NHS Safety Thermometer: Patient Harms and Harm Free Care

"The NHS Safety Thermometer is the measurement tool for a programme of work to support patient safety improvement. It is used to record patient harms at the frontline, and to provide immediate information and analyses for frontline teams to monitor their performance in delivering harm free care."

NHS Safety Thermometer: Patient Harms and Harm Free Care England November 2014 November 2015, official statistics 
Clinical Audit Support Unit
Health & Social Care Information Centre

December 2015

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How-to Guide: Prevent Catheter-Associated Urinary Tract Infection

"This How-to Guide describes key evidence-based care components for preventing catheter-associated urinary tract infections, describes how to implement these interventions, and recommends measures to gauge improvement."

How-to Guide: Prevent Catheter-Associated Urinary Tract Infection
Institute for Healthcare Improvement
2011

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Reducing hospital acquired pressure ulcers in intensive care

"The measures or changes to practice used to reduce hospital acquired pressure ulcers in the intensive care department achieved their goal and incidences of hospital acquired pressure ulcers decreased."

Reducing hospital acquired pressure ulcers in intensive care
E Cullen Gill
BMJ Quality Improvement Reports 2015;4: doi:10.1136/bmjquality.u205599.w3015

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Implementation of a ward round pro-forma to improve adherence to best practice guidelines

"This study has two main aims. Firstly, to measure the adherence to specific best practice guidelines for the prevention hospital acquired causes of mortality and morbidity (HACMMs) by doctors on a medical assessment unit in regional teaching hospital. Secondly, to measure the effectiveness of the study’s interventional checklist (the ward round pro-forma) on rates of adherence to best practice guidelines."

Implementation of a ward round pro-forma to improve adherence to best practice guidelines
X Boland
BMJ Quality Improvement Reports 2015;4: doi:10.1136/bmjquality.u207456.w2979

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Pressure ulcers: NICE clinical audit tools

NICE have published two clinical audit tools for pressure ulcer prevention, one for paediatric care and one for adults.

"Clinical audit tools are Excel spreadsheets developed to help with clinical audit. They contain clinical audit standards, data collection sheets, a clinical audit report an action plan template and a printable data collection form.  When data is entered into the data collection sheets the audit results are automatically displayed in the audit report."

Access the tools and find out more here.

Identifying systems failures in the pathway to a catastrophic event

"We identified areas of concern even within the context of a highly controlled standardised national process. If incident reporting systems include and encourage reports of no-harm incidents in addition to actual patient harm, they can facilitate monitoring the resilience of healthcare processes. Patient safety incidents that produce the most serious harm are often rare, and it is difficult to know whether patients are adequately protected. Our approach provides a potential solution."

Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids
BD Franklin, SS Panesar, C Vincent, LJ Donaldson
BMJ Quality and Safety, 2014;23:765-772

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Professional standards for homecare services in England

"The Royal Pharmaceutical Society Professional Standards for Homecare Services in England aims to ensure that patients experience a consistent quality of homecare services that will protect them from incidences of avoidable harm and help them to get the best outcomes from their medicines"

Handbook for homecare services in England: professional standards
Royal Pharmaceutical Society
May 2014

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A framework for measuring and monitoring safety

"The measurement of past harm will always be a cornerstone to understanding safety. Measures need to be specific and tracked over time to help to assess whether care in a particular area, and overall, is becoming safer."

A framework for measuring and monitoring safety: A practical guide to using a new framework for measuring and monitoring safety in the NHS

The Health Foundation

April 2014

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Positive and Proactive Care: reducing the need for restrictive interventions

"Rigorous governance is needed to ensure that positive and proactive care is the main approach within services to reduce excessive reliance on restrictive interventions and to ensure that if they are used, it is only ever as a last resort, and they are undertaken in a proportionate and least restrictive way."

Positive and proactive care: reducing the need for restrictive interventions
Social Care, Local Government and Care Partnership Directorate
Department of Health
April 2014

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Reducing harm to patients

"This briefing follows a March 2014 speech by the Secretary of State for Health at Virginia Mason Medical Center in Seattle. In his speech, Jeremy Hunt MP set out a new ambition to reduce avoidable harm to patients in the NHS."

Briefing: Reducing harm to patients
The Health Foundation
March 2014

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Strategies to prevent catheter-associated urinary tract infection

"Urinary catheter reminders and stop orders appear to reduce catheter-associated urinary tract infection rates and should be used to improve patient safety. Several evidence-based guidelines have evaluated CAUTI preventive strategies as well as emerging evidence regarding intervention bundles. Implementation strategies are important because reducing urinary catheter use involves changing well-established habits."

Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review
J Meddings, MAM Rogers, SL Krein, MG Fakih, RN Olmsted, S Saint
BMJ Quality and Safety, 2014, 23 (4) 277–289

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Innovations in prevention

"There is a need for preventative investment to be more strategic, moving from a part of service delivery, to an explicit, deliberate and integral part of the policymaking and commissioning process, to identify where harm can be prevented and cost savings realised."

Innovations in prevention
R Puttick
NESTA
October 2012

Read more here.