Development of a Safe Staffing App

"An ‘App’ was developed which is a simple, easy to use tool which allows managers and staff to see an accurate, live staffing position from ward to board.  The app is pre-programmed with agreed planned staffing for each shift for every ward. At handover the nurse in charge inputs actual staffing numbers and relevant information into the ward mobile device."

Development of a Safe Staffing App
Nottingham University Hospitals NHS Trust
NICE Shared learning example
April 2016

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Medication safety curriculum: enhancing skills and changing behaviors

"Students that participate in medication reconciliation/ optimization curricular activities are better prepared to critically assess medications for safety and efficacy in medical practice."

Medication safety curriculum: enhancing skills and changing behaviors
KD Karpa, LL Hom, P Huffman, EB Lehman, VM Chinchilli, P Haidet, SL Leong
BMC Medical Education (2015) 15:234

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Clinical guidance promoting safer medical care of patients detained under the Mental Health Act

"Through this project, we were able to identify defects in a system, provide needed guidance to enable safer and more equitable care to a vulnerable group, and foster closer collaboration between junior doctors and managers in the design and use of services."

How safe is our "place of safety"? Clinical guidance promoting safer medical care of patients detained under section 136 of the Mental Health Act
J Mouko, A Goddard, V Nimmo-Smith
BMJ Quality Improvement Reports 2015;4: doi:10.1136/bmjquality.u209141.w3721

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Do pneumonia readmissions flagged as potentially preventable by the 3M PPR software have more process of care problems?

"Among VA [Veterans Health Administration] pneumonia readmissions, PPR [Potentially Preventable Readmissions] categorisation did not produce the expected quality of care findings. Either PPR–yes cases are not more preventable, or preventability assessment requires other data collection methods to capture poorly documented processes (eg, direct observation)."

Do pneumonia readmissions flagged as potentially preventable by the 3M PPR software have more process of care problems? A cross-sectional observational study
AM Borzecki et al.
BMJ Quality and Safety 2015;24:753-763 doi:10.1136/bmjqs-2014-003911

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Continuous improvement of patient safety

"This report makes the case for changing the way patient safety is approached in the NHS. It argues that change is needed in: how safety is understood, because current approaches to measurement don’t provide the full picture; how safety is improved, because existing approaches alone will not address the most intractable problems; how risk is perceived, because comfort-seeking behaviours will not create a genuine culture of learning."

Published alongside the report is a safety improvement check list, as well as pointers to a host of other resources from the Health Foundation focused on assisting organisations in improving patient safety.

Continuous improvement of patient safety: The case for change in the NHS
J Illingworth
The Health Foundation
November 2015

Read more here.

Test result communication in primary care

"Our study has shown that the potential for error in the TRC [test result communication] process is large yet seemingly unrecognised in general practice. Staff have yet to introduce technological solutions with the result that the robustness of the system hinges on patients who may be unaware of their responsibility to retrieve results and in many cases act as the system fail-safe."

Test result communication in primary care: a survey of current practice
I Litchfield, L Bentham, R Lilford, RJ McManus, A Hill, S Greenfield
BMJ Quality and Safety 2015;24:691–699. doi:10.1136/bmjqs-2014-003712

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Perioperative dexamethasone administration in tonsillectomy patients

"Dexamethasone provides a low cost and relatively safe method to reduce post-operative complications in tonsillectomy patients. Despite this evidence, failure to administer dexamethasone still results in unplanned admissions, causing unnecessary costs to the National Heath Service"

Perioperative dexamethasone administration in tonsillectomy patients: A three-cycle audit showing improvement using printed theatre lists
S Bola, A Bartlett, R Williams
BMJ Quality Improvement Reports 2015;4: doi:10.1136/bmjquality.u208428.w3339

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Safer Wards: reducing violence on older people's mental health wards

"Through the Safer Wards project we aimed to reduce the number of incidents of physical violence on older people’s mental health wards."

Safer Wards: reducing violence on older people's mental health wards
J Brown et al.
BMJ Quality Improvement Reports 2015;4: doi:10.1136/bmjquality.u207447.w2977

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Fix and forget or fix and report

"We found that generally healthcare providers do not prioritise reporting if a safety problem is fixed. We argue that fixing and forgetting patient safety problems encountered may not serve patient safety as well as fixing and reporting. The latter approach aligns with recent calls for patient safety to be more preventive. We consider implications for practice."

Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting
TA Hewitt, S Chreim, A Forster, S Vanderloo, C Backman
BMJ Quality and Safety 2015;24:303-310 doi:10.1136/bmjqs-2014-003279

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Improving the Quality of Assessment and Management of Hypoglycaemia in Hospitalised Patients with Diabetes Mellitus

"We demonstrated that the introduction of ‘Hypo Boxes’ to diabetes wards significantly improved the assessment and management of episodes of hypoglycaemia. The appropriateness of treatment and the time to correction improved, and ultimately this aims to improve patient outcomes, something which can be adversely affected by hypoglycaemia."

