The role of the patient in clinical safety

"Staff have to acknowledge the worth of patients’ safety knowledge, their unique contribution, and, where necessary, the need to respond with action."

The role of the patient in clinical safety
R Lawton, G Armitage
The Health Foundation
May 2012

Read more here.

How can leaders influence a safety culture?

"The systematic delivery of safe and reliable care requires a safety culture, continuous learning, and improvement."

How can leaders influence a safety culture?
M Leonard, A Frankel
The Health Foundation
May 2012

Read more here.

A preliminary guide to measuring 'harm free' care

"This guide is designed to provide support in implementing the NHS Safety Thermometer and achieving the 2012/13 CQUIN. It shares learning about the best ways to use the tool and what support is available. It offers technical support in validating data and enables readers to start to understand their data."

Delivering the NHS Safety Thermometer CQUIN 2012/13: a preliminary guide to measuring 'harm free' care
QIPP Safe Care Team
Department of Health
May 2012

Read more here.

Helping hospitals deliver better care: a new toolkit for quality improvement

"The Agency for Healthcare Research and Quality (AHRQ) contracted with a team of researchers from RAND and the University HealthSystem Consortium (UHC), a large collection of academic medical centers, to develop a toolkit for hospitals to support their quality improvement efforts based on the AHRQ quality indicators."

Helping hospitals deliver better care: a new toolkit for quality improvement
RAND Health
May 2012

Read more here.

Access the toolkit here.

International perspectives on patient engagement

"Across countries,engaged patients reported receiving higher-quality care, fewer errors, and more positive views of the health system."

International perspectives on patient engagement: results from the 2011 Commonwealth Fund Survey
R Osborn, D Squires
Journal of Ambulatory Care Management, 2012, 35(2):118-128

Read more here.

Reducing prescribing errors

"The scan provides a rapid collation of empirical research about initiatives to reduce prescribing errors."

Evidence scan: reducing prescribing errors
Health Foundation
March 2012

Read more here.

Infection: prevention and control of healthcare-associated infections in primary and community care

"Patient safety has become a cornerstone of care, and preventing healthcare-associated infections remains a priority."

Infection: prevention and control of healthcare-associated infections in primary and community care
NICE clinical guideline 139
March 2012

Read more here.

Self-management of diabetes in hospital

"The aim of the document is to improve the safety of the in hospital management of diabetes."

Self-management of diabetes in hospital
Joint British Diabetes Societies for Inpatient Care Group
March 2012

Read more here.

Patient safety, satisfaction, and quality of hospital care

"Improvement of hospital work environments might be a relatively low cost strategy to improve safety and quality in hospital care and to increase patient satisfaction."

Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States
LH Aiken, et al
British Medical Journal, 2012, 344:e1717

Read more here.

Updated guidance on the diagnosis and reporting of Clostridium Difficile

"This revised guidance to healthcare providers identifies which two types of tests, which when used in combination, will deliver the most accurate results for C. difficile infection testing."

Updated guidance on the diagnosis and reporting of Clostridium Difficile
Department of Health
March 2012

Read more here.

Review of the evidence on falls prevention in hospitals

"To facilitate the development of a hospital falls prevention resource guide, we systematically reviewed and documented the existing evidence base for interventions to prevent falls in hospitals, provided an overview of the performance of existing tools with known measurement properties, and compiled available online resources."

Review of the evidence on falls prevention in hospitals: task 4 final report
S Hempel, S Newberry, Z Wang, PG Shekelle, R Shanman, B Johnsen, T Perry, D Saliba, DA Ganz
February 2012

Read more here.

'Harm free' care

This initiative is the national roll out of the pilot Safety Express QIPP programme. 'Harm free' care is defined by the absence of pressure ulcers, falls, urinary catheters, and venous thromboembolism, and this collection of resources and case studies has been developed to reduce these incidents.

Find out more and access all the resources here.

eLearning resources to improve patient care

The NHS Institute for Innovation and Improvement has formed a joint venture with Virtual College to develop the Productives e-learning suite. This suite is designed for staff, team leaders, programme managers and leaders to help them use The Productive Series: Releasing Time to Care (TM) programme. Read more here.

eLearning for Healthcare has developed "e-learning for Harm Free Care", an online educational resource designed to support frontline teams in delivering harm free care, as defined by an absence of four common harms: pressure ulcers, harm from falls, catheter acquired urinary tract infections (CaUTI) and venous thromboembolism (VTE).

Find out more here.

Health IT and patient safety

"Health IT is playing an ever-larger role in the care of patients, and some components of health IT have significantly improved the quality of health care and reduced medical errors."

Health IT and patient safety: building safer systems for better care
Institute of Medicine of the National Academies
National Academies Press
February 2012

Read more here - free registration required to download the PDF version of this document.

Raising and acting on concerns about patient safety

"This guidance sets out our expectation that all doctors will, whatever their role, take appropriate action to raise and act on concerns about patient care, dignity and safety."

Raising and acting on concerns about patient safety
General Medical Council
January 2012

Read more here.

Maturity of hospitals’ quality improvement systems is associated with measures of quality and patient safety

"From this data it seems that having a more developed quality improvement system is associated with lower rates of adjusted hospital complications."


Is the maturity of hospitals’ quality improvement systems associated with measures of quality and patient safety?
O Groene, N Mora, A Thompson, M Saez, M Casas, R Sunol
BMC Health Services Research, 2011, 11:344

Read more here.

Improving hand-washing practices by changing practice

This newspaper article highlights the findings of a forthcoming study into hand-washing practices in America, and shows how a simple change in signage can improve practice.

Getting doctors to wash their hands
A O'Connor
New York Times
1st September 2011

Read more here.


Original study:
It's not all about me: motivating hand hygiene among health care professionals by focusing on patients
AM Grant, DA Hofmann
Psychological Science, 2011, November 10th

Read the abstract here.

Eliminating central line infections

"This report synthesizes lessons from four hospitals that reported they did not experience any central line-associated bloodstream infections (CLABSI) in their intensive care units in 2009."

Eliminating central line infections and spreading success at high-performing hospitals
S Silow-Carroll, JN Edwards
The Commonwealth Fund
December 2011

Read more here.

EHR-based care coordination performance measures in ambulatory care

"Good coordination of care in the ambulatory setting has the potential to reduce unnecessary or duplicative use of health services, prevent hospitalizations for ambulatory care–sensitive conditions, improve patient safety, and potentially reduce costs."

EHR-based care coordination performance measures in ambulatory care
KS Chan, JP Weiner, SH Scholle, JB Fowles, J Holzer, L Samal, P Renner
The Commonwealth Fund
November 2011

Read the issue brief and the technical report.

Quality improvement guide: prevention and control of healthcare-associated infections

"The guide offers advice on management or organisational actions to prevent and control."

Quality improvement guide: prevention and control of healthcare-associated infections
National Institute for Health and Clinical Excellence
November 2011

Read more here.

Scroll to "Key documents" to read the full text, and access related material, such as a costing template and a topic briefing paper.