Learn: Learnhttps://www.pslhub.org/learn/research-data-and-insight/research/research-papers/page/5/?d=1Learn: LearnenThe harms of promoting ‘Zero Harm’https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/the-harms-of-promoting-%E2%80%98zero-harm%E2%80%99-r814/814Thu, 24 Oct 2019 10:04:00 +0000Is there a ‘best measure’ of patient safety?https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/is-there-a-%E2%80%98best-measure%E2%80%99-of-patient-safety-r813/813Thu, 24 Oct 2019 09:57:00 +0000BMJ: Practitioner and patient views on the implementation of an automated Computer-Aided Risk Score to predict the risk of death (2019)https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/bmj-practitioner-and-patient-views-on-the-implementation-of-an-automated-computer-aided-risk-score-to-predict-the-risk-of-death-2019-r802/ CARS estimates the risk of death following emergency admission to medical wards using routinely collected vital signs and blood test data. The aim of the study was to elicit the views of:

  1. Healthcare practitioners (staff) and service users and carers on  the potential value, unintended consequences and concerns associated with CARS.
  2. Practitioner views on the issues to consider before embedding CARS into routine practice.
]]>802Wed, 23 Oct 2019 10:24:00 +0000When complexity science meets implementation science: a theoretical and empirical analysis of systems change (30 April 2018)https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/when-complexity-science-meets-implementation-science-a-theoretical-and-empirical-analysis-of-systems-change-30-april-2018-r3339/3339Mon, 21 Oct 2019 13:55:00 +0000Psychological Science: The Invisible Gorilla Strikes Again: Sustained Inattentional Blindness in Expert Observers (2013)https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/psychological-science-the-invisible-gorilla-strikes-again-sustained-inattentional-blindness-in-expert-observers-2013-r947/947Sat, 19 Oct 2019 16:00:00 +0000How can pharmacists develop patient-pharmacist communication skills? A realist review protocol (January 2017)https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/how-can-pharmacists-develop-patient-pharmacist-communication-skills-a-realist-review-protocol-january-2017-r937/937Tue, 15 Oct 2019 14:52:00 +0000The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self‐management (April 2002)https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/the-relative-importance-of-physician-communication-participatory-decision-making-and-patient-understanding-in-diabetes-self%E2%80%90management-april-2002-r936/936Tue, 15 Oct 2019 14:39:00 +0000AHRQ: Engaging patients to improve quality of care: a systematic review (November 2018)https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/ahrq-engaging-patients-to-improve-quality-of-care-a-systematic-review-november-2018-r935/935Tue, 15 Oct 2019 14:18:00 +0000BMJ: Suffering in silence: a qualitative study of second victims of adverse events (November 2013)https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/bmj-suffering-in-silence-a-qualitative-study-of-second-victims-of-adverse-events-november-2013-r929/929Tue, 15 Oct 2019 12:00:00 +0000Patients as partners in learning from unexpected events (October 2016)https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/patients-as-partners-in-learning-from-unexpected-events-october-2016-r925/925Tue, 15 Oct 2019 10:12:00 +0000Medical Journal of Australia: Patients' and carers' perceptions of safety in rural general practice (July 2014)https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/medical-journal-of-australia-patients-and-carers-perceptions-of-safety-in-rural-general-practice-july-2014-r924/ Results: 

Participants who had experienced some level of harm were able to comment more extensively on safety aspects of care. Several key themes related to safety were identified from the analysis of all participant narratives. An assumed sense of safety in general practice was predominant, and was influenced by participants' level of risk awareness and trust in their general practitioner. Additional unique themes included feelings of vulnerability, desire for an explanation and apology, a forgiving view of mistakes, and preference for GP interpersonal skills over competence. 

Conclusions: 

This study revealed new insights into the factors that influence patients' and carers' perspectives of safety, and demonstrated the value of incorporating the patient voice into safety research. An assumed sense of safety due to a default position of trust, coupled with limited risk perception, directly contests the current literature on patient involvement in safety. Further exploration is required to determine how patients and carers can effectively engage in and assist with improving safety in general practice.

]]>924Tue, 15 Oct 2019 09:59:00 +0000BMJ: Safe handover (October 2017)https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/bmj-safe-handover-october-2017-r923/923Tue, 15 Oct 2019 09:41:00 +0000BMJ: How safe is primary care? A systematic review (2015)https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/bmj-how-safe-is-primary-care-a-systematic-review-2015-r890/890Fri, 11 Oct 2019 13:55:00 +0000The economics of patient safety: strengthening a value-based approach to reducing patient harm at national level (June 2017)https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/the-economics-of-patient-safety-strengthening-a-value-based-approach-to-reducing-patient-harm-at-national-level-june-2017-r886/ The authors examine how patient harm can be minimised effectively and efficiently. This is informed by a snapshot survey of a panel of eminent academic and policy experts in patient safety. System-level and organisational-level initiatives were seen as vital to provide a foundation for the more local interventions targeting specific types of harm. The overarching requirement was a culture conducive to safety.

