrapolating the study’s findings to the full patient population.

Assessing building blocks for patient safety culture – a quantitative assessment of Saudi Arabia (December 2019)

Mon, 09 Dec 2019 15:18:45 +0000

Interprofessional education in team communication: working together to improve patient safety (January 2013)

Sat, 30 Nov 2019 14:55:00 +0000

Factors affecting the nurse-patients’ family communication in Intensive Care Unit of Kerman: a qualitative study (March 2014)

Sat, 30 Nov 2019 14:04:00 +0000

Spoken communication and patient safety: a new direction for healthcare communication policy, research, education and practice? (September 2019)

Sat, 30 Nov 2019 12:30:00 +0000

The group’s conclusions are that six domains of care communication warrant attention and improvement:

the care environment
information exchange
attitude and listening
aligning and responding
team communication
communicating with unique groups.

Together, these domains expand the definition of healthcare communication from communication as information transaction to communication as complex social and local dynamic.

The report outlines the consequences of this expanded definition for healthcare communication improvement and improvement research.

BMJ: New South Wales mounts “patient based care” challenge (February 2015)

Sat, 30 Nov 2019 10:54:00 +0000

Exploring the sustainability of quality improvement interventions in healthcare organisations: a multiple methods study of the 10-year impact of the ‘Productive Ward: Releasing Time to Care’ programme in English acute hospitals

Sat, 30 Nov 2019 09:54:00 +0000

Is one-pen, one-patient achievable in the hospital? A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical center

Wed, 27 Nov 2019 15:00:00 +0000

Five root causes for accidental sharing of pens were identified:

knowledge gaps and practice variation
labels
insulin storage and removal process
information technology issues including those related to barcode medication administration and the electronic health record
insulin administration workflow.

Four major interventions to address the root causes were developed and tested:

patient-specific bar coding on insulin pens
redesign of labels
systematic removal of discharged patients’ medications
ongoing staff education.

Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review

Mon, 25 Nov 2019 16:08:00 +0000

The majority of studies identified active failures (errors and violations) as factors contributing to patient safety incidents. Individual factors, communication, and equipment and supplies were the other most frequently reported factors within the existing evidence base. This review has culminated in an empirically based framework of the factors contributing to patient safety incidents. This framework has the potential to be applied across hospital settings to improve the identification and prevention of factors that cause harm to patients.

Understanding the factors influencing doctors’ intentions to report patient safety concerns: a qualitative study (October 2019)

Wed, 13 Nov 2019 16:42:00 +0000

While raising a concern was considered an appropriate professional behaviour, there were multiple barriers to raising a concern, which could be explained by the Theory of Planned Behaviour.

Negative attitudes operated due to a fear of the consequences, such as becoming professionally isolated. Disapproval for raising a concern was encountered at an interpersonal and organisational level.

Organisational constraints of workload and culture significantly undermined the raising of a concern.

Responses about concerns were often side-lined or not taken seriously, leading to demotivation to report. This was reinforced by high-profile cases in the media and the negative treatment of whistle-blowers.

While regulator guidance acted as an enabler to justify raising a concern, doctors felt disempowered to raise a concern about people in positions of greater power, and ceased to report concerns due to a perceived lack of action about concerns raised previously.

BMJ: Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study (December 2018)

Mon, 11 Nov 2019 13:56:00 +0000

THIS.Institute: How to be a very safe maternity unit: An ethnographic study (January 2019)

Mon, 11 Nov 2019 13:51:00 +0000

Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: The promoting respect and ongoing safety through patient engagement communication and technology study (August 2017)

Wed, 06 Nov 2019 16:33:00 +0000

The relationship between patient safety culture and adverse events: a study in palestinian hospitals (9 September 2015)

Wed, 06 Nov 2019 16:22:00 +0000

Hospital-acquired condition reduction program is not associated with additional patient safety improvement

Mon, 04 Nov 2019 11:42:00 +0000