References

Scenario 1

Casey A and Wallis A (2011) Effective communication: Principle of Nursing Practice E, Nursing Standard, 25 (32), 13 April, pp.35-37.

Fitzsimons B, Bartley A and Cornwell J (2011) Intentional rounding: its role in supporting essential care, Nursing Times, 107 (27), 12 July, pp.18-19.

Healthcare Improvement Scotland (2009) NHS Scotland Pressure Ulcer Safety Cross, Edinburgh: Healthcare Improvement Scotland.  Available at: www.healthcareimprovementscotland.org/programmes/patient_safety/tissue_viability_resources/nhsscotland_safety_cross.aspx (accessed 23/11/11).

Kalisch BJ, Landstrom GL and Hinshaw AS (2009) Missed nursing care: a concept analysis, Journal of Advanced Nursing, 65 (7), July, pp.1509-1517.

Mascioli S, Laskowski-Jones L, Urban S and Moran, S. (2009) Improving handoff communication, Nursing, 2009, February, 39 (2), pp.52-55.

Tucker A, Brandling J and Fox P. (2009) Improving record-keeping with reading handovers, Nursing Management UK, 16 (8), December, pp.30-34.

Scenario 2

Kalisch BJ, Landstrom GL and Hinshaw AS (2009) Missed nursing care: a concept analysis, Journal of Advanced Nursing, 65 (7), July, pp.1509-1517.

National Patient Safety Agency (2011) Root Cause Analysis (RCA) investigation, London: NPSA. Available at: www.nrls.npsa.nhs.uk/resources/collections/root-cause-analysis/ (accessed 23/11/11).

National Patient Safety Agency (2011) Root Cause Analysis (RCA) toolkit, London: NPSA. Available at: www.nrls.npsa.nhs.uk/resources/?entryid45=59901 (accessed 23/11/11).

NHS Education for Scotland and Scottish Recovery Network (2007) Realising recovery: a national framework for learning and training in recovery focused practice, Edinburgh: NES/SRN. Available at: www.williamwhitepapers.com/pr/Recovery%20Definition%20Scotland.pdf  (accessed 23/11/11).

Patient Safety First (2010) Implementing human factors in healthcare ‘how to’ guide, London: Patient Safety First. Available at: www.patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/Intervention-support/Human%20Factors%20How-to%20Guide%20v1.2.pdf (accessed 23/11/11).

Core concepts in patient safety

Swiss cheese model

Patient Safety First (2010) ‘How errors and incidents occur’, in Implementing human factors in healthcare ‘how to’ guide, London: Patient Safety First, pp.6-9. Available at: www.patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/Intervention-support/Human%20Factors%20How-to%20Guide%20v1.2.pdf (accessed 23/11/11).

Duke University Medical Center (2005) Anatomy of an error: Swiss cheese model, Durham, NC: Duke University Medical Center.  Available at: http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html (accessed 23/11/11).

Three-bucket model

The Knowledge Network (2010) Managing human error: the three buckets approach, Edinburgh: The Knowledge Network.  Available at: www.evidenceintopractice.scot.nhs.uk/patient-safety/managing-human-error.aspx (accessed 23/11/11). 

National Patient Safety Agency (2008) Foresight Training resource pack 5: examples of James Reason’s ‘three bucket’ model, London: NPSA.  Available at: www.nrls.npsa.nhs.uk/resources/?EntryId45=59840 (accessed 23/11/11). 

Parker J and Huggett A (2008) One step ahead of an error, Nursing Standard, 22 (50), 20 August, pp.62-63.

Iceberg model

Battles JB (2001) Disaster prevention: lessons learned from the Titanic, Proceedings of the Bayliss University Medical Center, 14 (2), April, pp.150-153. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC1291331/  (accessed 23/11/11). 

Williamson S (2009) ‘Reporting medication errors and near-misses’, in Courtenay M, and Griffiths M (editors) Medication safety, Cambridge: Cambridge University Press, pp.155-172.

Human factors

Patient Safety First (2010) Implementing human factors in healthcare ‘how to’ guide, London: Patient Safety First. Available at: www.patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/Intervention-support/Human%20Factors%20How-to%20Guide%20v1.2.pdf (accessed 23/11/11).

Tools and techniques for improving patient safety

SBAR

Christie P and Robinson H (2009) Using a communication framework at handover to boost patient outcomes, Nursing Times, 105 (47), 1 December, pp.13-15. 

Mascioli S, Laskowski-Jones L, Urban S and Moran S (2009) Improving handoff communication, Nursing, 39 (2), February, pp.52-55. 

NHS Institute for Innovation and Improvement (2008) SBAR – Situation – Background - Assessment – Recommendation, Coventry: NHS Institute. Available at: www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/sbar_-_situation_-_background_-_assessment_-_recommendation.html (accessed 23/11/11).

Patient Safety First (2008) ‘A communication tool should be used for all patients to escalate concern between team members’, in The ‘How to guide’ for reducing harm from deterioration, London: Patient Safety First, pp.18-20. Available at: http://www.patientsafetyfirst.nhs.uk/Content.aspx?path=/interventions/Deterioration/ (accessed 23/11/11).

Tucker A, Brandling J and Fox P (2009) Improving record-keeping with reading handovers, Nursing Management UK, 16 (8), December, pp.30-34.

Incident decision tree

National Patient Safety Agency (2004) Incident decision tree toolkit, London: NPSA. Available at: www.nrls.npsa.nhs.uk/resources/?EntryId45=59900 (accessed 23/11/11). 

Root cause analysis

National Patient Safety Agency (2004) Root Cause Analysis (RCA) toolkit. Available at: www.nrls.npsa.nhs.uk/resources/?entryid45=59901 (accessed 23/11/11).

National Patient Safety Agency (2008) Significant event audit, London: NPSA. Available at: www.nrls.npsa.nhs.uk/resources/?entryid45=61500 (accessed 23/11/11).

National Patient Safety Agency (2010) Root Cause Analysis (RCA) investigation report writing templates, London: NPSA.  Available at: www.nrls.npsa.nhs.uk/resources/?entryid45=75419 (accessed 23/11/11).

Intentional rounding

Fitzsimons B, Bartley A and Cornwell J (2011) Intentional rounding: its role in supporting essential care, Nursing Times, 107 (27), 12 July, pp.18-19.

Principles of Nursing Practice

Royal College of Nursing (2011) Principles of nursing practice, London: RCN. Available at: www.rcn.org.uk/development/practice/principles (accessed 23/11/11).

Patient safety thermometer

Patient Safety First (2011) Safety thermometer, London: NPSA.  Available at: www.patientsafetyfirst.nhs.uk/Content.aspx?path=/interventions/relatedprogrammes/safety-thermometer/ (accessed 23/11/11).

Safety Express (2011) Guide to programme delivery, Eccles: Safety Express.  Available at: http://www.patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/SafetyThermometer/Safety_Express_Guide_24_January_2011.pdf (accessed 23/11/11).