This quarterly bulletin covers literature relating to clinical governance, with a section devoted to patient safety, and should be of interest to a variety of NHS staff. It is intended as an information tool to help you keep up to date with developments in your area of clinical expertise and interest. It is not an expression of organisational policy. The inclusion of a guideline, system, tool or similar in this newsletter does not imply that it is used, or should be implemented, within NHS Greater Glasgow and Clyde
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COVID-19 / Infection Control / Patient Experience and Engagement / Patient Safety / Primary Care / Quality Assessment and Improvement / Service Design, Evaluation and Improvement / Staff Roles, Skills, Effectiveness and Practice / Reports
COVID-19
BOTTLE, A., et al, 2021. Patient-level and hospital-level variation and related time trends in COVID-19 case fatality rates during the first pandemic wave in England: multilevel modelling analysis of routine data. BMJ Quality & Safety.
CHEUNG, C.R., et al, 2021. Developing new models of care at speed: learning from healthcare redesign for children with COVID-related multisystem inflammation. Archives of Disease in Childhood, 106(6), pp. 528-532.
CHOUDHRY B., et al, 2021. Safety evaluation of providing trauma service during COVID-19 phase one lockdown. Journal of Clinical Orthopaedics and Trauma, 18, pp. 44-50.
GRAY S., et al, 2021. Occupational exposure of healthcare workers to COVID-19 and infection prevention control measures in haemodialysis facilities in North West of England. Infection Prevention in Practice, 3(3), pp. no pagination.
KANNANGARA C.I., et al, 2021. Investigation and management of an outbreak of COVID-19 infection in an acute admission unit in a District General Hospital: lessons learnt. Infection Prevention in Practice, 3(3), pp. no pagination.
KURSUMOVIC, E., et al, 2021. The impact of COVID-19 on anaesthesia and critical care services in the UK: a serial service evaluation. Anaesthesia, 76(9), pp. 1167-1175.
LACKEY, S., et al, 2021. A mixed-methods study describing behavioral factors that influenced general practitioners' experiences using triage during the COVID-19 pandemic. BMC Family Practice, 22(1), pp. 1-11.
LEE G., et al, 2021. The perception of patient safety in an alternate site of care for elective surgery during the first wave of the novel coronavirus pandemic in the United Kingdom: a survey of 158 patients. Patient Safety in Surgery, 15(1), pp. no pagination.
RAPHAEL J., et al, 2021. Adapting practice in mental healthcare settings during the COVID-19 pandemic and other contagions: Systematic review. BJPsych Open, 7(2), pp. no pagination.
ROBBINS T., et al, 2021. Differential perceptions regarding personal protective equipment use during the COVID-19 pandemic by NHS healthcare professionals based on ethnicity, sex and professional experience. Infection Prevention in Practice, 3(3), pp. no pagination.
SAEED, K., et al, 2021. Investigations, actions and learning from an outbreak of SARS-CoV-2 infection among healthcare workers in the United Kingdom. Journal of Infection Prevention, 22(4), pp. 156-161.
SIMPSON, C.R., et al, 2021. Temporal trends and forecasting of COVID-19 hospitalisations and deaths in Scotland using a national real-time patient-level data platform: a statistical modelling study. The Lancet.Digital Health, 3(8), pp. e517-e525.
WILLIAMS D., et al, 2021. Rapid design and implementation of a virtual pain management programme due to COVID-19: a quality improvement initiative. British Journal of Pain, (pagination), pp. no pagination.
Infection Control
MANOUKIAN, S., et al, 2021. Evaluating the post-discharge cost of healthcare-associated infection in NHS Scotland. Journal of Hospital Infection, 114, pp. 51-58.
MANOUKIAN, S., et al, 2021. Bed-days and costs associated with the inpatient burden of healthcare-associated infection in the UK. Journal of Hospital Infection, 114, pp. 43-50.
STEWART, S., et al, 2021. Personalized infection prevention and control: identifying patients at risk of healthcare-associated infection. Journal of Hospital Infection, 114, pp. 32-42.
STEWART, S., et al, 2021. Epidemiology of healthcare-associated infection reported from a hospital-wide incidence study: considerations for infection prevention and control planning. Journal of Hospital Infection, 114, pp. 10-22.
STEWART, S., et al, 2021. Impact of healthcare-associated infection on length of stay. Journal of Hospital Infection, 114, pp. 23-31.
