Putting patients first - the Productive Series

"All of the examples here are real-life improvement initiatives at various stages of development and implementation during 2011."

Putting patients first - the Productive Series
NHS Institute for Innovation and Improvement
March 2012

Read more here.

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

Read more here.

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.

Personal accountability in healthcare: searching for the right balance

"In this thought paper, Professor Robert Wachter explores the issue of personal accountability in healthcare and describes how accountability for performance is a key element for a safe system."

Personal accountability in healthcare: searching for the right balance
R Wachter
The Health Foundation
May 2012

Read more here.

Proactive approaches to safety management

This paper offers some practical suggestions for proactively managing safety.

Proactive approaches to safety management
E Hollnagel
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.

National Diabetes Inpatient Audit 2011

"This year’s audit has demonstrated progress in several areas but also reveals that there is considerably more to be done if the safety and care of people with diabetes in hospital is to be assured."

National Diabetes Inpatient Audit 2011
Healthcare Quality Improvement Partnership, NHS The Information Centre, Diabetes UK
May 2012

Read more here.

Investigating the prevalence and causes of prescribing errors in general practice

"Strategies for reducing the prevalence of error should focus on GP training, continuing professional development for GPs, clinical governance, effective use of clinical computer systems, and improving safety systems within general practices and at the interface with secondary care."

Investigating the prevalence and causes of prescribing errors in general practice: the PRACtICe Study (PRevalence And Causes of prescrIbing errors in general practiCe): a report for the GMC
General Medical Council
May 2012

Read more here.

NICE guideline update: Infection control in primary and community care

"This clinical guideline (published March 2012) updates and replaces NICE clinical guideline 2 (published June 2003)."

Infection: prevention and control of healthcare-associated infections in primary and community care: CG139
National Institute for Health and Clinical Excellence (NICE)
March 2012

Read more here.

Health care leader action guide to effectively using HCAHPS

"HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems data) is a tool that can be used to help organizations improve the patient experience, and may have a related effect on clinical quality."

Health care leader action guide to effectively using HCAHPS
Health Research and Educational Trust
March 2012

Read more here.

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

Read more here.

Improving safety in maternity services

Improving safety in maternity services: a toolkit for teams, has been developed by Vinice Thomas and Anna Dixon at The King's Fund, and is organised around five key areas for improvement in maternity care on which the teams focused:

• teamworking
• communication
• training
• information and guidance
• staffing and leadership

'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.

Effectiveness and safety of emergency department short stay units

"Limited evidence from 1 systematic review indicates that SSUs may lead to improved patient satisfaction in specific clinical contexts."

The effectiveness and safety of emergency department short stay units: a rapid review
KJ Konnyu, E Kwok, B Skidmore, D Moher
Open Medicine, 2012, 6(1):e10

Read more here.

Leadership and management for all doctors

"This guidance sets out the wider management and leadership responsibilities of doctors in the workplace."

Leadership and management for all doctors
General Medical Council
January 2012

Read more here.

The Management Code

"An excellent manager will always have safety in mind when planning change and patient client services."

The Management Code
The Institute of Healthcare Management
January 2012

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.

Sharps safety

"RCN guidance to support implementation of the EU Directive 2010/32/EU on the prevention of sharps injuries in the health care sector."

Sharps safety
Royal College of Nursing
November 2011

Read more here.