Use of a safe procedure checklist in the cardiac catheterisation laboratory.

Background: The use of the WHO safe surgery checklist has been shown to reduce morbidity and mortality from surgical procedures. However, whether a WHO-style safe procedure checklist can improve safety in the cardiac catheterisation laboratory (CCL) has not previously been investigated.

Objectives: The authors sought to design and implement a safe procedure checklist suitable for all CCL procedures, and to assess its impact over the course of 1 year.

Mitigating Latent Threats Identified through an Embedded Simulation Program and Their Comparison to Patient Safety Incidents: A Retrospective Review.

Objective: To assess the impact of service improvements implemented because of latent threats (LTs) detected during simulation.

Design: Retrospective review from April 2008 to April 2015.

Setting: Paediatric Intensive Care Unit in a specialist tertiary hospital.

How to undertake a root cause analysis investigation to improve patient safety.

Root cause analysis is a tool that can be used when determining how and why a patient safety incident has occurred. Incidents that usually require a root cause analysis include the unexpected death of a patient, serious pressure ulcers, falls that result in injury, and some infections and medication errors. This article outlines the stages of the investigation process for undertaking a root cause analysis.

Thinking differently about complaints in the NHS.

NHS complaints have been both the precipitant and subject of numerous recent reports, inquiries and investigations. They are viewed and treated as a wholly negative aspect of NHS activity and consume significant resource and time in addition to the emotional impact on both patients and staff. Currently the stance taken by NHS providers is defensive and process-driven with little attention to the subject of the complaint and how this might provide useful and constructive information (delivery model).