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Found 56 results
  1. Content Article
    The data included in the review identified that 10% of patients experience a PSI in prehospital care. The review also provides more detailed insights into the prevalence of PSIs and associated harm in prehospital care, and the authors argue that this evidence justifies giving the same level of attention to patient safety in prehospital care as is given to secondary care. They also state that the review gives direction as to how to advance methods for identifying PSIs and harm in prehospital care.
  2. Content Article
    This review examined 21 sets of data on skin lesions, including more than 100,000 images. The findings of the review highlighted that many of the datasets were missing important information, such as how images were chosen to be included and evidence of ethical approval or patient consent. 14 of 21 datasets gave information on which country they came from and, of those, nine contained images from European countries. The review notes that only a small percentage of images were accompanied by information about the patients’ skin colour or ethnicity. Among pictures where skin colour was
  3. News Article
    The latest edition of the Wolters Kluwer Journal of Patient Safety has just been published. Original studies include: Is There a Mismatch Between the Perspectives of Patients and Regulators on Healthcare Quality? A Survey Study The Ideal Hospital Discharge Summary: A Survey of U.S. Physicians Impact of an Original Methodological Tool on the Identification of Corrective and Preventive Actions After Root Cause Analysis of Adverse Events in Health Care Facilities: Results of a Randomized Controlled Trial Detach Yourself: The Positive Effect of Psychological Detachme
  4. Content Article
    Burke et al. carried out a systematic review. All studies that explored an intervention to improve failure to rescue in the adult population were considered. They found that complications occur consistently within healthcare organisations and organisations vary in their ability to manage such events. Failure to rescue is a measure of institutional competence in this context. The authors propose “The 3 Rs of Failure to Rescue” of recognise, relay and react, and hope that this serves as a valuable framework for understanding the phases where failure of patient salvage may occur. Future effo
  5. Content Article
    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 exper
  6. Content Article
    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.
  7. Content Article
    Key findings Local reporting on complaints is inconsistent and inaccessible. Staff are not empowered to communicate with the public on complaints. Reporting focuses on counting complaints, not demonstrating learning.
  8. Content Article
    This thematic review presents a detailed analysis of claims made after an individual has attempted to take their life.Claims relating to completed suicide and attempted suicide are reviewed, regardless of whether the claim resulted in financial compensation. It identifies common problems with care and provides recommendations for improvement to support service delivery. Results The results are split into two parts. The first part analyses the problems identified from the clinical details of each claim and the second part analyses the quality of the serious incident reports. Part
  9. Content Article
    Key messages Medication errors (MEs) are common and persistent problems that may pose significant risk to critically ill children admitted to paediatric and neonatal intensive care units. Prescribing and medication administration errors were the common types of MEs and dosing errors were the most frequent ME subtype in both paediatric and neonatal intensive care unit settings. Anti-infective medications were the commonly reported drug class associated with MEs/preventable adverse drug events across both intensive care unit types. Further research is needed to examine me
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