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Showing results for tags 'protocols and procedures'.
Found 82 results
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Content ArticleThe variety of alarms from all types of medical devices has increased from 6 to 40 in the last three decades, with today’s most critically ill patients experiencing as many as 45 alarms per hour. Alarm fatigue has been identified as a critical safety issue for clinical staff that can lead to potentially dangerous delays or non-response to actionable alarms, resulting in serious patient injury and death. To date, most research on medical device alarms has focused on the nonactionable alarms of physiological monitoring devices. While there have been some reports in the literature related to drug library alerts during the infusion pump programming sequence, research related to the types and frequencies of actionable infusion pump alarms remains largely unexplored.
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Content ArticleOperating theatre fires remain an uncommon but real safety risk for patients undergoing nearly all types of procedures, and despite ongoing safety initiatives, occur more commonly than wrong-site surgeries. One of the most compelling cases for safety improvement in the surgical setting is within this area. Combining the simple steps of operating theatre team education; improving lines of communication between surgeons, anaesthetists, and operating theatre nurses or practitioners; and the deliberate separation of the elements of the fire triangle can almost completely eliminate the incidence of surgical fires. In this brief review, Cowles Jr and Culp Jr hope that readers will be able to reduce the risk of surgical fires effectively by the application of the safety principles described.
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Content ArticleOn 17 November, there will be a Parliamentary launch event of the Surgical Fires Expert Working Group’s report 'A case for the prevention and management of surgical fires in the UK, which focuses on the prevention of surgical fires in the NHS'. Unfortunately surgical fires are still a patient safety issue. Each year patients needlessly suffer burns during surgical procedures which leave them with long-lasting, life-changing injuries and burdens the NHS with millions of pounds of avoidable costs and liabilities. Despite this, there is not a consistent, standardised approach across the NHS to prevent them. Kathy Nabbie, a theatre scrub nurse practitioner, shares how she implemented Fire Risk Assessment Score (FRAS) into her department.
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Content ArticleThe NHS workforce has a remarkable record in providing safe, effective and equal care for everyone. But, like many healthcare systems around the world, the NHS is facing significant day-to-day challenges, made worse by the outbreak of COVID-19 and the resulting effects on health and social care. The NHS should only offer tests, treatments and procedures, often referred to as interventions, that the best available evidence shows is the most appropriate and clinically effective. Research evidence shows that some interventions are not clinically effective or only effective when they are performed in specific circumstances. And as medical science advances, some interventions are superseded by those that are less invasive or more effective. At both national and local levels, there is a general consensus that more needs to be done to ensure that the least effective interventions are not routinely performed, or only performed in more clearly defined circumstances. Earlier this year, NHS England and NHS Clinical Commissioners launched a new programme focusing on items that should not be routinely prescribed in primary care. 31 interventions were identified and the public invited to comment on them. The consultation period is complete and the responses that have been submitted will be considered and a final recommendation made later in the year.
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Content Article
CPSI: Safer Healthcare Now!
Patient Safety Learning posted an article in Healthcare Excellence Canada
The Safer Healthcare Now! campaign was launched in 2005 and provides interventions to raise awareness and facilitate implementation of best practices to support patient safety improvement in Canada. The interventions serve as a resource for frontline healthcare providers, healthcare organisations, and health quality committees and councils. This Canadian Patient Safety Institute (CPSI) web page provides information, resources, and tools you can put into practice to identify, prevent, and learn from patient safety incidents. -
Content ArticleEach quarter, the Patient Safety Movement Foundation hosts a free webinar on a variety of central patient safety topics aligned with their Actionable Patient Safety Solutions (APSS). This session addressed airway safety. It's focus was on how existing, high-impact solutions can be planned to reduce unplanned extubation. The presentation was given by Dr. Art Kanowitz.
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Content ArticlePatient Safety Movement Foundation is joined in this video by Kourtney Wilson, Clinical Practice Consultant, Regional Patient Care Services, Maternal Child Health-Obstetrical Concentration, Kaiser Permanente, to discuss the need for standardised massive transfusion protocols in the context of postpartum haemorrhage (PPH) and the common barriers hospitals face in effectively establishing these protocols.