Patient Experience and Engagement
CLAYDON, O., et al, 2021. Understanding complaints made about surgical departments in a UK district general hospital. International Journal for Quality in Health Care, 33(3).
DAVIDSON, L., et al, 2021. Patient experiences of integrated care within the United Kingdom: A systematic review. International Journal of Care Coordination, 24(2), pp. 39-56.
LOWE, D., et al, 2021. Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation. Cochrane Database of Systematic Reviews, (9),
MCCREADDIE, M., et al, 2021. A qualitative study of National Health Service (NHS) complaint-responses. BMC Health Services Research, 21(1), pp. 696.
SCHOLES, A., et al, 2021. Women service users' experiences of inpatient mental health services and staff experiences of providing care to women within inpatient mental health services: A systematic review of qualitative evidence. International journal of nursing studies, 118, pp. 103920.
Patient Safety
ALSHEHRI, G.H., et al, 2021. Medication Safety in Mental Health Hospitals: A Mixed-Methods Analysis of Incidents Reported to the National Reporting and Learning System. Journal of Patient Safety, 17(5), pp. 341-351.
BARTONICKOVA D., et al, 2021. How to measure patient safety culture? A literature review of instruments. Acta Medica Martiniana, 21(2), pp. 69-79.
BERRY P., et al, 2021. A three-tiered approach to investigating patient safety incidents in endoscopy: 4-year experience in a teaching hospital. Endoscopy International Open, 9(8), pp. E1188-E1195.
BRATCH, R. and PANDIT, J.J., 2021. An integrative review of method types used in the study of medication error during anaesthesia: implications for estimating incidence. British journal of anaesthesia, 127(3), pp. 458-469.
BRUMMELL, Z., et al, 2021. NHS 'Learning from Deaths' reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme. BMJ Open, 11(7), pp. e046619.
CAVELL G.F. and MANDALIYA, D., 2021. Magnitude of error: A review of wrong dose medication incidents reported to a UK hospital voluntary incident reporting system. European Journal of Hospital Pharmacy, 28(5), pp. 260-265.
DAVIS, M. and MCGARRY, J., 2021. Supporting women's sexual safety in acute mental health settings. Mental Health Practice, (4), pp. 35-41.
KILLIN L., et al, 2021. Advanced Medication Reconciliation: A Systematic Review of the Impact on Medication Errors and Adverse Drug Events Associated with Transitions of Care. Joint Commission Journal on Quality and Patient Safety, 47(7), pp. 438-451.
TASE, A., et al, 2021. Medical device error and failure reporting: Learning from the car industry. Journal of Patient Safety & Risk Management, 26(3), pp. 135-141.
Primary Care
BARNHOORN, P.C., et al, 2021. Patient complaints in general practice seen through the lens of professionalism: a retrospective observational study. BJGP Open , 2021; 5 (3) (June 2021),
CECIL E., et al, 2021. Factors associated with potentially missed acute deterioration in primary care: Cohort study of UK general practices. British Journal of General Practice, 71(708), pp. E547-E554.
CHERAGHI-SOHI, S., et al, 2021. Incidence, origins and avoidable harm of missed opportunities in diagnosis: longitudinal patient record review in 21 English general practices. BMJ Quality & Safety.
COLLINS, C., et al, 2021. Does education of primary care professionals promote patient self-management and improve outcomes in chronic disease?: an updated systematic review. BJGP Open , 2021; 5 (3) (June 2021).
GOPFERT, A., et al, 2021. Primary care consultation length by deprivation and multimorbidity in England: an observational study using electronic patient records. British Journal of General Practice, 71(704), pp. e185-e192.
KHAWAGI, W.Y., et al, 2021. Evaluating the safety of mental health-related prescribing in UK primary care: a cross-sectional study using the Clinical Practice Research Datalink (CPRD). BMJ Quality & Safety,
MORRISSEY M., et al, 2021. Effectiveness and perceptions of using templates in long-term condition reviews: A systematic synthesis of quantitative and qualitative studies. British Journal of General Practice, 71(710), pp. E652-E659.
O'CONNOR, P., et al, 2021. A meta-review of methods of measuring and monitoring safety in primary care. International Journal for Quality in Health Care, 33(3),
PARSONS, J., et al, 2021. Which patients miss appointments with general practice and the reasons why: a systematic review. British Journal of General Practice, 71(707), pp. (June 2021).
SAUNDERS, C.L., et al, 2021. Sociodemographic inequalities in patients' experiences of primary care: an analysis of the General Practice Patient Survey in England between 2011 and 2017. Journal of health services research & policy, 26(3), pp. 198-207.
