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Found 75 results
  1. Content Article
    Drawing together academic evidence and practical experience to produce a framework for safety measurement and monitoring.
  2. Content Article
    A US based study to determine whether medical errors, family experience and communication processes improved after implementation of an intervention to standardise the structure of healthcare provider-family communication on family centered rounds.
  3. Content Article
    Published in the Journal of Clinical Nursing this paper explores the experiences of the families of young adults with intellectual disabilities at the point of transition from child to adult health services.
  4. Content Article
    High numbers of non-urgent attendances at paediatric emergency departments (i.e. attendances for illness that could have safely been treated elsewhere) increases waiting times, inconveniences families, incurs significant costs to the NHS, and reduces the time hospital staff can spend treating severely ill children. This report, produced by the Behavioural Insights Team (BIT) in collaboration with the Connecting Care for Children (CC4C) programme, addresses this issue.
  5. Content Article
    Effective communication is critical to successful large-scale change. Yet, in our experience, communications strategies are not formally incorporated into quality improvement frameworks. The 1000 Lives Campaign was a large-scale national quality improvement collaborative that aimed to save an additional 1000 lives and prevent 50 000 episodes of harm in Welsh health care over a two year period. This research, published in the Journal of Communication in Healthcare, used the campaign as a case study to describe the development, application, and impact of a communications strategy embedded in a large-scale quality improvement initiative.
  6. Content Article
    Risk scores are widely used in healthcare, but their development and implementation do not usually involve input from practitioners and service users and carers (SU/C). This study from Dyson et al., published in BMJ Open contributes to the development of The Computer-Aided Risk Score (CARS) by eliciting views of staff and who provided important, often complex, insights to support the development and implementation of CARS to ensure successful implementation in routine clinical practice.
  7. Content Article
    The Health Foundation’s Report, Untapped potential: Investing in health and care data analytics, highlights nine key reasons why there should be more investment in analytical capability.
  8. Content Article
    The latest issue of the Patient Safety Journal is now out.  US patient safety journal brought to you by the Patient Safety Authority, an independent agency of the Commonwealth of Pennsylvania. Each issue publishes original, peer-reviewed research and data analyses and also gives patients a voice. It's mission is to give clinicians, administrators and patients the information they need to prevent harm and improve safety. 
  9. Content Article
    As improvement practice and research begin to come of age, Mary Dixon-Woods in this BMJ feature considers the key areas that need attention if we are to reap their benefits. Mary Dixon-Woods is the Health Foundation Professor of Healthcare Improvement Studies and Director of The Healthcare Improvement Studies (THIS) Institute at the University of Cambridge, funded by the Health Foundation. Co-editor-in-chief of BMJ Quality and Safety, she is an honorary fellow of the Royal College of General Practitioners and the Royal College of Physicians.
  10. Content Article
    "Looking back down the path of another person’s journey is not the same thing as making the trip yourself." What a great quote! It is so true. Henriksen and Kaplan discuss hindsight bias, outcome knowledge and adaptive learning in this paper published in BMJ Quality & Safety in 2003.
  11. Content Article
    Human factors is an established body of science that is positioned to assist with the challenge of improving healthcare delivery and safety for patients. In this paper published in BMJ Quality & Safety, Russ et al. attempted to clarify the goals of human factors and pave the way for interdisciplinary collaborations that may yield new, sustainable solutions for healthcare quality and patient safety.
  12. Content Article
    A collection of resources from NHS Improvement to help you analyse, understand and improve the health and well-being of your workforce. Based on NHS Improvements's learning from the Improving Health and Well-being direct support programme, they have developed and collated some resources which will assist analysis of your quantitative and qualitative workforce data to drive and enable development of impactful evidence-based workforce health and well-being interventions.
  13. Content Article
    Policy to date has mostly focused on the role of 'whistleblowers' in raising concerns about quality and safety of patient care in healthcare settings. However, most opportunities for personnel to identify and act on these concerns are likely to occur much further upstream, in the day-to-day mundane interactions of everyday work. Using qualitative data from over 900 hours of ethnographic observation and 98 interviews across 19 English intensive care units (ICUs), Tarrant et al., in a paper published in Social Science & Medicine, studied how personnel gave voice to concerns about patient safety or poor practice.
  14. Content Article
    Health and social care systems, organisations and providers are under pressure to organise care around patients’ needs with constrained resources. To implement patient-centred care (PCC) successfully, barriers must be addressed. Up to now, there has been a lack of comprehensive investigations on possible determinants of PCC across various health and social care organisations (HSCOs). This qualitative study from Hower et al., published in BMJ Open, examines determinants of PCC implementation from decision makers’ perspectives across diverse HSCOs.
