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Content Article
Prevention of future deaths report: Pamela Honeybone (25 September 2025)
Anonymous posted an article in Coroner reports
On 30 July 2025 an investigation was commenced into the death of Pamela Ann Honeybone, who died at Scarborough General Hospital on 19 October 2024 aged 90. The investigation concluded at the end of the inquest on 23 September 2025. The conclusion of the inquest was that: Pamela Ann Honeybone died as a consequence of naturally occurring disease. Diagnosis of her condition was delayed when another patient was scanned in error instead of Mrs Honeybone, but it has not been possible to determine on the balance of probabilities that this contributed to her death. On the 19 of September 2024 Pamela Ann Honeybone was admitted to Scarborough General Hospital following a fall. She required CT scanning but another patient with the same first name underwent the investigation in error and its results were attributed to Mrs Honeybone. Mrs Honeybone’s condition continued to deteriorate and a CT scan undertaken on the 15 of October 2024 revealed the presence of an abdominal mass suggestive of lymphoma. Mrs Honeybone was moved to end of life care and she died at the hospital on the 19 of October 2024. Matters of concern: It was accepted in evidence that neither the doctor who escorted the wrong patient from the Emergency Department to radiology, nor the radiographer who undertook the CT scan on her, checked the identity of the patient in question. No transfer checklist was completed, and the patient was not asked to complete and/or sign the CT scanning questionnaire herself. No member of staff inquired as to the outcome of this patient’s CT scan prior to her discharge a few hours later. The scanning error was recognised by a radiologist on the 15th of October 2024, but was not conveyed to Mrs Honeybone’s treating team until late October, by which time she had died and her death had been scrutinised by the Medical Examiner and certified by her treating doctor as wholly natural and not requiring referral to the Coroner. As a result of the aforementioned delay, a Trust investigation did not commence until late November 2024. No prompt after action review therefore occurred in the hours and days after the error was recognised. When the Trust investigation did commence, staff directly involved either could not be identified or had no recollection of events. Despite hearing evidence that it was a doctor who would have escorted the wrong patient to scanning, the Trust Investigation focussed on nursing involvement with the patients in question and did not seek to identify and question medical team members. An Action Plan was drawn up as a result of the Trust Investigation, but for various reasons no audit of compliance with patient identification processes commenced until early August 2025, some ten months after Mrs Honeybone’s death. The results of the audit thus far were made available to me at inquest and indicate that 1 in 5 audited treatment encounters between staff of all grades and specialisms still occur without the patient being positively identified. The coroner heard evidence that while radiology transfer checklists are routinely completed ‘in hours’ at Scarborough Hospital when a dedicated HCA is on duty to perform this task, no such checklist is in use at the Trust’s York site at any time of the day. Mrs Honeybone’s misidentification occurred ‘out of hours’ at Scarborough when no designated person assumes responsibility for this task at that site. The coroner considers the above represent a continuing risk to others from misidentification and delayed responses to identified errors, with clear implications for patient safety. -
Content ArticleClinical practices guidelines (CPGs) play a fundamental role in improving healthcare and patients’ outcomes by helping clinicians make the best evidence-based decisions for their patients in a time-efficient manner. By following the available methods and criteria to create trustworthy CPGs, panel members can develop high-quality guidelines. However, despite the improvements over the years, CPGs are still subjected to biases and limitations, with conflicts of interest being the ugliest problem GCPs must face. This review discusses the main characteristics of clinical practice guidelines, their pros and cons, and the future challenges they need to overcome.
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Content ArticleQuality checklists have demonstrated benefits in healthcare and other high-reliability organizations, but there remains a gap in the understanding of design approaches and levels of stakeholder engagement in the development of these quality checklists. This scoping review synthesised the current knowledge base regarding the use of various design approaches for developing quality checklists in healthcare. Secondary objectives were to explore theoretical frameworks, design principles, stakeholder involvement and engagement, and characteristics of the design methods used for developing quality checklists. Twenty-three distinct design methods were identified that were predominantly non-collaborative in nature (e.g., interviews, surveys, and other methods that involved only one researcher and one participant at a given time). Analysis of the levels of stakeholder engagement revealed a gap in studies that empowered their stakeholders in the quality checklist design process. Highly effective, clear, and standardized methodologies are needed for the design of quality checklists. Future work needs to explore how stakeholders can be empowered in the design process, and how different levels of stakeholder engagement might impact implementation outcomes.
