Journal of health services research & policy
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J Health Serv Res Policy · Jan 2010
Feedback from reporting patient safety incidents--are NHS trusts learning lessons?
For the study, first published in 2006, the researchers examined how well NHS organisations had attempted to use the information they gathered from adverse clinical incidents and whether they were learning from it. By looking at existing relevant research worldwide, interviewing experts, surveying NHS organizations (acute, community and ambulance), consulting health care and other high-risk industry safety experts and NHS risk managers, and investigating case studies of good practice, they developed a model to assess how ready NHS systems were to learn from incidents. This is known as Safety Action and Information Feedback from Incident Reporting (SAIFIR).
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J Health Serv Res Policy · Jan 2010
Testing new devices to help prevent 'misconnection' errors in health care.
The study, the first part of which was published in 2008, looked at, prospectively, how effective and safe new, non-traditional connectors were for use in spinal connector equipment such as spinal needles and infusion lines. The researchers analysed existing evidence on adverse incidents in this area, held workshops to discuss the problem, tested new devices with a simulator, and evaluated them in clinical practice trials at four different hospitals in England.
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The study, first published in 2006, looks at patient safety from the perspective of surgery, looking at surgeons' technical skills, surgical team performance in the operating theatre, the team's views of their performance, interruptions and distractions, and multidisciplinary team training in surgery using simulated training scenarios.
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The study, first published in 2003, looks at how trusts reacted to and implemented a safety alert on a drug, in this case potassium chloride, which can help save lives, but which is dangerous in high concentrations.
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The study, first published in 2005, looks at errors made in the operating theatre by observing operations at first hand, recording them for closer scrutiny and evaluation of non-technical skills such as human error, system problems and teamwork, questioning health professionals to assess safety culture, and using computer simulations to study how hospital systems might increase the chances of surgical error.