Governing patient safety: lessons learned from a mixed methods evaluation of implementing a ward-level medication safety scorecard in two English NHS hospitals (original) (raw)
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The New Zealand medical journal, 2016
To undertake a review of Waitemata District Health Board's (WDHB) hospital medication system for patient safety assessment and improvement purposes. A multidisciplinary group rated current WDHB hospital medication systems against the Medication Safety Self-Assessment for Australian Hospitals (MSSA®-AH) criterion of 247 aspirational practices using a five point scale ("no" to "fully implemented"). Items with a lesser extent of implementation represented practice gaps. The MSSA®-AH database and weighted adjustment scoring system generated an overall hospital score. Of the maximum possible score that could be obtained had all MSSA®-AH practices been implemented, WDHB scored 63% and this was comparable to other demographically similar hospitals in Australia. Lowest scoring practices needing improvement related to staffing. Conflict resolution was a previously unidentified practice gap. Previously identified gaps, such as those relating to electronic medication sy...
BMJ quality & safety, 2011
To assess the quality and impact of medication safety outputs issued by the National Patient Safety Agency (NPSA) to the NHS in England and Wales. A multi-method study comprising (1) focus groups and interviews with NHS Chief Pharmacists and (2) an electronic survey of medical, nursing and clinical governance directors. Acute sector respondents agreed that the medication outputs had a major impact on patient safety. Pharmacists welcomed national support for medication safety improvement, despite the resulting workload. Medical Directors were much less likely to be aware of alerts and Rapid Response Reports (RRRs) than their nursing and clinical governance colleagues. One key finding was the inability of around half of NHS trusts to communicate effectively and reliably with their junior doctors. Medication alerts issued by the NPSA have stimulated significant work to improve medication safety and are believed to have had an important impact on patient safety.
Studies in health technology and informatics, 2011
In the field of the detection and prevention of preventable ADEs, several methods have been explored to decrease the rate of ADEs due to monitoring errors. This paper describes an innovative method that aims at improving patient safety by increasing ADEs' awareness of healthcare professionals. To this end, ADE-scorecards that provide healthcare professionals with retrospective data about ADEs' causes and rates have been developed. In order to evaluate the impact of this method on the ADE rate, in-field clinical tests have been set up. Data were collected by both qualitative (semi-structured interviews) and quantitative methods (log analysis and ADE rate calculation). Preliminary results reveal that ADE-scorecards are well-accepted by most of the healthcare professionals who intend to use them as discussion supports and/or learning tools. Thus, ADE-scorecards seem to be a relevant method to improve patient safety by increasing ADE-awareness of healthcare professionals.
Value in Health, 2015
agers, pharmacy staff, and pharmacy clients. The target population of this study was community pharmacies settled in Tehran, the capital city of Iran. The managerial team of the invited pharmacies must remain unchanged for at least three years ending to the study. Manager's and staff questionnaires contained questions about their job satisfaction, self assessment of knowledge, skills, and performance. Staff was also asked about manager's behavior. Client's questionnaire evaluated client's satisfaction with the pharmacy. Confirmatory factor analysis and correlation test were performed using SPSS 16.0.0. Results: Data from 187 pharmacies was gathered. Based on the results, applying strategy planning had significant relationship with financial (R= 0.204, p-value< 0.05) and societal results (R= 0.451, p-value < 0.01). Manager's behavior was significantly (p-value < 0.01) correlated with society, staff and client result (R= 0.234, 0.674 and 0.307, respectively). Staff's knowledge and skills was related with staff's satisfaction (R= 0.211, p-value < 0.01), society (R= 0.339, p-value < 0.01) and financial (R= 172, p-value < 0.05) result, but client's satisfaction correlation was only significant with technical pharmacist's skills (R= 0.275) and non-pharmaceutical knowledge (communication, information exchange, and ethics) (R= 0.301). ConClusions: Although community pharmacies, in Iran, suffer from low professionalization and health policy makers' inattention, results of this study are promising, because show that manger's can still affect pharmacy achievements by improving their behavior, knowledge and skills. PHP175 CHaraCter of toxiC Damage of Liver in infLuenCes of substanCes of meDiator to fetaL CeLLs on HePatoCytes in aCute Liver faiLure
SMASH! The Salford medication safety dashboard
Journal of Innovation in Health Informatics, 2018
Background: Patient safety is vital to well-functioning health systems. A key component is safe prescribing, particularly in primary care where most medications are prescribed. Previous research demonstrated that the number of patients exposed to potentially hazardous prescribing can be reduced by interrogating the electronic health record (EHR) database of general practices and providing feedback to general practitioners in a pharmacist-led intervention. We aimed to develop and roll out an online dashboard application that delivers this audit and feedback intervention in a continuous fashion.Method: Based on initial system requirements we designed the dashboard’s user interface over 3 iterations with 6 general practitioners (GPs), 7 pharmacists and a member of the public. Prescribing safety indicators from previous work were implemented in the dashboard. Pharmacists were trained to use the intervention and deliver it to general practices.Results: A web-based electronic dashboard wa...
Journal of Patient Safety, 2020
Objectives: Our study aimed to explore to what extent the priority areas and domains of the World Health Organization (WHO)'s third Global Patient Safety Challenge were being addressed in a sample of hospital organisations. Methods: A qualitative approach was taken using a combination of focus groups, semistructured interviews and documentary analysis in four UK teaching hospital organisations. A purposive sampling strategy was adopted with the aim of recruiting healthcare professionals who would be likely to have knowledge of medication safety interventions that were being carried out at the hospital organisations. Medication safety group meeting notes from 2017 to 2019 were reviewed at the hospital organisations to identify interventions recently implemented, those currently being implemented and plans for the future. A content analysis was undertaken, using the WHO's third Global Patient Safety Challenge priority areas and domains as deductive themes. Results: All the domains and priority areas of the WHO Medication Safety Challenge were being addressed at all four sites. However, a greater number of interventions focused on 'healthcare professionals' and 'systems and practices of medicines management' than on 'patients and the public'. In terms of the priority areas, the main focus was on 'high risk situations', particularly high-risk medicines, with fewer interventions in the areas of 'transitions of care' and 'polypharmacy'. Conclusions: More work may be needed to address patient and public involvement in medication safety and the priority areas of 'transitions of care' and 'polypharmacy'. Comparative global studies would help build an international picture and allow shared learning.
An audit of drug allergy documentation in a district general hospital
■ Drug allergies are currently an important issue in risk management within the NHS. Are they being documented correctly? ■ Allergy status records and red alert wrist band use across three hospital directorates were checked and compared to the standard set in the trust drug policy ■ Recording of allergy status is not in line with local policy and is often absent from patient records; this includes a clear statement for those patients with no drug allergies. ■ Prominent allergy alert systems such as red wrist bands are not being used in line with local policy