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Content ArticleHealthcare safety activists have looked to checklists to solve a myriad of problems, particularly with the current iteration of checklists that have been imported from aviation. Large-scale implementations with conflicting outcomes suggest that these tools are not as simple or effective as hoped. Scholars debating the efficacy of checklist implementation in healthcare have identified important reasons for varying results: that success requires complex, cultural and organisational change efforts, not just the checklist itself; that results may be confounded by a mix of the technical and socioadaptive elements, and that local contexts may either augment or undermine the implementation's outcomes. When ideas are translated from one industry to another, the assumptions underlying the original concepts may be lost or diluted. As checklists are increasingly imposed through a variety of professional and regulatory mandates in North America, Europe and elsewhere, perhaps it is time to review the fundamental principles of checklist use, including why they might work and how we can implement them better.
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Content ArticlePatient safety has become a central component of quality of care. One of the best known and most widely used security tools in all work settings is the checklists. The checklist is a tool that helps to not forget any step during the performance of a procedure, to do tasks with an established order, to control the fulfilment of a series of requirements or to collect data in a systematic way for its subsequent analysis. It is an aid to improve the efficiency of teamwork, promote communication, decrease variability, standardise care and improve patient safety. This article discusses the barriers in establishing checklists and the practical applications in paediatrics.
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Content ArticleDespite improving patient safety in some perioperative settings, some checklists are not living up to their potential and complaints of “checklist fatigue” and outright rejection of checklists are growing. Problems reported often concern human factors: poor design, inadequate introduction and training, duplication with other safety checks, poor integration with existing workflow, and cultural barriers. Each medical setting—such as an operating room or a critical care unit—and different clinical needs—such as a shift handover or critical event response—require a different checklist design. One size will not fit all, and checklists must be built around the structure of medical teams and the flow of their work in those settings. Useful guidance can be found in the literature; however, to date, no integrated and comprehensive framework exists to guide development and design of checklists to be effective and harmonious with the flow of medical and perioperative tasks. Burian and colleagues propose such a framework organised around the 5 stages of the checklist life cycle: (1) conception, (2) determination of content and design, (3) testing and validation, (4) induction, training, and implementation, and (5) ongoing evaluation, revision, and possible retirement. They illustrate one way in which the design of checklists can better match user needs in specific perioperative settings (in this case, the operating room during critical events). Medical checklists will only live up to their potential to improve the quality of patient care if their development is improved and their designs are tailored to the specific needs of the users and the environments in which they are used.
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News Article
From checklists to more personalised care
Patient_Safety_Learning posted a news article in News
Kent and Medway Mental Health NHS Trust has made a major shift in how they assess and respond to risk, putting patients’ voices and lived experience at the heart of every safety decision. In a move designed to improve care, prevent harm, and deliver efficient, more compassionate support, the trust has moved away from relying on static checklists or fixed scoring systems, and is instead working with patients to explore their individual circumstances, triggers, strengths, and needs. The change is already helping staff respond faster and more effectively when a person’s situation changes, ensuring that they receive the right help at the right time. Read full story Source: Kent and Medway Mental Health NHS Trust, 17 February 2026 -
Content ArticleThis narrative review aimed to explore the impact of checklists and error reporting systems on hospital patient safety and medical errors. A systematic search of academic databases from 2013 to 2023 was conducted, and peer-reviewed studies meeting inclusion criteria were assessed for methodological rigor. The review highlights evidence supporting the efficacy of checklists in reducing medication errors, surgical complications, and other adverse events. Error reporting systems foster transparency, encouraging professionals to report incidents and identify systemic vulnerabilities. Checklists and error reporting systems are interconnected. Interprofessional collaboration is emphasized in checklist implementation. In this review, limitations arise due to the different methodologies used in the articles and potential publication bias. In addition, language restrictions may exclude valuable non-English research. While positive impacts are evident, success depends on organizational culture and resources. This review contributes to patient safety knowledge by examining the relevant literature, emphasizing the importance of interventions, and calling for further research into their effectiveness across diverse healthcare and cultural settings. Understanding these dynamics is crucial for healthcare providers to optimise patient safety outcomes.
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Content ArticleMost healthcare organisations (HCOs) find diagnostic errors hard to address. Singh et al. developed a checklist (the Safer Dx Checklist) of 10 high-priority safety practices HCOs can use to conduct a proactive risk assessment to address diagnostic error.
