Search the hub
Showing results for tags 'Blood / blood products'.
-
Content ArticleIn 2008, the National Patient Safety Agency (NPSA) issued a Rapid Response Report concerning problems with infusions and sampling from arterial lines. The risk of blood sample contamination from glucose‐containing arterial line infusions was highlighted and changes in arterial line management were recommended. Despite this guidance, errors with arterial line infusions remain common. Gupta and Cook report a case of severe hypoglycaemia and neuroglycopenia caused by glucose contamination of arterial line blood samples. This case occurred despite the implementation of the practice changes recommended in the 2008 NPSA alert. They report an analysis of the factors contributing to this incident using the Yorkshire Contributory Factors Framework. They discuss the nature of the errors that occurred and list the consequent changes in practice implemented in their unit to prevent recurrence of this incident, which go well beyond those recommended by the NPSA in 2008.
- Posted
-
- Human error
- Human factors
- (and 5 more)
-
Content Article
Annual SHOT report 2019
Patient Safety Learning posted an article in Other
SHOT (Serious Hazards of Transfusion) is the UK's independent professionally led haemovigilance scheme. This year’s Annual SHOT Report looks back at trends and data for the last calendar year, but also highlights several very important messages for us in the present extraordinary times. The data in the report come from across the UK and include material from all areas of healthcare where transfusion is practised.- Posted
-
- Medicine - Haematology
- Blood / blood products
- (and 3 more)
-
Content ArticleUnknown to its hypertension specialists, a major teaching hospital changed the cuffs on its sphygmomanometers from manufacturer-validated to a uniform washable alternative, in line with ‘Health and Safety’ concerns surrounding potential cross-contamination between patients. When clinic doctors suspected serious under-reading with the new cuffs, a systematic comparison was undertaken in 54 patients using two UM-101 sphygmomanometers: one using the original, manufacturer-supplied cuff and the other with the washable replacement. The study confirmed an average under-reading of 8±10/5±5 mm Hg using the washable cuff, and a third of patients with poorly controlled hypertension were considered normotensive, after using this cuff. The UM-101 sphygmomanometers have now been re-fitted with the original cuffs. Sphygmomanometer cuffs are not interchangeable between devices and a modicum of common sense should be shown to prevent changes made in the name of Health and Safety from having the opposite effect to that intended.
- Posted
-
- Blood / blood products
- Medical device
-
(and 2 more)
Tagged with:
-
Content ArticleBlood pressure (BP) has been measured with a cuff for over a 100 years. Recently, ‘tricorders’ and smartwatches that measure BP without a cuff using pulse transit time (PTT) have become available. These BP measurements are based on the inverse relationship between BP and PTT. PTT can be measured as the timing delay in a QRS complex on an EKG and the onset of a photoplethysmography wave, for example measured from a finger. Since these measurements are relatively more user‐friendly than conventional cuff‐based measurements they may aid in more frequent BP monitoring. Using a guidelines‐based protocol, Bard et al. investigated the accuracy and precision of two popular PTT‐based BP measuring devices: the Everlast TR10 fitness watch (Everlast, New York City, NY) and the BodiMetrics tricorder (BodiMetrics, Manhattan Beach, CA).
- Posted
-
- Blood / blood products
- Medical device
-
(and 2 more)
Tagged with:
-
Content ArticleThe ongoing coronavirus outbreak is an understandable concern for all of us and people with a weakened immune system are at a higher risk of experiencing more serious complications from it. This web resource from the charity Anthony Nolan, gives advice on the coronavirus for people who have received or are waiting to receive a stem cell transplant to treat their blood cancer or blood disorder. Anthony Nolan is working alongside other cancer charities, medical experts and the NHS to make sure this advice is updated as the situation develops.
- Posted
-
- Surgery - General
- Blood / blood products
- (and 3 more)
-
Content ArticleMaybe your blood pressure has been creeping up over time, or you’re starting treatment for hypertension. So your doctor suggests you buy a home blood pressure monitor to help keep track between office visits. Simple enough, right? But a quick check online reveals hundreds of different models — and even a bunch of apps for your smartphone. How do you even start to sort through all that without, well, spiking your blood pressure? This article highlights six things you need to know.
- Posted
-
- Blood / blood products
- Medical device
-
(and 3 more)
Tagged with:
-
News Article
Infected Blood Enquiry: Timetable and factsheet for expert hearings
Clive Flashman posted a news article in News
This is the independent public statutory inquiry into the use of infected blood. The timetable and factsheet to provide information for those attending the hearings in London on 24-28 February have just been published. Go to this link for more information >> https://www.infectedbloodinquiry.org.uk/news- Posted
-
- Investigation
- Legal issue
- (and 3 more)
-
Content ArticleSHOT is the United Kingdom independent, professionally led haemovigilance scheme. Since 1996 SHOT has been collecting and analysing anonymised information on adverse events and reactions in blood transfusion from all healthcare organisations that are involved in the transfusion of blood and blood components in the United Kingdom. Where risks and problems are identified, SHOT produces recommendations to improve patient safety. The recommendations are put into its annual report which is then circulated to all the relevant organisations including the four UK Blood Services, the Departments of Health in England, Wales, Scotland and Northern Ireland and all the relevant professional bodies as well as circulating it to all of the reporting hospitals. As haemovigilance is an ongoing exercise, SHOT can also monitor the effect of the implementation of its recommendations.
