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Showing results for tags 'Blood / blood products'.
Found 140 results
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Content ArticleFrequent and wide ‘swings’ in blood glucose levels are common in the hospital setting, for both diabetic and non-diabetic patients, due to factors including, but not limited to, physiologic stress, certain medications and procedures. However, these uncontrolled swings in glucose levels can be detrimental to patients and can compromise wound healing, increase risk of infection, and delay surgical procedures and discharge. Early recognition and anticipation of blood sugar swings have proven to be effective in improving outcomes but require significant infrastructural changes within the organisation. Many healthcare organisations have successfully implemented and sustained blood glucose management initiatives.These organisations have focused on projects that included education around and trigger tools for early recognition and anticipation of blood sugar “swings”. This document provides a blueprint that outlines the actionable steps organisations should take to successfully improve blood glucose management and summarises the available evidence-based practice protocols.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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. -
Content ArticleThe National Infusion and Vascular Access Society (NIVAS) is a multidisciplinary organisation made up of healthcare professionals with a special interest in vascular access and IV therapy. This white paper by NIVAS lays out evidence that having a nursing-led vascular access team in every hospital in the UK will improve patient safety, reduce workload pressures for other staff, and save the NHS money. Vascular access involves the use of devices such as catheters to deliver or remove fluids, blood or medication from a patient’s bloodstream. The paper examines the arguments advocating for Vascular Access Services Team (VAST) across the NHS, acknowledging the current pressures of restarting the NHS following the pandemic and the roadmap to reduce the elective waiting lists. It also outlines how integrating a standardised model of VAST into the healthcare systems of the NHS will benefit patients, the new Integrated Care Systems (ICS) and the wider objectives of the NHS.