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Content ArticleThis investigation aims to improve patient safety by supporting healthcare staff in a surgical setting to select and insert the appropriate type of implant (vascular graft) for haemodialysis treatment. The Healthcare and Safety Investigation Branch (HSIB) explored the factors that affect the ability of staff to safely select and insert vascular grafts for haemodialysis treatment. The national investigation focused on: The identification of factors within the healthcare system as a whole that influence patient safety risks associated with the selection and insertion of vascular grafts in an operating theatre environment. Exploration, using a systems approach, of the design of labelling and packaging used for the different types of vascular grafts for patients on haemodialysis treatment. Exploration of the impact on operating theatre teams of staff redeployment and repurposing of working environments in response to the COVID-19 pandemic. Reference event Teri had chronic kidney disease and needed regular haemodialysis. He had previously received haemodialysis via a connection between an artery and a vein. However, this connection was failing due to narrowing of the blood vessels and she needed to have a vascular graft implanted so that her treatment could continue. Teri was referred to her local hospital for insertion of a ‘rapid access’ type of vascular graft, to enable her haemodialysis treatment to be carried out as planned. Before Teri’s operation, a consultant vascular surgeon and members of the operating theatre team went to the store cupboard to look at the types of vascular grafts stocked. The consultant vascular surgeon was not sure which size would be needed, so two different sized vascular grafts were selected. However, it was not recognised at the time that they were different types of vascular graft, with one being the intended rapid access type and the other a delayed use graft. Following surgery, the consultant vascular surgeon immediately realised that a delayed use vascular graft had been inserted instead of a rapid access graft. Because the wrong type of vascular graft was inserted, Teri needed to have another surgical procedure and an overnight stay in hospital, which may not have otherwise been needed. Findings The packaging of rapid access and delayed use vascular grafts may be very similar, resulting in an increased risk of staff selecting and inserting the wrong type of graft. The wording used on packaging and labels to describe vascular grafts does not reflect the terminology used by clinicians in the operating theatre. There is Medicines and Healthcare products Regulatory Agency (MHRA) guidance for the labelling and packaging of medicines, but not for medical devices such as vascular grafts. There was a lack of standardisation and therefore variation in how checklists and ‘team briefs’ (procedures that aim to ensure patient safety) were completed/ conducted and recorded in different operating theatres. The incorporation of national safety standards alone may not be successful without an embedded safety culture being in place. Barcode scanning technology (Scan4Safety) can be used to mitigate the risk of an incorrect medical device being selected/inserted. Due to the reduced central management of the Scan4Safety programme, trusts have been developing applications and using adaptations of the scanning technology, resulting in inconsistent use and variable effectiveness. Safety recommendations HSIB made four safety recommendations as a result of this investigation. HSIB recommends that NHS England reviews system requirements for barcode scanning technology, in order to support local organisations to reduce the risk of incorrect selection and insertion of prostheses/implants. HSIB recommends that the British Standards Institution updates the applicable standard/s, and raises with the International Organization for Standardization, to state that medical device labelling and packaging should detail the specific use of an item. This should be developed with user input to drive consistency in the terminology used on medical device labelling/packaging. HSIB recommends that the Medicines and Healthcare products Regulatory Agency ensures the assurance processes for designated approved bodies (to check medical device manufacturers conform to packaging standards) are amended to consider context of use and usability guidelines, to reduce the risk of selecting and inserting the incorrect device. HSIB recommends that the Medicines and Healthcare products Regulatory Agency publishes guidance on the labelling and packaging of medical devices, to promote best practice and reduce selection of the incorrect item. Safety observations HSIB makes the following safety observations: It may be beneficial if the term ‘user’ in the context of medical devices was defined in international and national standards to incorporate all staff who interact with the device, including those who select the device, check it before use and use it. It may be beneficial for healthcare organisations to deliver multi-disciplinary team training on the key principles of the revised ‘National safety standards for invasive procedures’ to support the implementation and embedding of these standards. It may be beneficial for trusts to assign experienced operating theatre clinicians to lead on the implementation of the ‘National safety standards for invasive procedures’, to address the cultural issues hindering implementation. Related resources on the hub: NatSSIP2 sequential steps: The NatSSIPs Eight – Flow chart Error traps gallery
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Gordon talks to us about how bureaucracy in the health service can compromise patient safety, the vital importance of agreed quality standards and what hillwalking has taught him about healthcare safety. -
Content ArticleCommercial aviation practices, including the role of the pilot monitoring, the sterile flight deck rule, and computerised checklists, have direct applicability to anaesthesia care. Checklists are commonly used in the operating room, especially the World Health Organization surgical safety checklist. However, the use of aviation-style computerised checklists offers additional benefits. In this editorial, Jelacic et al. discuss how these commercial aviation practices may be applied in the operating room.
