Educational Resources and Tools
This page contains a variety of educational resources and tools for Patient Safety, developed and supported by members of the NES Patient Safety Multi-disciplinary Group.
Patient
involvement in patient safety education: Background, practical
considerations and recommendations (August 2011)
[PDF]
The aims of this report are: To provide a contextual background of
patient involvement in general and specifically in health care
education; To summarize the available research and experience of
active patient involvement in health care education; To consider
the potential implications for patient safety education with
recommendations for increasing active patient involvement.
Healthcare Improvement and PDSA
Cycles of Change: A Realist Synthesis of the
Literature (poster, 2011) [PDF]
This poster, by Esther Curnock, John McKay, Julie Ferguson and Paul
Bowie, attempts to clarify and map key emerging theories
around Plan-Do-Study-Act (PDSA). Plan-Do-Study-Act (PDSA) is a
change and improvement method which is often implemented in a
diverse range of safety and quality improvement programmes,
and which aims to pursue effective changes in healthcare
processes that favourably affect outcomes, using rapid small-step
change cycles.
Fundamentals of Patient Safety and Human Factors in Healthcare:
Progress report of the development and pre-testing of a
certificated e-learning module for NES training groups and
educational supervisors (June 2011) [PDF]
The NES Patient Safety Multi-disciplinary Group has funded the
design of a certificated e-learning module on the fundamentals of
patient safety. The intention is for the module to be piloted
initially with selected NES training groups and supervisors, before
being made available to the wider NHS Scotland workforce. This
report, by Carl de Wet, Sabine Nolte and Paul Bowie, contains
information on the background to this project, the modules
themselves, and feedback from the initial pilot group.
Learning from Patient Safety
Incidents in NHS Scotland (update, February 2011) [PDF]
This work aims to:
- investigate the experiences of NHS staff who have
undertaken RCA (root cause analysis training) and subsequently
undertaken an RCA
- To examine retrospectively the quality of RCAs undertaken
by clinical staff who have undergone RCA training
- To compare the results with a previous study, carried out
by J. Braithwaite (Experiences of health professionals who
conducted root cause analysis after undergoing a safety improvement
programme, 2008).
A Review of Patient Safety e-Learning Modules and Resources
(working draft, January 2010) [PDF]
This report was commissioned by the NES Patient Safety
Multidisciplinary Steering Group in recognition of the need to
develop (and/or adapt) new and suitable e-learning patient safety
modules. The aims of this report were:
- to conduct a high-level scoping exercise to identify
existing national and international patient safety e-learning
products (modules, programmes and/or courses), and to provide a
summary and evaluation of those idenitified.
- to identify potential online resources that may be
useful in designing and developing future patient safety modules
for the NHS Scotland setting.
Clinical Audit and Quality
Improvement in NHS Scotland: Time for a Rethink? (poster,
2009) [PDF]
This poster, by Paul Bowie, Nick Bradley and Rosemary
Rushmer, summarises this study, which aimed to explore
clinical audit advisors' views and experiences of their role in
supporting health care teams with the audit process.
The
Development and Testing of a Global Trigger Tool to Detect Error
and Patient Harm in Primary Care Records (poster, 2009)
[PDF]
The Trigger Tool is a relatively new method which originated in the
United States and has shown potential in secondary care studies.
The approach involves the focused review of a random sample of
patient records using a series of 'triggers' that alert reviewers
to potential errors and previously undetected adverse events. This
poster, by Carl de Wet and Paul Bowie, looks at work they
carried out which aimed to develop and test a global trigger
tool to detect errors and adverse events in primary care
records.
The Anatomy of Errors and Educational Outcomes: Perceiving Causes of Errors in the Prescribing and Dispensing of High Risk Drugs (poster, 2009) [PDF]Research into medication error has largely focused on secondary care, although it is estimated that 75% of prescribing takes place in primary care. Most research has systematically reviewed prescriptions or hospital admittance rates and does not take account of adverse events with drugs that are sourced in errors made by health professionals, or the systems that govern prescribing and dispensing. The aim of this study was to use a collection of drugs (Prednisolone, Warfarin, Lisinopril, Morphine, Carbamazepine, Digoxin, and Methotrexate), highlighted by the Department of Health as 'high risk' to indicate the causes of errors among drugs of high risk in primary care.
Clinical Skills and
Assessment (poster, 2009) [PDF]
This poster gives an overview of NES research in this area,
including projects looking at:
- the development of assessment tools in healthcare
settings
- the evaluation of the effectiveness of different assessment
tools and approaches
- the development and evaluation of educational
interventions.
Other Resources
"The Power of Apology" (Focus
article, April 2010) [PDF]
This article (by Dorothy Armstrong, Programme Director,
NMAHP) gives practical advice on the importance of apologising
in a professional context, and when and how to do it. Key
recommendations are:
- apologising is a key part of our lives
- apology can be very powerful when done well
- staff should be empowered to say sorry, even if they
are not directly involved
- use the 3 Rs: Regret, Reason and Remedy
- avoid being vague, passive, conditional or
empathetic
- it's not easy to apologise, but it's everyone's
business.
