Patient safety and human factors: guidance and tools

The following are selected sources of guidance and tools from across the four UK countries that can be used to improve patient safety.

For resources and tools that support infection control and the prevention of healthcare associated infection please see the RCN resource dedicated to this at: Infection prevention and control.

You may also want to look at:

• agencies (Government bodies and other organisations)  
• campaigns, programmes and networks  
• policy and strategy.

Guidance and tools

These resource were last accessed on 5 March 2013. Some of these resources may be in PDF format - see how to access PDF files.

Guidance and tools developed specifically for mental health and primary care settings can be found together in a separate section on this page at Primary care and mental health guidance and tools.

1000 Lives Plus publications and resources
1000 Lives Plus is a national improvement programme supporting individuals and organisations in improving patient safety and reducing avoidable harm across NHS Wales. Publications and resources from the programme include white papers, which address key issues facing NHS Wales, improvement guides, videos and links to selected general tools. Examples of these are

• Achieving high reliability in NHS Wales
  This draws on technical theory and practical work from the NHS and other industries to explore how 'high reliability' could make NHS Wales a better and safer place to both work and be a patient in. The white paper includes a driver diagram that identifies the five key areas NHS Wales organisations need to consider when seeking to achieve high reliability: effective engagement; looking beyond the simple and obvious; learning from failure; valuing expertise and promoting situational leadership and organisational reflection.
• Providing assurance, driving improvement
  Explores the ways NHS Wales organisations have conducted mortality reviews The white paper has collected information from across Wales about how mortality reviews have been used to monitor the quality of care and whether patients have been affected. Mortality reviews have helped in the identification of key themes that need to be addressed - an example given is improving the co-ordination of certain kinds of illness like sepsis.

Department of Health, Social Services and Public Health: Governance in HPSS: Controls Assurance Standards
These standards have been developed by the Department to support the embedding of organisation-wide risk management in health and personal social services bodies. These include standards for infection control and for decontamination of re-usable medical devices.

Harm Free Care
Harm Free Care developed from the work done by a quality improvement programme called the Safety Express which was set up as part of the Safe Care workstream within the Quality, Innovation, Productivity and Prevention (QIPP) programme. 'Harm free care' is described as a new mindset in patient safety improvement. The aim is to deliver harm free care as defined by the absence of pressure ulcers, falls, CA-UTI and VTE. A step by step guide is provided and the website includes learning sessions, a baseline audit, measurement, resources and case studies.

The NHS Safety Thermometer allows teams to measure harm and the proportion of patients that are 'harm free' during their working day, for example at shift handover or during ward rounds, and provides a 'temperature check' on harm and can be used alongside other measures of harm to measure local and system progress. This page within Harm Free Care provides information about the NHS safety Thermometer can how it can be used.

Health Foundation: Patient safety
The Health Foundation has undertaken a number of influential projects on patient safety. For details see the section in this resource on Agencies (UK wide). Initiatives the Health Foundation is involved in include - Developing patient safety in primary care. Relevant to this project are the following research scans published by the Foundation in November 2011:

• Improving safety in primary care. This research scan collates empirical evidence that addresses the following questions: What initiatives have been implemented to improve safety in primary care and what are the impacts of these initiatives? How have patients, professionals, researchers and funders been involved? Are there ongoing studies or media stories about this topic?
• Levels of harm in primary care. This research scan collates empirical evidence that addresses the following questions: How is harm measured in primary care? What are the levels of harm in primary care? What are the main causes or sources of harm in primary care? Is there unpublished or ongoing work or media stories about this topic?

All the Health Foundation publications relevant to patient safety can be viewed at Patient safety publications. 

NHS Patient Safety: Patient safety resources
The National Reporting and Learning System (NRLS) within the NPSA analyses reports of patient safety incidents and uses this to produce resources aimed at improving patient safety. All resources are listed by type of resource and are also searchable by topic, healthcare setting, clinical speciality, audience, type or collection.

Key resources are:

Seven steps to patient safety - your guide to safer patient care
Seven steps is a series of publications that provide detailed guidance on how to improve patient safety locally. There are four guides including: seven steps to patient safety; seven steps to patient safety and primary care; seven steps to patient safety in mental health; and seven steps to patient safety in general practice.

