This paper describes the use of the “trigger tool”, a relatively low cost and “low tech” technique for capturing medication related harm. The adapted technique appears to increase the rate of adverse drug event detection approximately 50-fold over traditional reporting methodologies.
This report is one of a suite of papers in relation to the measurement of medication-related harm and the evaluation of the electronic medication management (eMM) Programme.
Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety
This paper summarises the findings of a more extensive report and proposes a framework which can guide clinical teams and healthcare organisations in the measurement and monitoring of safety and in reviewing progress against safety objectives. The framework has been used so far to promote self-reflection at both board and clinical team level, to stimulate an organisational check or analysis in the gaps of information and to promote discussion of ‘what could we do differently’.
Improving the Quality of Assessment and Management of Hypoglycaemia in Hospitalised Patients with Diabetes Mellitus by Introducing 'Hypo Boxes' to General Medical Wards with a Specialist Interest in Diabetes
This improvement report looked at how the introduction of ‘Hypo Boxes’ to diabetes wards over a 4 week period improved the assessment and management of patients with hypoglycaemia.
This Quality Improvement Report carried out an audit on the use of the Malnutrition Universal Screening Tool (MUST). It found that patients did not consistently have a MUST score documented, the scores were calculated incorrectly and that high MUST scores were not being acted on appropriately.
This improvement report looked at how to increase the availability of vision and hearing aids in the intensive care unit of the Bristol Royal Infirmary.
A system of payment by results exists for the management of hip fractures in England and Wales.UCLH performed badly in the 2013 national hip fracture database (NHFD) audit against the national standards.
Through the introduction of a multi-disciplinary patient pathway and clerking pro forma, the proportion of patients earning the best practice tariff uplift increased from 44.4% to 91.7%.
A presentation by David Dalton, Chief Executive of Salford Royal NHS Foundation Trust about changing patient safety culture in an organisation.