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Showing results for tags 'Near miss'.
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Community PostHi The new Patient Safety Incident Response Framework is due for publication this month for early adopters and as 'introductory guidance' for everyone else: https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/ I wondered if there is anyone who is involved in an organisation that is an early adopter who can share what has happened so far and also would be willing to share any local learning as the new framework is implemented? Also, more generally wondered if anyone has any initial comments on the proposals which were mentioned in the NHS patient safety strategy and any things in particular which they think will bring benefit or could represent significant challenges or issues?
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Content ArticleContent includes: Patient Safety: We’ve Come a Long Way National Patient Safety Consortium: Learning from Large-Scale CollaborationPatient Engagement in a Large-Scale Change Initiative: “As Safe as Possible, as Soon as Possible” Commentary: Three Ideas About “Post-Vention” Patient Safety Never Events: Cross-Canada Checkup Empowering Patients: 5 Questions to Ask About Your Medications Accelerating Post-Surgical Best Practices Using Enhanced Recovery After Surgery Patient Safety Culture Bundle for CEOs and Senior Leaders Commentary: We Must Look at Multiple Perspectives Homecare Safety Virtual Quality Improvement Collaboratives Commentary: Patient Safety in the Home Measuring and Monitoring Healthcare-Associated Infections: A Canadian Collaboration to Better Understand the Magnitude of the Problem Patient Safety: Patient Involvement Matters.
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Annual SHOT report 2019 (7 July 2020)
Patient Safety Learning posted an article in Other
As in previous years, it is certain that under-reporting is significant. Reporting rates in some of the higher usage Trusts/Health Boards vary twentyfold. Given the cultural, resource and procedural similarities of these organisations, it is highly unlikely that the error and mishap rate varies by anything like this much, so reporting rates are likely to play a large part. One area where this is likely to have greatest impact is in the reporting of near misses, the most fertile learning area. The leading causes of transfusion-related incidents are, again this year, ‘human factors’ related, with procedural failures and flawed decision-making contributing in large measure. While decision support tools and information technology have gained some traction, and continue to help us progress in these areas, their universal adoption remains some way off. Until these are more widespread, we continue to rely on education and peer pressure to encourage best practice. A ‘human factors’ approach is key to understanding why errors and accidents continue to occur, despite, in many cases, adequate training, knowledge, expertise and currency. Those areas of hospitals which are under greatest stress and pressure, for example, emergency departments, continue to report a year on year increase in errors. Despite this, transfusion remains very safe indeed,with the risk of serious harm being 1 in 17,884 and death 1 in 135,705 transfused components in the UK. -
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Misuse of hydrogen peroxide in a theatre environment
Kathy Nabbie posted an article in Good practice
During my many years of working in operating theatres, I observed that hydrogen peroxide was adopted by surgeons as a ritual for washing out wounds and deep cavities. An entire bottle of 200 ml hydrogen peroxide was mixed with 200 ml of normal saline. It seems this ritual was passed down from consultant to trainee and it then became a habit. In a recent post on the hub, I mentioned that women in 1920 were given Lysol as a disinfectant to preserve their feminity and maritial bliss! Lysol contains hydrogen peroxide, so women were daily irrigating their vaginas with a harmful solution of fizz, unaware of the hazards. I believe it is still being used to colour hair, remove blood stains, as a mouthwash gargle and also to whiten teeth. Then suddenly a breakthrough! In 2014, in my email inbox, a yellow sticker warning appeared from the Medicines and Healthcare products Regulatory Agency (MHRA) regarding the use of hydrogen peroxide in deep cavities. So why did the MHRA ban the use of hydrogen peroxide in deep cavities? Hydrogen peroxide is contraindicated for use in closed body cavities or on deep or large wounds due to the risk of gas embolism. Hydrogen peroxide breaks down rapidly to water and oxygen on contact with tissues. If this reaction occurs in an enclosed space, the large amount of oxygen produced can cause gas embolism.[1] There has been several case reports that have been published from around the world of life threatening or fatal gas embolism with use of hydrogen peroxide in surgery, of which five were from the UK. Most of the global reports describe cardiorespiratory collapse occurring within seconds to minutes of instillation of hydrogen peroxide as wound irrigation or when used to soak swabs for wound packing. This was sometimes accompanied by features associated with excess gas generation such as surgical emphysema, pneumocephalus, aspiration of gas from central venous lines, or the presence of gas bubbles on transoesophageal echocardiography. Non-fatal events were sometimes associated with permanent neurological damage such as neuro-vegetative state and hypoxic encephalopathy.