Learning and Mindfulness: Improving Perioperative Patient Safety

Graling, P.R. (2017) AORN Journal. 105(3) pp. 317–321


Image source: stavos – Flickr // CC BY-NC-ND 2.0

In 1980, McLain identified the top five risk management issues in the OR as wrong patient; wrong procedure performed; improper consent; unreconciled sponge, needle, or instrument count; and burns from equipment.

Approximately 20 years later, the Institute of Medicine report To Err Is Human: Building a Safer Health System described the complexity of health care systems in the United States and the epidemic occurrence of medical errors. Despite widespread awareness of medical errors, there has been little progress in this area to improve patient safety, and sentinel or never events continue to occur in the United States.

Read the abstract here

Learning from Patient Safety Incidents

It is estimated that 1:10 patients in health care sustain harm that is potentially avoidable and which often highlight system errors that were not appreciated | Faculty of Intensive Care Medicine

Investigation results in the identification of these system errors and the generation of solutions to prevent future incidents. Sharing and implementing these lessons improves patient safety.

National Patient Safety Alerts relevant to intensive care

National alerts are produced in response to analysis of centrally reported patient safety incidents. Details of all alerts may be found on the Central Alerting System website (https://www.cas.dh.gov.uk/Home.aspx).

Lessons from adverse incidents

Lessons from local incidents may not be shared widely and to improve wider patient safety, the Joint Standards Committee of the Faculty and the Intensive Care Society has created this forum to allow lessons from local investigations into adverse incidents to be disseminated to the intensive care community.

We welcome you to share important safety lessons that have occurred in your own departments that may have general relevance. Please use the form below (or your local form if you would prefer) to submit an anonymised summary of the incident, the learning arising and any changes that have been implemented to prevent future a reoccurrence.

SAFETY MATTERS: Local Incident Lessons

Read the full overview here

Collaboration with an infection control team for patients with infection after spine surgery

Kobayashi, K. et al. American Journal of Infection Control. Published online: 22 February 2017



  • The risk of infection after spine surgery has increased due to aging of society.
  • An infection control team (ICT) manages infected cases at our hospital.
  • The ICT guided use of antibiotics in 30 cases and investigated infection in 10.
  • The bacteria detection rate was 88% (35/40 patients) in cases treated by the ICT.
  • Early assistance from the ICT is a key to preventing onset of MRSA infection.

Read the full abstract here

A Nursing Intervention for Improving Patient Safety in Critical Care

Pfrimmer, D.M. et al. (2017) Dimensions of Critical Care Nursing36(1) pp. 45–52

11556-2Background: Nursing surveillance has been identified as a key intervention in early recognition and prevention of errors/adverse events. Nursing Intervention Classification (NIC) defines surveillance as “the purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making.” Because nurses are the main staffing constant in the critical care environment, the importance of surveillance as an intervention is fundamental.

Discussion: Surveillance was expressed through nurses’ gathering cues, reflecting on past knowledge, asking questions, verifying, and pulling it all together to find meaning. During handoff, surveillance involved collaborative cognitive work to find meaning in cues.

Read the full abstract here

Four tools to enhance significant event analysis in primary care

The Health Foundation | Published online 25 August 2016

Significant event analysis (SEA) is a collective learning technique used to investigate patient safety incidents (circumstances where a patient was or could have been harmed) and other quality of care issues.

The project developed a framework and then a series of practical tools, which aim to help people working in primary care to apply the approach.

1. E-learning module

This short ‘read and click’ e-learning module is available as a PDF from the Quality Improvement Hub. It explains and illustrates the principles which underpin the enhanced SEA approach, including sections on: Basic error theory; Human factors principles; Taking a systems-centred approach; and the Enhanced SEA method.

2. Enhanced SEA booklet

The enhanced SEA booklet (PDF), developed by the project team, gives a clear, readable overview of the approach, including the basics of human factors theory and an example story. It aims to help individuals reflect on the potential emotional impacts of a significant event by using these principles to gain a clearer understanding of all of the contributory factors involved.


Image source: The Health Foundation

3. Deskpad

In addition to individual reflection, it’s important that teams reflect together on events and analysis. Each sheet of this enhanced SEA deskpad (PDF) contains instructions and prompts to help guide a team in taking this approach to event analysis, and to take notes on what was agreed.

4. Reporting template

The project team also designed and developed a new report format (PDF) for writing up SEAs, which accommodates this approach. This format is recommended for GP specialty training and medical appraisal, as well as for practice manager and nurse vocational training and appraisal.  It is also being used in community pharmacy and dental practice in Scotland.

Read the full project overview here

Patient Safety Collaboratives

Patient Safety Collaboratives: making care safer for all via NHS Improvement 

Patient Safety Collaboratives are led by Academic Health Science Networks and are made up of NHS, academic and health care experts. The aim of the collaboratives is to improve patient safety, spread examples of success and influence system leaderships. This report highlights the work of 15 teams of Patient Safety Collaboratives that aimed to improve patient safety and reduce avoidable harm in the NHS.

The new report lists achievements including:

  • developing care bundles that reduced mortality after emergency laparotomies by 42 per cent
  • establishing safety ‘huddles’ that has reduced inpatients falls by 60 per cent
  • achieving a 50 per cent increase in patients returning to mental health wards on time
  • producing guidance that improves the communication of information on acute kidney injury between healthcare teams when a patient is discharged
  • reducing inpatient medication errors

Hospital patient discharge process: an evaluation

European Journal of Hospital Pharmacy

Qualitative study in the UK found that to improve the patient discharge process, innovative solutions are required to overcome current issues. A significant finding was a lack of patient involvement in the discharge process throughout the 13 hospitals included.

Objectives Medication discrepancies for patients after discharge from hospital are well documented. They have been shown to cause unnecessary harm to patients and can result in hospital readmission. To improve patient discharge, the current process of discharging patients from hospital (the discharge process) needs evaluating to determine where and why medication issues occur. This study aimed to identify and evaluate the discharge process used in a range of acute National Health Service hospitals across the North West of England.

Methods This qualitative study involved semi-structured telephone interviews with 13 chief pharmacists or an appropriately nominated member of the hospital pharmacy team. Thematic analysis of the transcribed interview data was performed. Data analysis revealed eight main themes which all impacted on the discharge process.

Results The study was successful in identifying the discharge process across the range of hospitals as well as key issues and examples of good practice. The hospitals involved in the study were found to have similar discharge processes with issues common to all. One significant finding was a lack of patient involvement in the discharge process.

Conclusions To improve the patient discharge process, innovative solutions are required to overcome the current issues. In future work, the study findings will be used to develop a new model of care for patient discharge from hospital.

Eur J Hosp Pharm doi:10.1136/ejhpharm-2016-000928