Patient safety alerts
The NRLS has developed alerts based on analysis of reports of patient safety incidents, and safety information from other sources. Signals have also been issued and are notifications of key risks emerging from review of serious incidents reported to the NRLS.

Action against Medical Accidents (AvMA) produce regular reports on the implementation of Patient Safety Alerts
The August 2011 report shows that nearly 50% of trusts have failed to comply with at least one alert. Of nine extra-urgent 'Rapid Response Report' alerts issued in 2010, not a single one had been complied with by every trust. For the AvMA reports see Patient safety alerts.

Foresight training
This training resource aims to help pre and post-registration nurses and midwives develop and practise the skills needed to identify situations when a patient safety incident is more likely to occur. It uses scenarios which are set in primary care, acute care and mental healthcare settings.

Tools and resources from the NPSA on specific aspects and activities:

• Incident Decision Tree. The Incident Decision Tree is a web-based tool which has been created to help NHS managers and senior clinicians decide whether they need to suspend (exclude) staff involved in a serious patient safety incident and to identify appropriate management action. The aim is to promote fair and consistent staff treatment within and between healthcare organisation.
• Being open when patients are harmed. The NPSA's Being open policy is part of a national drive to help health care staff communicate. The Being open policy advises healthcare staff to apologise to patients, their families or carers if a mistake or error is made that leads to moderate or severe harm or death, explain clearly what went wrong and what will be done to stop the problem happening again.
• Manchester Patient Safety Framework (MaPSaF). The Manchester Patient Safety Framework (MaPSaF) is a tool to help NHS organisations and healthcare teams assess their progress in developing a safety culture.
• Never Events. Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. The NPSA has worked with stakeholders to co-produce the Never Events Framework 2009/10. It sets out guidance for PCT commissioners on implementing the Never Events policy and builds on existing processes and mechanisms.
• Root Cause Analysis. Root Cause Analysis (RCA) provides a framework for reviewing patient safety incidents (and claims and complaints). Investigations can identify what, how, and why patient safety incidents have happened. Analysis can then be used to identify areas for change, develop recommendations and look for new solutions. Ultimately, they should help stop incidents from happening again.
• Risk Assessment Guides. These risk assessment tools help promote vigilance in identifying risk and the ways in which risk can be minimised. They also include guidance that will encourage greater consistency in the way risk assessment is applied across the NHS.

Health Foundation: Patient safety
The Health Foundation has undertaken a number of influential projects on patient safety. For details see the section in this resource on Agencies (UK wide). All the Health Foundation publications relevant to patient safety can be viewed at Patient safety publications. 

NHS Confederation (2010) Questions are the answer: putting patients and the public back into patient safety
This factsheet looks at how NHS boards can better engage patients and the public in safety issues. It details six questions which board members should ask "in order to seek assurance that the patient voice is heard at the top of their organisation".

NHS Education for Scotland (NES): Patient safety and clinical skills
This section of the NES website brings together information about guidance and tools, educational resources and tools, key initiatives and programmes in Scotland along with other relevant resources and materials.

NHS Institute for Innovation and Improvement: Tools for safer care
These tools are part of the NHS Institutefs Safer Care programme. There is also a collection of Safer Care trigger tools.

NHS Quality Improvement Scotland (2008) Healthcare Associated Infection (HAI) standards
These standards are one component of the drive for a safer NHSScotland, and complement the comprehensive HAI programme already under way, including the work of the Scottish Patient Safety Programme and Health Protection Scotland. NHS board compliance with these standards is assessed by the Healthcare Environment Inspectorate which is now part of Health Improvement Scotland.

NHS Safety Thermometer
This tool allows teams to measure harm and the proportion of patients that are 'harm free' during their working day, for example at shift handover or during ward rounds, and provides a 'temperature check' on harm and can be used alongside other measures of harm to measure local and system progress. This page within Harm Free Care provides information about the NHS safety Thermometer can how it can be used.