- Posted
-
- Blood / blood products
- Medicine - Haematology
- (and 2 more)
-
News Article
Refusing Scottish help a 'grave error' in blood scandal, letter says
Patient Safety Learning posted a news article in News
Hundreds of people with haemophilia in England and Wales could have avoided infection from HIV and hepatitis if officials had accepted help from Scotland, newly released documents suggest. A letter dated January 1990 said Scotland’s blood transfusion service could have supplied the NHS in England and Wales with the blood product factor VIII, but officials rejected the offer repeatedly. Large volumes of factor VIII were imported from the US instead, but it was far more contaminated with the HIV and hepatitis C viruses because US supplies often came from infected prison inmates, sex workers and drug addicts who were paid to give blood but not screened. The death of scores of people with haemophilia and blood transfusion patients and the infection of thousands of others across the UK in the contaminated blood scandal has been described as the worst health disaster to hit the NHS. The latest document was released under the Freedom of Information Act to campaigner Jason Evans, whose father died in 1993 having contracted hepatitis and HIV. In it, Prof John Cash, a former director of the Scottish Blood Transfusion Service, said the decision not to use Scotland's spare capacity to produce Factor VIII for England was "a grave error of judgement". Read full story Source: The Guardian, 3 January 2020- Posted
-
- Decision making
- Risky behaviour
-
(and 1 more)
Tagged with:
-
Content ArticleIn 2008, the UK National Patient Safety Agency (NPSA) made recommendations for safe arterial line management. Following a patient safety incident in their intensive care unit (ICU), Leslie et al. surveyed current practice in arterial line management and determined whether these recommendations had been adopted. They contacted all 241 adult ICUs in the UK; 228 (94.6%) completed the survey. Some NPSA recommendations have been widely implemented – use of sodium chloride 0.9% as flush fluid, two‐person checking of fluids before use – and their practice was consistent. Others have been incompletely implemented and many areas of practice (prescription of fluids, two‐person checking at shift changes, use of opaque pressure bags, arterial sampling technique) were highly variable. More importantly, the use of the wrong fluid as an arterial flush was reported by 30% of respondents for ICU practice, and a further 30% for practice elsewhere in the hospital. This survey provides evidence of continuing risk to patients.
- Posted
-
- Medical device / equipment
- Blood / blood products
- (and 7 more)
-
Content ArticleIn the US, approximately 700 women die annually from pregnancy-related complications.The most frequent cause of severe maternal morbidity and preventable maternal mortality is obstetric haemorrhage — excessive blood loss from giving birth. As a result of this significant patient safety concern, The Joint Commission introduced two new standards, effective 1 July 2020, to address complications in maternal haemorrhage and severe hypertension/ preeclampsia. This Quick Safety provides background information around strategies for the management of maternal haemorrhage that are outlined in new Provision of Care, Treatment, and Services standard.
- Posted
-
- Obstetrics and gynaecology/ Maternity
- Patient death
- (and 1 more)
-
Content ArticleThe Healthcare Safety Investigation Branch (HSIB) latest report highlights that mislabelling of blood samples could pose a deadly risk to patients. The reference event in the report is a case where patient details became mixed up on blood samples sent from a maternity unit. In the case of mislabelling on blood transfusion samples, the impact could be devastating. There’s the potential for serious injuries and even death.
- Posted
-
- Near miss
- Blood / blood products
- (and 4 more)
-
Content ArticlePulmonary embolism resulting from deep vein thrombosis, collectively referred to as venous thromboembolism, is the most common preventable cause of hospital death in the US. Pharmacologic methods to prevent venous thromboembolism are safe, effective, cost-effective, and advocated by authoritative guidelines, yet large prospective studies continue to demonstrate that these preventive methods are significantly underused.
- Posted
-
- Surgery - Vascular
- Hospital ward
- (and 3 more)
-
Content ArticleThis action plan was produced by the Ipswich & East Suffolk Clinical Commissioning Group and West Suffolk Clinical Commissioning Group following a treatment delay for a patient in intensive care.
- Posted
-
- Patient
- Accident and Emergency
- (and 12 more)
-
Content ArticleThis guideline from the National Institute for Health and Care Excellence (NICE) covers preventing and controlling healthcare-associated infections in children, young people and adults in primary and community care settings. It provides a blueprint for the infection prevention and control precautions that should be applied by everyone involved in delivering NHS care and treatment.
- Posted
-
- Health and safety
- Blood / blood products
- (and 6 more)