National Diabetes Inpatient Audit 2013 national summary

"The National Diabetes Inpatient Audit is a snapshot audit of diabetes inpatient care in England and Wales. The audit is set out to answer the following questions:

• Did diabetes management minimise the risk of avoidable complications?
• Did harm result from the inpatient stay?
• Was patient experience of the inpatient stay favourable?
• Has the quality of care and patient feedback changed...?"

National Diabetes Inpatient Audit 2013 national summary

Health and Social Care Information Centre

2014

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Hard truths: essential actions

"The focus on measuring safety is welcome, but measures should be developed to assess the future risk of harm, not just the occurrence of past harm."

Hard truths: essential actions
The Health Foundation
December 2013

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Development of a framework to estimate the cost of opioid dependence

"This report sets out the findings of a targeted review of the harms of opioid dependence, and an assessment of the existing estimates of the costs of opioid dependence."

Development of a framework to estimate the cost of opioid dependence
E Disley, A Mulcahy, M Pardal, J Rubin, K Ruggeri
RAND Europe, prepared for Reckitt Benckiser Pharmaceuticals
November 2013

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Measuring and monitoring safety: a primary care perspective

"This thought paper considers the differences between primary care and other settings and explains that a variety of factors mean that assessing harm and safety in primary care remains a challenge."

Measuring and monitoring safety: a primary care perspective
A Esmail
The Health Foundation
October 2013

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Asymmetry of influence: the role of regulators in patient safety

"By working together to create conditions which promote engagement with professional responsibility and identity, regulators can create a consistent regulatory system within which safe care can flourish."

Asymmetry of influence: the role of regulators in patient safety
D Bilton, H Cayton
The Health Foundation
October 2013

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Measuring harm

"This was the third in a series of roundtable discussions looking at potential future improvements in patient
safety involving a broad approach which:

• incorporates greater involvement of patients and citizens in their own safety and the safer design of services
• measures and monitors the multiple dimensions that make up a safety culture
• develops ‘leading’ (before the event) as well as ‘lagging’ (after the event) performance measures to more 
• accurately assess the current experience of people using healthcare services."

Measuring harm: a summary of learning from a Health Foundation roundtable
The Health Foundation
October 2013

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Retrospective record review in proactive patient safety work

"By adding a retrospective record review of randomly selected records to conventional incident-reporting, health care providers can gain a clearer and broader picture of commonly occurring, no-harm incidents in order to improve patient safety."

Retrospective record review in proactive patient safety work: identification of no-harm incidents
K Schildmeijer, M Unbeck, O Muren, J Perk, K Pukk Harenstam, L Nilsson
BMC Health Services Research, 2013, 13:282

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Nursing a safer future

"Nurses are well placed to make care safer and are doing impressive work to improve the safety of their patients."

Nursing a safer future: how nurses are using proactive approaches to manage patient safety
Health Foundation, Nursing Times
July 2013

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SAFER communication guidelines

"These are guidelines for communications between health visitors and local authority children’s social care teams using the SAFER process when a child may be suffering or is likely to suffer significant harm."

SAFER communication guidelines
Department of Health
June 2013

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The measurement and monitoring of safety

"The aim of this report is to provide a framework and approach to measuring and monitoring safety in all relevant dimensions and facets. The report is based on review of safety literature, enquiries into safety practice in other industries, case studies of organisations, and discussions and interviews with a wide variety of people."

The measurement and monitoring of safety
C Vincent, S Burnett, J Carthey
The Health Foundation
April 2013

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Lining up: how is harm measured?

"Lessons from an ethnographic research study of interventions to reduce central line infections."

Learning report: Lining up: how is harm measured?
The Health Foundation
February 2013

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Lining up: how is harm measured?

"Lessons from an ethnographic research study of interventions to reduce central line infections."

Lining up: how is harm measured? Learning report
The Health Foundation
February 2013

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Delivering the NHS Safety Thermometer CQUIN 2013/14

"The data from the NHS Safety Thermometer is powerful because it allows us, over time, to establish a baseline against which we can track improvement."

Delivering the NHS Safety Thermometer CQUIN 2013/14
NHS Harm Free Care
December 2012

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A comprehensive model to reduce harm and save lives

"From 2008 through 2011, a 31% reduction in harm events and an 18% reduction in inpatient mortality occurred systemwide."

The Henry Ford Health System No Harm Campaign: A comprehensive model to reduce harm and save lives
WA Conway, S Hawkins, J Jordan, MJ Voutt-Goos
The Joint Commission Journal of Quality and Patient Safety, 2012, 38(7)

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Communicating risk

"The communication of risk is an important and often difficult aspect of clinical practice. This clinical review aims to provide practising clinicians with a comprehensive and up to date overview of current evidence in this developing area."

Communicating risk
H Ahmed, G Naik, H Willoughby, AGK Edwards
British Medical Journal, 2012, 344:e3996

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Deciphering harm measurement

"Improvement in health care quality and safety can be notable when measurement criteria are clear, evidence is strong, and policy and interventions are focused."

Deciphering harm measurement
G Parry, A Cline, D Goldmann
Journal of the American Medical Association, 2012, 307(2):2155-2156

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Levels of harm in primary care

"This research scan found that about 1–2% of primary care consultations may include adverse events, with the most common errors relating to medication and communication."


Evidence scan: levels of harm in primary care
The Health Foundation
November 2011

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High-value, cost-conscious health care

"This article discusses 3 key concepts for understanding how to assess the value of health care interventions."

High-value, cost-conscious health care: concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions
DK Owens, A Qaseem, R Chou, P Shekelle
Annals of Internal Medicine, 2011, 154(6):174-180

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