SWAITHES, L., et al, 2021. Experience of implementing and delivering group consultations in UK general practice: a qualitative study. British Journal of General Practice, 71(707), pp. (June 2021).
Quality Assessment and Improvement
GRAY, W.K., et al, 2021. Identifying unwarranted variation in clinical practice between healthcare providers in England: Analysis of administrative data over time for the Getting It Right First Time programme. Journal of evaluation in clinical practice, 27(4), pp. 743-750.
MITCHELL, P., et al, 2021. Pushing poverty off limits: quality improvement and the architecture of healthcare values. BMC Medical Ethics, 22(1), pp. 91.
PRATT, A.C. and WOOD, R.M., 2021. Addressing overestimation and insensitivity in the 85% target for average bed occupancy. International Journal for Quality in Health Care, 33(3),
SCHANG, L., et al, 2021. What makes a good quality indicator set? A systematic review of criteria. International Journal for Quality in Health Care, 33(3),
SUBBE, C.P., et al, 2021. Quality: What does it mean in Acute Medicine and how do we measure it?. Acute Medicine, 20(2), pp. 125-130.
SUGARMAN, M., et al, 2021. Implementation of the 'TAKE STOCK' Hot Debrief Tool in the ED: a quality improvement project. Emergency Medicine Journal, 38(8), pp. 579-584.
WILLETT, J., et al, 2021. Telling the story of complex change: an Impact Framework for the real world. International Journal for Quality in Health Care, 33(3),
WRIGHT, D., et al, 2021. Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies. BMJ Quality & Safety.
Service Design, Evaluation and Improvement
BION, J., et al, 2021. Changes in weekend and weekday care quality of emergency medical admissions to 20 hospitals in England during implementation of the 7- day services national health policy. BMJ Quality & Safety, 30(7), pp. 536-546.
BISHOP, A., et al, 2021. Providing patients with direct access to musculoskeletal physiotherapy: the impact on general practice musculoskeletal workload and resource use. The STEMS-2 study. Physiotherapy, 111, pp. 48-56.
DAVY, A., et al, 2021. A Predictive Model for Identifying Patients at Risk of Delayed Transfer of Care: A Retrospective, Cross-Sectional Study of Routinely Collected Data. International Journal for Quality in Health Care,
HARRIS, D., et al, 2021. Service evaluation of the bereavement care delivered in a UK intensive care unit. British Journal of Nursing, 30(11), pp. 644-650.
IQBAL, Z., et al, 2021. Waiting list eradication in secondary care psychology: Addressing a National Health Service blind spot. Clinical Psychology & Psychotherapy, 28(4), pp. 969-977.
Staff Roles, Skills, Effectiveness and Practice
DYSON, J. and COWDELL, F., 2021. How is the Theoretical Domains Framework applied in designing interventions to support healthcare practitioner behaviour change? A systematic review. International Journal for Quality in Health Care, 33(3),
ELLIOTT-MAINWARING, H., 2021. How do power and hierarchy influence staff safety in maternity services? British Journal of Midwifery, 29(8), pp. 430-439.
ELLIS, R., et al, 2021. Dual surgeon operating to improve patient safety. British Journal of Oral & Maxillofacial Surgery, 59(7), pp. 752-756.
FORSETLUND, L., et al, 2021. Continuing education meetings and workshops: effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, (9),
GRAILEY, K., et al, 2021. Exploring the factors that promote or diminish a psychologically safe environment: a qualitative interview study with critical care staff. BMJ Open, 11(8), pp. e046699.
HENSHALL, C., et al, 2021. Interventions and strategies aimed at clinical academic pathway development for nurses in the United Kingdom: A systematised review of the literature. Journal of Clinical Nursing (John Wiley & Sons, Inc.), 30(11), pp. 1502-1518.
Reports
ROYAL COLLEGE OF PHYSICIANS, 2021. Caring for hospital patients with COVD-19: quality of care in England examined by case record review. London: RCP, August 2021.
KNIGHT M. et al on behalf of MBRRACE-UK, 2021. Saving Lives, Improving Mothers’ Care Rapid Report 2021: Learning from SARS-CoV-2-related and associated maternal deaths in the UK June 2020- March 2021. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2021.
PARLIAMENTARY AND HEALTH SERVICE OMBUDSMAN, 2021. Unlocking solutions in imaging: working together to learn from failings in the NHS.
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