]]>886Fri, 11 Oct 2019 12:17:00 +0000Surveillance of sight loss due to delay in ophthalmic treatment or review: frequency, cause and outcomehttps://www.pslhub.org/learn/research-data-and-insight/research/research-papers/surveillance-of-sight-loss-due-to-delay-in-ophthalmic-treatment-or-review-frequency-cause-and-outcome-r1301/1301Thu, 10 Oct 2019 14:59:00 +0000Informatics opportunities to involve patients in hospital safety: a conceptual model (October 2019)https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/informatics-opportunities-to-involve-patients-in-hospital-safety-a-conceptual-model-october-2019-r874/874Sun, 06 Oct 2019 14:32:00 +0000Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study (December 2018)https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/nurse-staffing-nursing-assistants-and-hospital-mortality-retrospective-longitudinal-cohort-study-december-2018-r1045/1045Wed, 02 Oct 2019 11:40:00 +0000Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study (2013)https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/culture-and-behaviour-in-the-english-national-health-service-overview-of-lessons-from-a-large-multimethod-study-2013-r838/838Tue, 01 Oct 2019 14:26:00 +0000<![CDATA[BMJ Quality & Safety: The problem with checklists (2015)]]>https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/bmj-quality-safety-the-problem-with-checklists-2015-r837/837Tue, 01 Oct 2019 14:02:00 +0000Contributory factors to patient safety incidents in primary care: protocol for a systematic review (2015)https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/contributory-factors-to-patient-safety-incidents-in-primary-care-protocol-for-a-systematic-review-2015-r833/ The review will summarise the literature relating to contributory factors to patient safety incidents in primary care. The findings from this review will provide an evidence-based contributory factors framework for use in the primary care setting. It will increase understanding of factors that contribute to patient safety incidents and ultimately improve quality of healthcare.

]]>833Tue, 01 Oct 2019 11:48:00 +0000Why do parents bring children with minor illness to emergency and urgent care departments? (2017)https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/why-do-parents-bring-children-with-minor-illness-to-emergency-and-urgent-care-departments-2017-r830/ Literature review and report of fieldwork in North West London.

]]>830Tue, 01 Oct 2019 09:00:00 +0000The Health Foundation: The implications of high bed occupancy rates on readmission rates in England (2019)https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/the-health-foundation-the-implications-of-high-bed-occupancy-rates-on-readmission-rates-in-england-2019-r801/801Mon, 23 Sep 2019 10:18:00 +0000The invisible gorilla strikes again: sustained inattentional blindness in expert observers (January 2013)https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/the-invisible-gorilla-strikes-again-sustained-inattentional-blindness-in-expert-observers-january-2013-r836/836Sun, 01 Sep 2019 13:57:00 +0000The development of safety cases for healthcare services: Practical experiences, opportunities and challenges (August 2015)https://www.pslhub.org/learn/research-data-and-insight/research/research-papers/the-development-of-safety-cases-for-healthcare-services-practical-experiences-opportunities-and-challenges-august-2015-r2916/ Key highlights
  • Empirical description of safety case development at service level in healthcare.
  • Safety cases can support adoption of proactive and rigorous safety management.
  • Adaptation to purpose and use of safety cases might be required in healthcare.
  • Education should be provided to practitioners and regulators.
]]>2916Sun, 01 Sep 2019 12:48:00 +0000Intravenous infusion administration: A comparative study of practices and errors between the United States and England and their implications for patient safetyhttps://www.pslhub.org/learn/research-data-and-insight/research/research-papers/intravenous-infusion-administration-a-comparative-study-of-practices-and-errors-between-the-united-states-and-england-and-their-implications-for-patient-safety-r220/ Intravenous medication administration is widely reported to be error prone. Technologies such as smart pumps have been introduced with a view to reducing these errors. The research groups, from the UK and US, drew on findings of separate point prevalence studies conducted across hospitals in each country. They compared what was being administered at the time of observation with the prescription and relevant policies, errors were classified by type and severity, and proportions of infusions featuring each error type were calculated. They also reviewed what adaptations to the US protocol were needed for the UK.

Although US sites made greater use of smart infusion devices, and had more precisely defined requirements around infusion device use, patterns of errors were similar. Differences among clinical contexts within each country were as marked as differences across countries.

They concluded that infusion administration is a complex adaptive system with multiple interacting agents (professionals, patients, software systems, etc.) that respond in rich ways to their environments; safety depends on complex, interrelated factors.

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