NHS Scotland: Quality Improvement Hub: Safe
The NHSScotland Quality Improvement Hub is "a national collaboration among special health boards and Scottish Government Health Directorates which aims to support NHS boards with implementation of the Healthcare Quality Strategy through effective partnership working between the collaborating organisations". Three 'Quality Ambitions' (Person-Centred, Safe and Effective) provide the focus for this strategy. Sections of the Hub are arranged according to these quality dimensions. This is the section for the safe dimension. It includes guidance and information on specific aspects of patient safety. 

Nursing and Midwifery Council: Safeguarding
Safeguarding is part of everyday nursing and midwifery practice in whatever setting it takes place. Do you know what to do?h. This online hub on safeguarding adults has been developed by the Nursing and Midwifery Council to encourage nurses and midwives gto critically reflect on personal and team practice and to make changes where necessary so that safeguarding activities are prioritisedh. The hub includes links to safeguarding policies across the UK, a training toolkit, specially commissioned films and opportunities to share examples and experiences.

Nursing and Midwifery Council: Raising and escalating concerns
The Nursing and Midwifery Council has produced guidance on raising and escalating concerns for all nurses, midwives and pre-registration students. It establishes principles for best practice in the raising and escalating of concerns and aims to complement local whistleblowing policies and safeguarding procedures. This online hub has a toolkit with additional resources to help facilitate discussion and promote the importance of raising and escalating concerns amongst health care teams.

Patient Safety First: Tools and resources to support you
This section and related areas within the campaign website provide a range of resources, tools and implementation support. This includes a series of 'how-to' guides.

Patient Safety First 'How to' guide: Implementing human factors in healthcare
"Human factors encompass all those factors that can influence people and their behaviour. In a work context, they are the environmental, organisational and job factors, and individual characteristics which influence behaviour at work". This guide provides an introduction to the concept of human factors and provides suggestions of how it can be applied by individuals and teams to improve patient safety.

Risky Business
Risky Business is a non-profit collaborative venture. It aims to share new ideas about managing risk and human factors from other high industries. Due to the popularity of their conferences, it was decided that the best way to share the lessons and defining talks from these conferences was to create a web site where as many talks as possible were made freely available.

Guidance and tools for primary care and mental health

Health Foundation: Developing patient safety in primary care
"Improving communication and the reliability of systems in place between the two care settings has the potential to significantly increase the quality and safety of patient care". This programme, which is working in parallel with the Scottish Quality & Safety Improvement in Primary Care Closing the Gap project, is developing and testing change packages in four areas: Medication reconciliation at discharge from hospital; medication reconciliation after attendance at outpatient appointments; clinical communication between specialist outpatient clinics and primary care; systems for managing results.
Relevant to this project are the following research scans published by the Foundation in November 2011:

• Improving safety in primary care. This research scan collates empirical evidence that addresses the following questions: What initiatives have been implemented to improve safety in primary care and what are the impacts of these initiatives? How have patients, professionals, researchers and funders been involved? Are there ongoing studies or media stories about this topic?
• Levels of harm in primary care. This research scan collates empirical evidence that addresses the following questions: How is harm measured in primary care? What are the levels of harm in primary care? What are the main causes or sources of harm in primary care? Is there unpublished or ongoing work or media stories about this topic?

NHS Institute for Innovation and Improvement  Safer Care: Primary care Trigger Tool
The Trigger Tools were developed as part of the NHS Institute’s Safer Care initiative are a means of conducting rapid structured case note review to measure the rate of harm in healthcare. Because they are a metric, they can also be used to track improvements in safety over time. This is currently only available to NHS staff in England.

NHS Patient safety resources: Seven steps to patient safety
These guides developed by the National Patient Safety Agency to provide a framework for patient safety include a full reference guide for primary care  , and a summary guidance and good practice examples for mental health 

Scottish Patient Safety Programme: Patient safety in primary care 2013-2014 - it’s no trouble at all
This booklet provides summary information on the Scottish Patient Safety Programme in Primary Care due to be launched in March 2013. The booklet can be downloaded from this page.

University of Manchester Centre for Mental Health and Risk: Safer mental health services: a self-assessment toolkit
Mental health care providers can use this online toolkit to self-assess their local services and individual practice against key recommendations made by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness which is a leading research programme in this field in the UK. These recommendations are based on the work that the Inquiry has carried out over the last decade.