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ECRI: Wrong-site surgery (14 December 2020)
Patient Safety Learning posted an article in Surgery
Wrong-site surgery is a broad, generic term that encompasses all surgical procedures performed on the wrong patient, the wrong body part, or the wrong side of the body; it can also describe performing the wrong procedure on, or performing on the wrong part of, a correctly identified anatomic site. This guidance from ECRI reviews the various types of wrong-site surgery; discusses the incidence, risk factors, and causes of wrong-site surgery; examines barriers to effective risk reduction; highlights Joint Commission’s elements of performance for the Universal Protocol and other accreditation and regulatory issues; and offers guidance for implementing strategies to prevent the occurrence of wrong-site surgery -
Content Article
Mölnlycke: SSI Risk Reduction Partnership
Patient Safety Learning posted an article in Surgery
Surgical Site Infections (SSIs) are a problem of increasing concern with major implications for both patients and the NHS. Between 2014 – 2019 SSIs, as a percentage of all healthcare associated infections, jumped from 16% 1 to 20%. It is a growing problem, in need of a solution. Mölnlycke has developed the Risk Reduction Partnership is a new initiative that has been specifically designed to combat the problem and potentially help reduce its incidence and impact. -
Content ArticleHealth information technology (HIT) provides many benefits, but also facilitates certain types of errors, such as wrong-patient errors in which one patient is mistaken for another. These errors can have serious patient safety consequences and there has been significant effort to mitigate the risk of these errors through national patient safety goals, in-depth research, and the development of safety toolkits. Nonetheless, these errors persist. Kim et al. analysed 1,189 patient safety event reports using a safety science and resilience engineering approach, which focuses on identifying processes to discover errors before they reach the patient so these processes can be expanded.They analysed the general care processes in which wrong-patient errors occurred, the clinical process step during which the error occurred and was discovered, and whether the error reached the patient. For those errors that reached the patient, they analysed the impact on the patient, and for those that did not reach the patient, they analysed how the error was caught.
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Content ArticleWrong-site surgery (WSS) is a well-known type of medical error that may cause a high degree of patient harm. In Pennsylvania, healthcare facilities are mandated to report WSS events, among other patient safety concerns, to the Pennsylvania Patient Safety Reporting System (PA-PSRS) database.
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Content ArticleMany types of audits are commonly used in hospital care to promote quality improvements. However, the evidence on the effectiveness of audits is mixed. The objectives of this review from Gans et al. is (1) to understand how and why audits might, or might not, work in terms of delivering the intended outcome of improved quality of hospital care and (2) to examine under what circumstances audits could potentially be effective.
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Content ArticleStewart Munro, Managing Director of Pentland Medical Ltd, highlights some of the current procurement problems within the NHS and explains why this needs to change if we want to improve patient and staff safety.
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Content ArticleThis article from Delaveris et al. outlines one health system's experience implementing a bundle to reduce sepsis-related mortality and the observed connection between adherence to the bundle and improved sepsis care.
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Content ArticleThis article from Petriceks and Schwartz, published in Palliative & Supportive Care, describes a four-element approach centered on Goals, Options, Opinions and Documentation that serves as an effective structure for clinicians to have conversations with patients and families to address care management when the path forward is unclear.
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Content ArticleECRI Institute's mission is to protect patients from unsafe and ineffective medical technologies and practices. More than 5,000 healthcare institutions and systems worldwide, including four out of every five U.S. hospitals, rely on ECRI Institute to guide their operational and strategic decisions.
