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Showing results for tags 'Blood / blood products'.
Found 137 results
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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 -
Content ArticleBlood transfusion is considered one of the safer aspects of healthcare, however potentially avoidable patient-safety incidents led to 14 deaths in the UK in 2017. Improvement initiatives often focus on staff compliance with standard operating procedures. This fails to understand adaptations made in a complex, dynamic environment, so the aim of this study from Watt et al. is to examine the extent and nature of adaptations at all stages of the vein to vein transfusion process.
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Content ArticleThe efficacy of injection therapy in diabetes depends on correct injection technique. The aim of the Insulin Injection Technique Questionnaire was to understand how people with diabetes inject, so that guidance can be tailored towards improving injection technique. This article in the Journal of Diabetes analyses the results of the 2008-2009 survey and identifies areas where improvements have been made since the last survey, and areas where there is still progress to be made.
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Content ArticleThis article in the Journal of Diabetes Science and Technology reviews the literature from various geopolitical regions and describes how a substantial number of patients with diabetes improperly discard their sharps. Data support the need to develop multifaceted and innovative approaches to reduce the risks associated with improper disposal of medical sharps into local communities.
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Content Article
In this blog, Lotty Tizzard, Patient Safety Learning’s Content and Engagement Manager, looks at the difficulties people experience in disposing of needles and injection devices safely at home. Variation in services across the UK can lead individuals to dispose of sharps incorrectly, posing a risk to refuse workers and the wider public. -
Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) looks at the issue of emergency blood transfusions given to newborn babies who need resuscitation when they are born. If a baby has lost blood before or during birth, efforts to resuscitate them may be less effective because they may not have enough blood to carry the oxygen their body needs. Delays in the administration of a blood transfusion in this scenario can therefore result in brain injury caused by lack of oxygen to the baby’s brain. As its ‘reference case’, the investigation examined the experience of Alex and Robert, whose baby Aria was born by emergency caesarean section following an acute blood loss. Baby Aria required resuscitation and was given a blood transfusion before being transferred to the neonatal (newborn baby) unit. Baby Aria sadly died when she was two days old.
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Content ArticleThe Safer Healthcare and Biosafety Network (SHBN) is seeking input from occupational health managers based in the UK to support the establishment of a new annual UK national database of blood and body fluid exposures in healthcare workers.
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Content ArticleThe National Comparative Audit of Blood Transfusion (NCABT) is a programme of clinical audits which looks at the use and administration of blood and blood components in NHS and independent hospitals in England. Blood services in Northern Ireland, Scotland and Wales are also invited to take part. The audit aims to provide evidence that blood is being ordered and used appropriately and administered safely, and to highlight where practice is deviating from guidelines and may cause patients harm. The latest audit took place in 2021, and previous audits are also available to download on this page.
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Content ArticleThis Annual Quality Statement provides a summary of the work of Cardiff and Vale University Health Board in 2019-2020, with a particular focus on community mental health.
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Content ArticleSerious Hazards of Transfusion (SHOT) introduced a new Human Factors Investigation Tool (HFIT) in 2021. The tool can be used to investigate and capture systemic as well as individual factors where there has been an error. This case study uses the updated Human Factors Investigation Tool and Systems Engineering Initiative for Patient Safety (SEIPS) framework to work through an ABO incompatible red cell transfusion case reported to SHOT.
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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.
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Content ArticleThe purpose of this document from the Medicines and Healthcare products Regulatory Agency (MHRA) is to provide information and guidance to all involved with the purchase, management and use of non-invasive blood pressure measurement devices. It reviews the advantages and disadvantages of mercury, aneroid, electronic manual sphygmomanometers and automated blood pressure measuring devices. This should help to ensure the most appropriate technology is selected for use.
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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.
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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).
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Content Article
Ensuring safe vascular access
PatientSafetyLearning Team posted an article in Improving patient safety
This guide, published in the Health Service Journal, looks at how greater standardisation and ultimately accreditation of specialised vascular access teams would ensure a basic level of competency and quality of care. -
Content ArticleThis article discusses a new consultation that has been launched by Robert Francis QC regarding the terms of reference for an independent study into the infected blood scandal. The article covers the suggested scope, the approach and the rationale behind the research and what it won't do, such as run through evidence already heard by the Inquiry.
