Reducing inpatient falls in a 100% single room elderly care environment

"The nurse training programme on falls risk assessment has improved nurse knowledge of falls risk and actual completion of Falls Risk Assessments. This is especially in areas of cognition, environmental hazard, osteoporosis risk. The collaborative quality improvement work has led to a reduction of inpatient falls by 34% in a high-risk 100% single room environment." 

Reducing inpatient falls in a 100% single room elderly care environment: evaluation of the impact of a systematic nurse training programme on falls risk assessment (FRA)
I Singh, J Okeke
BMJ Quality Improvement Reports 2016;5: doi:10.1136/bmjquality.u210921.w4741

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Patients and families as teachers: a collaborative learning model for medical error disclosure and prevention

"An educational paradigm that includes patients as teachers and collaborative learners with clinicians in patient safety is feasible, valued by clinicians and P/F and promising for P/F-centred medical error disclosure and prevention training."

Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention
T Langer, W Martinez, DM Browning, P Varrin, B Sarnoff Lee, SK Bell
BMJ Quality and Safety 2016;25:615-625 doi:10.1136/bmjqs-2015-004292

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How safe is primary care?

"Improving patient safety is at the forefront of policy and practice. While considerable progress has been made in understanding the frequency, causes and consequences of error in hospitals, less is known about the safety of primary care."

How safe is primary care? A systematic review
S Singh Panesar et al.
BMJ Qual Saf 2016;25:544-553 doi:10.1136/bmjqs-2015-004178

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Methods for Reducing Sepsis Mortality in Emergency Departments and Inpatient Units

"In 2011, North Shore-LIJ Health System (now Northwell Health) launched a strategic partnership with the Institute for Healthcare Improvement to accelerate the pace of sepsis improvement, focusing initially on sepsis recognition and treatment in emergency departments (EDs). The health system reduced overall sepsis mortality by approximately 50 percent in a six-year period (2008-2013; sustained through 2014) "

Methods for Reducing Sepsis Mortality in Emergency Departments and Inpatient Units
ME Doerfler  et al.
Joint Commission Journal on Quality and Patient Safety. 2015 May;41(5):205-211.

Read more here (registration required).

Impact of the DoH Commissioning for Quality and Innovation incentive on the success of venous thromboembolism risk assessment

"We achieved 95% RA [Risk Assessment] compliance which has favourably impacted on our daily practice and improved the quality of the clinical care."
The impact of the DoH Commissioning for Quality and Innovation incentive on the success of venous thromboembolism risk assessment in hospitalised patients. 
A Shlebak, P Sandhu, V Ali, G Jones, C Baker
Journal of the Royal Society of Medicine Open June 2016 vol. 7 no. 6 2054270416632702

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Succeeding in Sustained Reduction in the use of Restraint using the Improvement Model

"As part of the Scottish Patient Safety Programme – Mental Health one of the main drivers was the reduction of harm to patients caused by restraint. The aim of this project was to reduce the number of restraints on our Acute Admissions ward."

Succeeding in Sustained Reduction in the use of Restraint using the Improvement Model
A Bell, N Gallacher
BMJ Quality Improvement Reports 2016;5: doi:10.1136/bmjquality.u211050.w4430

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Half-life of a printed handoff document

"In this report, we identify a very high potential for inaccurate information in printed handoff documents. If a handoff document is printed at the start of a night shift, it is reasonable to assume that within 6 h the document will contain inaccuracies on half of the patients. The field most likely to contain inaccuracies is the medication lists, followed by code status."

Half-life of a printed handoff document

G Rosenbluth, R Jacolbia, D Milev, AD Auerbach

BMJ Quality and Safety, 2016;25:324-328 doi:10.1136/bmjqs-2015-004585

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Developing and evaluating oncology trainee education around minimization of adverse events and improved patient quality and safety

"Our study demonstrates that an online game is well accepted by junior doctors as a method to increase their quality improvement awareness. Developing effective and sustainable training for doctors is important to ensure positive patient outcomes are maintained in the hospital setting."

A mixed methods approach to developing and evaluating oncology trainee education around minimization of adverse events and improved patient quality and safety
A Janssen et al.
BMC Medical Education, 2016 16:91, DOI: 10.1186/s12909-016-0609-1  J

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The use of a pro forma to improve quality in clerking vascular surgery patients

"We found that using a pro forma helped to aid junior doctors in clerking new patients, and significantly improved the quality of their history and examinations. This leads to a potential positive impact on patient safety during their inpatient stay, and should be rolled out more widely across the hospital."