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Content ArticleDr Kristin Harris, Research Fellow in the Department of Anaesthesia and Critical Care at Haukeland University Hospital, Bergen, Norway, discusses why patient safety patient involvement personally matters to her and talks about the tool she's currently working on, which are safety checklists specific to surgical patients.
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Content ArticleThis checklist has been developed by the Alzheimer’s Society to allow patients to check symptoms that could be a possible sign of dementia. Endorsed by the Royal College of General Practitioners (RCGP), it is a simple tool to help patients and their families clearly communicate their symptoms and concerns to a GP or other healthcare professional. It is not a diagnostic tool, but aims to provide a basis for helpful conversations.
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Content ArticleAccording to the World Health Organization, humanity faces its greatest ever threat: the climate and ecological crisis. Healthcare services globally have a large carbon footprint, accounting for 4-5% of total carbon emissions. Surgery is particularly carbon intensive, with a typical single operation estimated to generate between 150-170kgCO2e, equivalent to driving 450 miles in an average petrol car. The UK and Ireland surgical colleges have recognised that it is imperative for us to act collectively and urgently to address this issue. The Royal College of Surgeons of Edinburgh have collated a compendium of peer-reviewed evidence, guidelines and policies that inform the interventions included in the Intercollegiate Green Theatre Checklist. This compendium should support members of the surgical team to introduce changes in their own operating departments. The recommendations apply the principles of sustainable quality improvement in healthcare, which aim to achieve the “triple bottom line” of environmental, social and economic impacts. How to use the checklist The checklist is divided into four sections, the first dedicated to anaesthetic care, and the subsequent three looking at preparation for surgery, intra-operative practice and post-operative measures. It is suggested the checklist is initially used at the daily brief at the start of an operating list, as an aide-memoire for the team of the modifications that could be applied there and then. Once these practices become embedded into practice, then the checklist may be used less frequently. At present, some theatres will lack the infrastructure required to enact all the suggested interventions and so the checklist can serve as a roadmap for discussion with management, or at departmental meetings, to guide required changes. Finally, if completed regularly, the checklist could also be used as a scorecard to monitor progress.
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Content ArticleTraditional approaches to patient safety and handoffs need redesigning to acknowledge the different constraints, goals, and requirements necessary for each individual patient. There is no “one size fits all” approach to patient safety, handoffs or a perfect checklist. Despite the inherit complexity present in healthcare systems, we tend to reduce our thinking about handoffs into simple solutions of checklists and cognitive aids. In studies of these tools, their association with patient outcomes is unclear with mixed results in large studies. Incorporating general resilience engineering principles of visibility, understanding, anticipation, and learning provides new opportunities for increased patient safety. This involves situating the handoff in the context of the system - understanding the process of summarising pre-handoff and of developing understanding post-handoff, tracing flows of information and patients, and considering the role of feedback and control loops in the system. Direct observations, analysis of multiple outcomes, focus on patient evolving specific exceptions, reducing the number of handoffs, taking time for two-way discussions, and user-centred design and redesign may promote acceptability and sustainability of a new view of handoffs for improved patient safety.
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News ArticleEarly warning scores are used in the NHS to identify patients in acute care whose health is deteriorating, but medics say it could actually be putting people in danger. The rollout of an early warning system used in hospitals to identify patients at the greatest risk of dying is based on flawed evidence, according to a study published in the BMJ which suggests that much of the research supporting the rollout of NEWS was biased and overly reliant on scores that could put patients at greater risk.. Medical researchers said problems with NHS England's National Early Warning Scores (NEWS) system had emerged "frequently" in reports on avoidable deaths. The system sees each patient given an overall score based on a number of vital signs such as heart rate, oxygen levels, blood pressure and level of consciousness. Doctors and nurses can then prioritise patients with the most urgent NEWS scores. But some professionals have argued that the system has reduced nursing duties to a checklist of tasks rather than a process of providing overall clinical assessment. Professor Alison Leary, a fellow of the Royal College of Nursing and chair of healthcare and workforce modelling at London South Bank University, told The Independent: “In our analysis of prevention of future death reports from coroners, early warning scores and misunderstanding around their use feature frequently". “It's clear that some organisations use scoring systems and a more tick box approach to care as they lack the right amount of appropriately skilled staff, mostly registered nurses.” “Early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care,” the authors of the research conclude. “Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice.” Read full story Source: The Independent, 21 May 2020
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Content ArticleThe Patient Safety Database (PSD), previously called Anesthesia Safety Network, is committed in the delivery of better perioperative care. Its primary goal is to make visible the lack of reliability of healthcare and the absolute necessity to build a new system for improving patient safety. They have begun by developing an open and anonymous incident reporting system focused on non-technical skills. Each quarter they summarise in their newsletter cases reported on the platform. Read the latest newsletter.