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Content Article
Needlestick injuries – making the point for safety
Becky T posted an article in Staff safety
An article outlining the significance of needlestick injuries - their risks to healthcare workers, their cost, and the importance of prevention. -
Content ArticleSharps injuries (SI) and mucocutaneous exposures (MCE), collectively termed “blood and body fluid exposure” (BBFE), pose a diseases-transmission risk and a psychological stress to health care workers and a responsibility on employers to prevent their occurrence. However, little UK national data is published on their incidence. The Royal College of Nursing (RCN) present results from a survey of their members.
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Content ArticleSerious Hazards Of Transfusion (SHOT) is the UK's independent, professionally-led haemovigilance scheme. This guidance replaces previous versions and provides information for healthcare professionals on reporting serious adverse reactions and serious adverse events to SHOT.
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Content ArticleThis article in The Lancet Haematology examines the impact of having different anaemia thresholds for men and for women at different life stages. It challenges the data that current medical assumptions are based on, arguing that they have been extrapolated from healthy, predominantly white populations that are not representative of real-world populations. The authors look at the arguments that has been used to determine sex-based differences in haemoglobin concentrations, and argue that there is limited evidence to justify having different anaemia thresholds for men and women. They suggest that removing sex-specific reference ranges for haemoglobin and ferritin may improve the health of women and their offspring.
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Content ArticleProfessor Ahmet Fuat, North East and North Cumbria Cardiac Network Heart Failure Lead, shares how one tool is helping reduce the current pressures and deliver better outcomes for patients. NT-proBNP testing – a NICE recommended diagnostic tool – is being used to rule out heart failure in primary care. In the North East and North Cumbria, patients must have an NT-proBNP test to be referred for an echocardiogram. This mandated testing helps them to streamline the diagnosis journey for heart failure patients by confirming or ruling out heart failure at the earliest possible opportunity, and reducing unnecessary referrals for echos. For patients, this saves time and distress, and for GPs and Nurse Practitioners, which reduces the number of repeat visits these patients often need to make.
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Content ArticleThis study in Scientific Reports aimed to understand the current situation of occupational exposure to blood-borne pathogens in a women's and children's hospital in China. The authors analysed the causes of exposure to provide a scientific basis for improving occupational exposure prevention and control measures.
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EventThis session will focus on blood and bodily fluids exposure, including sharps injuries as well as their risk factors and prevention strategies. This webinar will present the 2020 RCN study and the 2022 UK NHS Trust study of sharps injury (SI) among UK HCW and, by comparing these results with other countries, question whether UK 2013 Sharps Regulations went far enough, and whether increased emphasis may be required on reporting, recording and implementation of effective prevention strategies. Learning outcomes: Define sharps injuries (SI); the four steps in sharps usage that place staff at risk; and the top two staff groups at risk of SI. Discuss the incidence of SI in the UK and UK HCW staff groups compared with international incidences. Appraise whether facility’s reporting and recording of SI enables benchmarking of the efficacy of their preventive strategies. Define three prevention strategies proven to reduce SI. Register
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Event
SHOT: Transfusing wisely webinar
Patient-Safety-Learning posted an event in Community Calendar
untilSign up for this webinar -
Content ArticleDelays in the detection or treatment of postpartum haemorrhage can result in complications or death. A blood-collection drape can help provide objective, accurate, and early diagnosis of postpartum haemorrhage, and delayed or inconsistent use of effective interventions may be able to be addressed by a treatment bundle. Authors of this study, published in the New England Journal of Medicine, conducted an international, cluster-randomized trial to assess a multicomponent clinical intervention for postpartum haemorrhage in patients having vaginal delivery. The intervention included a calibrated blood-collection drape for early detection of postpartum haemorrhage and a bundle of first-response treatments (uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, examination, and escalation), supported by an implementation strategy (intervention group).