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Content Article
Safe practices for drug allergies using CDS and health IT (2019)
Claire Cox posted an article in Allergies
The Partnership for Health IT Patient Safety, a national collaborative convened by ECRI Institute, has released a new report on drug allergy interactions and how clinical decision support (CDS) and health information technology (IT) can be used to improve safety. Drug allergy alerts, a feature of clinical decision support (CDS), incorporated within the electronic health record (EHR), act as a safeguard against prescribing or dispensing a medication to which a patient has a documented allergy that could cause an adverse event for a patient. Drug allergy interactions are an important patient safety concern. Inadequate communication and display of drug allergy interaction information may result in incorrect treatment, delay care, or result in additional or prolonged care for a patient. -
Content ArticleWhen patients are harmed as a result of the care they receive through Alberta Health Services (AHS), the organisation has a responsibility to understand how the harm happened and, where appropriate, respond to improve the healthcare system. This handbook has been developed to assist and support AHS staff and medical staff to retrospectively review clinical adverse events, hazards and close calls using Systems Analysis Methodologies (SAM). It is not an administrative review of individual healthcare provider performance. Using these methodologies, the complex interactions of all the components within the health system are considered, not the individual contributions of healthcare providers that have or may have led to harm. This creates opportunities to identify vulnerabilities in structures, processes and practices that can be improved and ultimately make care safer.
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Content ArticleMedicines reconciliation and medication reviews play an integral part in medicine optimisation. Medicines reconciliation is the process of accurately listing a person’s medicines. This could be when they're admitted into a service or when their treatment changes. It involves recording a current list of medicines, including over-the-counter and complementary medicines. Then, the list is compared with the medicines the person is actually using. It involves recognising and resolving any discrepancies and documenting any changes. The medicines reconciliation process will vary depending on the care setting that the person has moved into (or from). Trained and competent staff should carry out the medicines reconciliation. They should consult with a health professional. Ideally, this should be the person’s GP, nurse or pharmacist.
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My experience in a coroner’s court – a nurse perspective
Anonymous posted an article in Florence in the Machine
This is the story of a nurse's experience when attending a coroner's court and how the Trust supported them through this difficult time.- Posted
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Letter from America: a Fall tradition to learn from
lzipperer posted an article in Letter from America
‘Letter from America’ is a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. The series will cover successes large and small. I share them here to generate conversations through the hub, over a coffee and in staff rooms to transfer these innovations to the frontline of UK care delivery. -
Content Article
Safer outcomes for people with psychosis
Dorit posted an article in By patients and public
Dorit describes the assessment and subsequent death of her much loved daughter-in-law who died during a psychotic episode having been discharged the previous evening. Her story raises a number of questions: How should families be included in making judgements and assessments about the patient and their well-being? What support do they need to care for a very distressed loved one? Why aren't written care and contingency plans provided to the patient and their family? What more needs to be done to ensure standard practices are in place to protect patients with psychosis? -
Content Article
Patient Safety Journal
Claire Cox posted an article in Suggest a useful website
The latest issue of the Patient Safety Journal is now out. US patient safety journal brought to you by the Patient Safety Authority, an independent agency of the Commonwealth of Pennsylvania. Each issue publishes original, peer-reviewed research and data analyses and also gives patients a voice. It's mission is to give clinicians, administrators and patients the information they need to prevent harm and improve safety. -
Content ArticleIn January 2017, I read an article in Outpatient Surgery involving an elderly patient in the US who suffered multiple burns following the use of chlorohexidine bottled alcoholic prep. The Oregon woman filed a million-dollar lawsuit against the Oregon Outpatient Surgery Center in Tigard, Ore., saying she suffered severe burns when her face caught on fire during an electrocautery procedure. Having read this tragic story and escalated it to my theatre manager and colleagues, I decided to design and evaluate a FRAS (Fire Risk Assessment Score) and use it as part of the WHO Surgical Checklist at "time out" to raise awareness of fires in operating theatres.
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Content ArticleThe National Institute for Healthcare Research (NIHR) are the nation's largest funder of health and care research and provide the people, facilities and technology that enables research to thrive. Working in partnership with the NHS, universities, local government, other research funders, patients and the public, they deliver and enable world-class research that transforms people's lives, promotes economic growth and advances science.