Improving the Quality of Assessment and Management of Hypoglycaemia in Hospitalised Patients with Diabetes Mellitus by Introducing 'Hypo Boxes' to General Medical Wards with a Specialist Interest in Diabetes
R Livingstone, J Boyle
BMJ Quality Improvement Reports 2015;4: doi:10.1136/bmjquality.u207686.w3067

Read more here.

The IDEAL Collaboration

"The IDEAL Collaboration is an initiative to improve the quality of research in surgery... IDEAL is a set of recommendations for the evidence-based practice of surgery. It is geared towards participants in all stages of gathering and using evidence for the ultimate goal of improving outcomes for patients."

Find out more here.

Using a theory of planned behaviour framework to explore hand hygiene beliefs

"Improving hand hygiene among health care workers (HCWs) is the single most effective intervention to reduce health care associated infections in hospitals. Understanding the cognitive determinants of hand hygiene decisions for HCWs with the greatest patient contact (nurses) is essential to improve compliance."

Using a theory of planned behaviour framework to explore hand hygiene beliefs at the ‘5 critical moments’ among Australian hospital-based nurses

KM White et al.
BMC Health Services Research 2015, 15:59  doi:10.1186/s12913-015-0718-2

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Patient handover in orthopaedics, improving safety using Information Technology

"Following the merger of two orthopaedic departments into a single service in a new hospital, it was felt that a number of safety issues within the handover process needed to be addressed. This quality improvement project addressed these issues through the creation and implementation of a new patient database which spanned the department, allowing trouble free, safe, and comprehensive handover."

Patient handover in orthopaedics, improving safety using Information Technology
T Pearkes
BMJ Quality Improvement Reports 2015;4: doi:10.1136/bmjquality.u207329.w2939

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The endoscopy safety checklist

"We conclude that use of the endoscopy safety checklist is an opportunity for cost-effective quality improvement in endoscopy services. On-going attention needs to be given to encourage routine uptake of the checklist for its true potential on safety and outcomes to be realised."

The endoscopy safety checklist: A longitudinal study of factors affecting compliance in a tertiary referral centre within the United Kingdom
M Matharoo et al.
BMJ Quality Improvement Reports 2015;4: doi:10.1136/bmjquality.u206344.w2567

Read more here.

Out of hours intravenous fluid therapy

"Recent NICE guidance has highlighted the importance of appropriate and safe intravenous fluid use. We aimed to improve the quality of out of hours fluid prescription in a Bristol hospital by ensuring that indications and cautions for fluid therapy were clearly documented at the time of initiation."

Out of hours intravenous fluid therapy: a prompt to guide prescribing
J Fehmi et al.
BMJ Quality Improvement Reports 2015;4: doi:10.1136/bmjquality.u204010.w3139

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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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Exploring patterns of error in acute care using framework analysis

"In order to improve the management of acutely unwell patients by junior doctors, medical educators must understand the causes of common errors. Adequate knowledge alone does not ensure prompt and appropriate management and referral."

Exploring patterns of error in acute care using framework analysis
VR Tallentire, SE Smith, J Skinner, HS Cameron
BMC Medical Education 2015, 15:3 doi:10.1186/s12909-015-0285-6

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Adverse events in patients with return emergency department visits

"We recently implemented an electronic system enabling automated detection, investigation and statistical analysis of Emergency Department return visits. The objectives of this study were to determine what proportion of triggered return ED visits represented adverse events and what patient and visit factors predicted these adverse events"

Adverse events in patients with return emergency department visits
L Calder, A Pozgay, S Riff, D Rothwell, E Youngson, N Mojaverian, A Cwinn, A Forster
BMJ Quality and Safety 2015;24:142-148 doi:10.1136/bmjqs-2014-003194

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Finding patients before they crash: the next major opportunity to improve patient safety

"We believe that the coming together of four major trends or innovations promises substantial improvements to patient outcomes by preventing this perennial problem of delayed recognition and management of deteriorating patients on general hospital wards."

Finding patients before they crash: the next major opportunity to improve patient safety
DW Bates, E Zimlichman
BMJ Quality and Safety 2015;24:1-3 doi:10.1136/bmjqs-2014-003499

Read more here.

Safer Clinical Systems: evaluation findings

"Safer Clinical Systems is an approach for improving safe and reliable health care. It is based on principles adapted from high-reliability organisations, established risk management techniques from hazardous industries, and quality improvement methods."

Safer Clinical Systems: evaluation findings
M Dixon-Woods et al.
The Health Foundation
December 2014

Read more here.