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Content ArticleThis Joint Committee International handbook offers checklists for healthcare staff to keep themselves safe from chemical and physical hazards, infectious agents, workplace violence, ergonomic problems, work-related stress, and more. The book also includes managers’ checklists to ensure that the right administrative controls and processes are in place to safeguard health care staff. All checklists are based on authoritative, evidence-based sources that have proven valuable. All the checklists are straightforward and easy to use and understand and cover the key areas of risk for health care workers. Each section of checklists is introduced by compelling statistics that show how dangerous working in the healthcare environment can be, without proper precautions. The checklists provide the procedures or must-do activities to ensure that health care workers are as safe as can be.
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Content ArticleThe prevalence of facility-based childbirth in low-resource settings has increased dramatically during the past two decades, yet gaps in the quality of care persist and mortality remains high. The World Health Organization (WHO) Safe Childbirth Checklist, a quality-improvement tool, promotes systematic adherence to practices that have been associated with improved childbirth outcomes. This study, published in The New England Journal of Medicine, found that birth attendants’ adherence to essential birth practices was higher in facilities that used the coaching-based WHO Safe Childbirth Checklist program than in those that did not, but maternal and perinatal mortality and maternal morbidity did not differ significantly between the two groups.
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News Article
‘Dr. Checklist’ Peter Pronovost gets chance to transform University Hospitals
Patient Safety Learning posted a news article in News
The ghosts of medical errors haunt Dr. Peter Pronovost. Two deaths, both caused by mistakes. First, his father’s, who died as the result of a cancer misdiagnosis. Then a little girl, a burn victim who succumbed to infection and diagnostic missteps at the hospital where Pronovost worked early in his career. Those deaths led Pronovost to pursue a medical career dedicated to patient safety, and to create the medical checklist he has become known for worldwide. Now, he’s implementing his second act, at University Hospitals in the USA, as its Chief Transformation Officer, a job he has held since late 2018. His goal: To transform a $4 billion health care system by reducing shortcomings in medical care and increasing the quality of treatment. The challenge fits Pronovost, says one of his former Johns Hopkins University professors, Dr. Albert Wu. “He’s one of the few people for whom the title might be appropriate, because his work has led to significant changes and innovations in how we deliver health care in the United States. “He’s a once-in-a-generation guy.” Read full story Source: Cleveland.com, 9 February 2020 -
Content ArticleHaugen et al. studied the impact of the Norwegian National Patient Safety Campaign and Program on Surgical Safety Checklist (SSC) implementation and on safety culture. They found that the National Patient Safety Program, fostering engagement from trust boards, hospital managers and frontline operating theatre personnel enabled effective implementation of the SSC. As part of a wider strategic safety initiative, implementation of SSC coincided with an improved safety culture.