[1] As the Practice Development Lead for the theatre department where I worked it was my role to pass on and act on the information received from the MHRA, so I discussed it with my very supportive theatre manager and then escalated to the theatre staff. But some consultants still ask for it today; it is always refused. So why do consultants request it when they are aware of the hazards? One theatre never event describes a syringe of hydrogen peroxide given to a consultant and injected into a joint instead of the required local anaesthetic![2] The patient survived but required care in the intensive care unit. As a scrub nurse practitioner this scares me. What about you? Would you now research this yellow sticker alert further, implement best practice and speak up, or would you just keep quiet and go "with the flow?" We all make mistakes, but learning from our errors will always be the ultimate key to improvement in healthcare and best practice and safety for our patients. References 1. Medicines and Healthcare products Regulatory Agency. Hydrogen peroxide: reminder of risk of gas embolism when used in surgery. 19 December 2014. 2. Chung J and Jeong M. Oxygen embolism caused by accidental subcutaneous injection of hydrogen peroxide during orthopedic surgery. A case report. Medicine (Baltimore) 2017; 96(43): e8342. -
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Hitting the target, missing the point
Anonymous posted an article in Florence in the Machine
What’s the worst thing you have ever seen? For those that work on the frontline in healthcare you may have heard this question asked many times… usually by friends or people you meet when you are trying to relax outside of work. They often want to hear some awful blood and guts story, something unusual being stuck in an unfortunate person’s orifice or a heroic story of a dramatic rescue. We all have something to tell along these lines. Especially when you work in ED, like me. Yep, they are awful episodes, especially for those involved, these awful stories often happen in ED. Car crashes, trauma, cardiac arrests, injured, sick children… you name it, I’ve probably seen it. When tragic things happen, we have support to get us through them. We have support from our wonderful work colleagues who understand – most of the time black humour gets us through. I want to tell you about the worst thing I ever saw, I still see, we all still see. It wasn’t a one off, I didn’t get any support, we didn’t get any support. In fact, it went unnoticed and it happened multiple times and often for hours on end. It’s like being in a recurrent bad dream, the trouble is that it isn’t a dream. It’s real and it's probably happening in hospitals up and down the country today. Rose tinted spectacles… It’s a Tuesday afternoon. It’s a warm, sunny day. I have had 2 whole days off. I’m rested and ready for the day ahead. I drive to work in a good mood. Today is going to be a great day. I walk up to the ED entrance. My hopes of a good day are dashed. There are already eight ambulances outside. I hear the sirens of another in the distance coming up the road. Perhaps the department was already empty… it might not be that bad? I step inside. Two paramedics wheel an elderly man up to the desk. He looks frail, he has a bruised face and blood running from his nose. He looks frightened. He has fallen in his rest home. "… you will have to park him in the corridor, love..." The corridor is now an ‘area’ in our ED. It’s not a walkway between two clinical areas, it’s now clinical area itself. We even have allocated a ‘corridor nurse’ to care for this group of patients. The corridor is full. Each side of the corridor there are people. People on trollies, in chairs, in wheelchairs. I feel their eyes staring at me. Someone is calling out for water, someone has vomited on the floor, an elderly lady is wandering around with her hospital gown on, it's not done up properly and everyone can see her bottom. Every few steps I take I hear someone ask when they are going to be seen. I see a couple crying, trying to console each other in full view of the onlooking people who have nothing else to do but wait. I must walk down to get to the staff room to start my shift. I feel like I am running the gauntlet. I need to get changed and get on with moving people out of the department. I hear staff members muttering "thank god the day staff are here" and "good luck, you’re going to need it". Ok, If I was able to nurse the way I have been taught; ensuring patients are listened to, made comfortable, had medication on time, are given food and water, turned if required, clean… basic nursing care, maybe I wouldn’t feel as crap as I do when I go home. Maybe I’m in the wrong job? But… this type of nursing takes time. Time is forever ticking, especially in ED. It's all about flow. Get them seen, treated and moved – within 12 hours. Sounds a long time 12 hours, doesn’t it? It’s not in healthcare. Blink, 12 hours have gone in a flash. Site managers constantly circle the nurses’ station with their clip boards, trying to strategically place patients on appropriate wards. Single sexed bays, side room, isolation rooms, monitored beds, surgical, medical, trauma, elective, the list goes on. It must be like playing one of those online strategy games, but