The use of a pro forma to improve quality in clerking vascular surgery patients
J Kentley, A Fox, S Taylor, Y Hassan, A Filipek
BMJ Quality Improvement Reports 2016;5: doi:10.1136/bmjquality.u210642.w4280

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Eliminating guidewire retention during ultrasound guided central venous catheter insertion

"A multi-modal structured training program, integrated with a modified, pre-packed CVC set, and drapes with reminder stickers (all included in CVC PLUS) were cost effective, and improved patient safety by eliminating guidewire retention during CVC insertion."

Eliminating guidewire retention during ultrasound guided central venous catheter insertion via an educational program, a modified CVC set, and a drape with reminder stickers
WM Peh, WJ Loh, GC Phua, CM Loo
BMJ Quality Improvement Reports 2016;5: doi:10.1136/bmjquality.u209550.w3941

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Characteristics of morbidity and mortality conferences associated with the implementation of patient safety improvement initiatives

"This study suggests that the implementation of improvement initiatives relates to MCC [Morbidity and mortality conferences] characteristics. Recommendations for developing more effective patient safety-oriented MMCs can be proposed."

Characteristics of morbidity and mortality conferences associated with the implementation of patient safety improvement initiatives, an observational study
P François, F Prate, G Vidal-Trecan, JF Quaranta, J Labarere, E Sellier
BMC Health Services Research, 2016, 16:35 DOI: 10.1186/s12913-016-1279-8

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A quality improvement project to tackle under-reporting of hazards by doctors by using an anonymous telephone hotline

"The trial of the reporting answerphone demonstrated that if reporting was made easier, quicker and anonymous then reporting rates increased exponentially."

A quality improvement project to tackle under-reporting of hazards by doctors by using an anonymous telephone hotline
S Johnson
BMJ Quality Improvement Reports 2016;5: doi:10.1136/bmjquality.u208718.w3660

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Anticipatory management communication in end-of-shift medicine and nursing handoffs

"The different frequencies for types of AMC likely reflect differences in how residents and nurses work and disparate professional cultures. But, verbal communication in both groups included important information unlikely to be captured in written handoff tools or the electronic medical record, underscoring the importance of direct communication to ensure safe handoffs."

“Mr Smith's been our problem child today…”: anticipatory management communication (AMC) in VA end-of-shift medicine and nursing handoffs
AA Bergman, ME Flanagan, PR Ebright, CM O'Brien, RM Franke
BMJ Quality and Safety 2016;25:84-91 doi:10.1136/bmjqs-2014-003694

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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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The Health Foundation: November Research Scan

The Health Foundation have released their November research scan summarising the latest research of interest to those working in healthcare quality improvement. The scan covers the themes of person-centred care, patient safety, value for money and improvement approaches.

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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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.

Improving the Quality of Weekend Medical Handover at a London Teaching Hospital

"A new weekend handover pro forma modelled on RCP guidance can improve the quality of information provided to the weekend team. This can help the on-call team to manage the weekend more effectively and safely. A Friday WR [ward round] sheet can also improve the availability of thorough patient summaries in the notes in the event that someone needs to be reviewed unexpectedly over the weekend."

"Chase CRP", "Review patient": Improving the Quality of Weekend Medical Handover at a London Teaching Hospital
A Saifuddin, L Magee, R Barrett
BMJ Quality Improvement Reports 2015;4: doi:10.1136/bmjquality.u201656.w1919

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A patient-initiated voluntary online survey of adverse medical events

"This large voluntary survey of medical harm highlights the potential efficacy of patient-initiated surveys for providing meaningful feedback and for guiding improvements in patient care."

A patient-initiated voluntary online survey of adverse medical events: the perspective of 696 injured patients and families
FS Southwick, NM Cranley, JA Hallisy
BMJ Quality and Safety 2015;24:620-629 doi:10.1136/bmjqs-2015-003980

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Improving the efficacy of elderly patients' hospital discharge

"After several months of sustained effort, the average time to complete eDANs fell by over an hour resulting in discharge medication dispensed earlier in the day and improved patient safety."

Improving the efficacy of elderly patients' hospital discharge through multi-professional safety briefings and behavioural change
J Corrado, K Topley, A Cracknell
BMJ Quality Improvement Reports 2015;4: doi:10.1136/bmjquality.u209431.w3871

Read more here.