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Content Article
When a patient can’t breathe by themselves, healthcare staff may decide to intubate them to make it easier to get air into and out of the lungs. A tube goes down the throat and into the windpipe, and a machine called a ventilator pumps in air with extra oxygen. It can be life-saving, but life-threatening complications can also occur during a significant number of these procedures. Sam Goodhand is a registrar in the Sussex region, specialising in anaesthetics and intensive care medicine. In this interview for Patient Safety Learning he tells us how and why he developed an accessible checklist for staff involved in intubation processes. What are the safety challenges of intubation? Intubation is a highly committing procedure. After we induce anaesthesia, our patient stops breathing, and we must rapidly secure the airway and establish ventilation in order to maintain oxygen levels. If oxygen levels drop major organs are rapidly unable to function, in particular the heart, which will stop within minutes. Particularly for our critically ill patients, forward planning and communication are crucial. Anaesthetic drugs and mechanical ventilation are life-saving, but do come at an immediate cost to the overall stability of our patient, who may already be compromised. Environmental and human factors play a huge part in the safety and success of these interventions too, and are arguably easier to optimise beforehand. This involves making clear plans which we share with the whole team, good ergonomics of space and equipment, and just the right number of aide memoirs/checklists to make error harder to occur. It’s also about being aware of your own limitations and surroundings – being mindful of your own level of experience, tiredness, stress, and whether it’s the best time and place to do what you’re about to do. Can you tell us about the intubation safety checklist you developed? As a novice anaesthetist, I became aware that pre-procedure checklists for intubation weren’t always available. My training would emphasise their use, but often it was during highly pressured situations in the farthest corner of the hospital that the checklist was unavailable. The fear of forgetting an essential drug or piece of kit was very real. When, finally, I forgot to prepare a drug to maintain blood pressure during a remote intubation, I resolved to produce a solution for myself and my colleagues. It started with a home-printed sticker, which stuck to the ID card holder. My whole team loved it, so I proceeded to make a plastic card using the DAS emergency intubation guideline checklist. This way, it’s always on your person - avoiding a whole host of potential issues around availability and departmental (dis)agreement on a specific checklist. It seemed a no-brainer, but I’d never have believed there would now be 10,000 cards in circulation worldwide! What feedback have you had from staff who have used it? The feedback has been overwhelmingly positive. And it’s not just a tool for doctors – they’re really popular with Intensive Care and A&E nurses, and operating department practitioners. They can really help bring the team together in a shared mental approach before an intubation, and hopefully help bridge gaps in knowledge too. How can staff get hold of the checklist card? If you’re lucky, you might have grabbed one as a freebie at a DAS conference. A handful were also sent to every trust in the UK in 2019, funded by DAS. If you would like to order a pack of intubation checklist cards for your team, simply complete the attached form. What have you learnt personally in this quality improvement journey? A few things really stand out. Firstly, if you’re passionate about an idea and its potential to improve things, it shouldn’t feel like hard work. Secondly, a concept won’t succeed without the support of your colleagues, but I would caution against asking everybody’s opinion! This sounds controversial, but particularly as a more junior doctor, it can cause awkwardness to not include everybody’s ideas. Be persistent and don’t let your juniority hold you back – you may actually have a sharper eye for cracks in the system, which the familiarity of experience unconsciously bridges. You also need a bit of luck; I’m lucky to have worked in brilliantly supportive departments and to have had a couple of fortuitous introductions. You're now developing a paediatric version, can you tell us a bit more? After the success of the adult checklist card, a lot of people were asking about a version for emergency airway management in kids. I’ve now developed this with the support of my colleagues at The Alex Children’s Hospital in Brighton. Aside from the intubation checklist, I’ve tried to include elements which may not be second nature to paediatric non-specialists in a district general hospital, such as emergency drug dosing and airway kit sizing. Caring for a critically ill baby or child can be unsettling, but I hope this tool provides an extra layer of safety and confidence until definitive paediatric teams take over. You can use the attached form if you would like to order a pack of paediatric checklist cards. Do you have any other ideas up your sleeve for improving patient safety? I have a couple of ideas. I feel the way we store our equipment doesn’t always integrate with our meticulous approach to sick patients, or work well with the limitation of space in hospitals. So I’m working on something…watch this space! Do you have an idea to share with Patient Safety Learning? Have you designed a tool or process that has improved patient safety? Would you like to share your insights with others? Why not sign up to the hub today (for free) and use the 'share' function to tell us more. You can also contact us at [email protected]. By registering for the hub you'll be joining a global network of patients, staff, researchers, managers (and many more) who are passionate about patient safety. -
Content ArticleIn April 2009 a ‘considerative checklist’ was developed to ensure that all important aspects of care on a team's routine and post-take general internal medicine ward rounds had been addressed and in order to answer the question: How long should a ward round take, when conducted to high standards of quality and safety at the point of care? The checklist has been used on 120 ward rounds: 90 routine ward rounds and 30 post-take ward rounds. Overall, the average time per patient was 12 minutes (10 minutes on routine rounds and 14 minutes on post-take rounds). The considerative checklist has encouraged and enabled documented evidence of high quality and safe medical care, and anecdotally improved team working, communication with patients, and team and patient satisfaction.
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Content ArticleLecture from Dr Gordon Caldwell on ward rounds, covering quality, safety, personalising care and checklists.