it never ends. I’m now waiting for handover. The noise is deafening. White noise. I try and block out other people’s instructions, conversations, phones ringing, doors banging. My senses are overloaded. Not only is it too loud, the smell of stale alcohol and vomit is left in the air from an overdose that came in earlier, the irony smell of blood left by lady with a bleeding ulcer, the heat of the corridor and a hint of pseudomonas from a leaking leg ulcer – there are no windows here to give us any relief. This is my next 12 hours. People who are wearing lanyards appear. I see them when things go ‘tits up’. No idea who they are, what they do or where they come from. Never have they spoken to me and I have never seen them speak to a patient. They arrive in immaculate clothing and smell fresh, whereas I have been here a few hours and already blended in with the current smells. They are obsessed with how long people have stayed in the department. I see them frown and start talking to the site managers, who then speak to our nurse in charge, who then will speak to me. "We need to move X number of patients out of here in the next 2 hours." So, if I choose to help a man who may have soiled himself – this may take up to 40 minutes. That’s too long. I should have been preparing my patients to move off. But then if I don’t help him, the ward he moves onto will report me. Notes to prepare, IV antibiotics to give with in 1 hour, comfort rounds every 2 hours, mouth care, turn charts, feeding regimes, safety documentation to be completed, toileting, venepuncture, sepsis pathways, NEWS charting, escalation protocols… so many targets to be met. I can’t do this. It’s impossible. ‘The standard you walk past is the standard you accept’ Every time I walk down that corridor – I say this in my head. I have failed. We have failed our patients. That is the worst thing I have ever seen.- Posted
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Community PostWhat do hub members think about use of the term "near miss" vs "close call" vs "good catch" to describe errors that are caught before the reach or harm the patient? If you have a favorite, can you say why?
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Community PostDo any areas of healthcare capture ALL near misses and act on them? What systems do you use?
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Content ArticleIn this five minute video, the authors chose to focus on the main theme – the human cost to healthcare workforce when there is a failure to cultivate a just culture and systems approach overall, but especially when managing unfortunate harm events.
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Content ArticleNational data from SHOT (Serious Hazards of Transfusion) indicates there were 792 ‘wrong blood in tube’ near misses (where the error was spotted in time and no patient suffered harm) relating to blood transfusion samples, in 2018 across England. This doesn’t account for blood samples taken for any other purpose. The HSIB report showed why these incidents happen and most importantly what can be done to reduce the risk of it happening again. The investigation looked at all the factors involved and found evidence to show that electronic systems could help staff in busy environments, by making the processes easier and more efficient, to manage and reduce the risk to patients.
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Content ArticleMedication errors are not usually required to be reported to the CGC unless in these circumstances: death injury abuse, or allegation of abuse incident reported to or investigated by the police. Challenge: How do social care and non-NHS providers ensure that concerns are raised and there is a safe reporting culture?
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The Heinrich/Bird safety pyramid
Claire Cox posted an article in In health care
The Heinrich/Bird safety pyramid is presented in an article in Risk Engineering. It includes an infographic with Heinrich's Accident Triangle. This triangle suggests that the ratio between fatal accidents, accidents, injuries and minor incidents are similar across all industries. It highlights the importance of investigating the minor incidents to present fatal incidents. Challenge: In healthcare, are we investigating the wrong incidents? -
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Patients given wrong air in oxygen mix-up at hospital
Patient Safety Learning posted a news article in News
A hospital has made changes after two patients were accidentally given medical air instead of oxygen. The two incidents, which took place at the Norfolk and Norwich University Hospital (NNUH), were classed as "never events" meaning they were serious but preventable. They happened to patients in November who were being handed over to the hospital by the East of England Ambulance Service. The patients should have been given oxygen but were given medical air instead which only contains 20pc oxygen. The ambulance service said in a message to staff: "Severe harm or death can occur, if medical air is accidentally administered to patients instead of oxygen. As per NNUH's request, with immediate effect, when handing over at the NNUH, all medical equipment and oxygen should be swapped only by an emergency department doctor or registered nurse." Read full story Source: Eastern Daily Press, 2 December 2019 -
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