  15. Content Article
    This study by Noble and Sweeney, published in Workplace Health & Safety, assessed barriers to the use of assistive devices in safe patient handling and mobility that contribute to health care worker injuries.
  16. Content Article
    Poster summarising the barriers in sharing learning across organisations in healthcare.
  17. Content Article
    Dr Sara Ryan is a senior researcher and autism specialist at Oxford University's Nuffield department of primary health sciences. Her son, Connor Sparrowhawk, died in a residential unit, aged 18.
  18. Content Article
    On 20 March 2018 NHS Improvement launched an engagement programme to seek views from a wide range of stakeholders about how and when patient safety incidents should be investigated. Often those affected by incidents are not appropriately supported or involved in the investigation process; the quality of investigation reports is generally poor; and improvements to prevent the recurrence of harm are not effectively implemented. To obtain views on the problems with the current approach to the investigation of Serious Incidents, the issues driving these problems, and how such issues might be resolved, NHSI ran an online survey, national workshops and a live twitter chat, and held discussions with many individuals including patients, families, NHS staff, regulators and others. This document summarises the feedback received.
  19. Content Article
    This paper from Kok et al in the Journal of Health Services Research & Policy explores how Dutch hospitals organise patient or family engagement in incident investigations, maps out incident investigators’ experiences of involving patients or their families in incident investigations and identifies the challenges encountered.
  20. Content Article
    This study from Landefeld et al., published in the Indian Journal of Community Medicine, looks at the perceptions of healthcare providers about barriers to improved patient safety in the Indian state of Kerala. Five focus group discussions were held with 16 doctors and 20 nurses across three institutions (primary, secondary and tertiary care centers) in Kerala, India and transcripts were analysed by thematic analysis.
  21. Content Article
    In accident investigation, the ideal is often to follow the principle “what-you-find-is-what-you-fix”, an ideal reflecting that the investigation should be a rational process of first identifying causes, and then implement remedial actions to fix them. Previous research has however identified cognitive and political biases leading away from this ideal. Somewhat surprisingly, however, the same factors that often are highlighted in modern accident models are not perceived in a recursive manner to reflect how they influence the process of accident investigation in itself. Those factors are more extensive than the cognitive and political biases that are often highlighted in theory. The purpose in this study from Lundberg et al. (published in Accident, Analysis and Prevention) was to reveal constraints affecting accident investigation practices that lead the investigation towards or away from the ideal of “what-you-find-is-what-you-fix”.
  22. Content Article
    Technology is often viewed as either positive or negative. On one hand weight loss apps are usually seen as a positive influence on users. From the sociocultural perspective, on the other hand, media and technology can negatively impact body satisfaction and contribute to eating disorders; however, these studies fail to include weight loss apps. While these apps can be beneficial to users, they can also have negative effects on users with eating disorder behaviours. Yet few research studies have looked at weight loss apps in relation to eating disorders. In order to fill this gap,these researchers conducted interviews with 16 women with a history of eating disorders who use(d) weight loss apps. While findings suggest these apps can contribute to and exacerbate eating disorder behaviours, they also reveal a more complex picture of app usage. Women’s use and perceptions of weight loss apps shift as they experience life and move to and from stages of change. This research troubles the binary view of technology and emphasises the importance of looking at technology use as a dynamic process. This study contributes to the understanding of weight loss app design.
  23. Content Article
    The PReCePT Programme is a quality improvement project designed to reduce the incidence of cerebral palsy through the administration of magnesium sulphate to eligible preterm mothers across England.
  24. Content Article
    The WHO guidance for after action review (AAR) presents the methodology for planning and implementing a successful AAR to review actions taken in response to public health event, but also as a routine management tool for continuous learning and improvements. Four formats of AARs are described including the debrief, working group, key informant interview and mixed method AARs, and the accompanying toolkits containing materials to support the designing, preparing, conducting, and following up on each AAR format. Whilst the AAR methodology described in this document can be used for any response, a specific guidance to conduct an AAR following the response to emergencies that were not caused by biological hazards such as natural disasters is also provided to help the health sector to review its specific contribution to the multisectoral response and coordination.
  25. Content Article
    Fewer than 1% of UK general practice consultations occur by video. This study by Trisha Greenhalgh and colleagues aims to explain why video consultations are not more widely used in general practice.
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