Search the hub
Showing results for tags 'Blood / blood products'.
Found 137 results
-
Content ArticleSusan Warby, 57, was mistakenly given a glucose rather than a saline drip at West Suffolk Hospital after an operation for a perforated bowel in July 2018. Staff noticed a rise in blood sugar concentrations but gave her insulin to lower them rather than check the drip, which remained in place for 36 hours. In 2008 the National Patient Safety Agency made recommendations for safe arterial line management. In 2014 the Association of Anaesthetists published guidelines aimed specifically at preventing such events. Structured processes to prevent inadvertent use of a glucose-containing fluid to flush an arterial line and regular blood glucose sampling from a location other than the arterial line are only partial solutions. However, a survey of management of arterial lines undertaken in 2013 indicated that this was a common problem, that many of the NPSA recommendations were not widely implemented and that almost one third of respondents were aware of ‘wrong flush’ errors on their unit and a further third in other locations within their hospital. In this Rapid Response in the BMJ, Tim Cook says now is the time for patient representatives, clinicians, regulators and industry to work together to achieve widespread implementation of an engineered solution to prevent arterial line errors.
-
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.
-
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. -
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.
-
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.
-
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.
-
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.
-
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.
-
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.
-
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.
-
Content ArticleThe Patient Safety Movement Foundation is joined by Aryeh Shander, from Ichan School of Medicine at Mount Sinai and Englewood Hospital and Medical Center in this video. There has been a long-standing perception in medicine that blood products can be used without judicious consideration. It is important to recognise that blood is a biological product and, as such, is subject to virus, which can be transmitted from donor to recipient without detection. While there have been improvements in transfusion safety, it is important to recognise the patient's risk and benefit ratio based on their individual circumstance and thoroughly evaluate all alternatives to a transfusion.
-
Content Article
Did you know venous thromboembolism (VTE), is an umbrella term for deep vein thrombosis and pulmonary embolism? VTE is a significant cause of mortality, long-term disability and long-lasting ill-health problems – many of which are avoidable. 1 in 20 people will have a VTE at some time in their life and the risk increases with age. This NHS Resolution guide provides more information about the risks of VTE and how to spot the common signs and symptoms.
