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Found 12 results
  1. Content Article
    Some aspects of COVID-19 presentation and treatment present special challenges for safely confirming nasogastric tube position. The dense ground-glass x-ray images can make x-ray interpretation more difficult, and the increasing use of proning manoeuvres in conscious patients increases the risk of regurgitation of gastric contents into the oesophagus and aspiration into the lungs which will render pH checks less reliable This aide-memoire is not designed to replace existing, established, NHSI compliant practice of NG confirmation. If a critical care provider is in the fortunate situation of having nursing and medical staff who have all completed local competency-based training in nasogastric tube placement confirmation aligned to local policy, they would be able to continue more complex local policies. Such policies might include specific advice indicating which critical care patients could have pH checks for initial placement confirmation, and which require x-tray confirmation, and how second-line checks should be used if first-line checks are inconclusive. However, staff returning to practice, or redeployed to critical care environments, including in Nightingale hospitals, will be helped by reminders of established safety steps in a form that can be used for all critical care patients, rather than requiring different processes for different patients.
  2. Content Article
    BAPEN recognises that resources will be limited and often patchy depending on availability of appropriately trained staff – doctors, nurses, dietitians and pharmacists. The demands posed by large numbers of COVID -19 patients with pneumonia, especially on CPAP or ventilators in critical care and intensive care settings will test the capacity of all involved. It follows that special care still needs to be taken to ensure nutritional support is given where indicated whilst avoiding complications associated with tube misplacement in the lungs or oesophagus followed by infusion of nutrients, drugs or water – so called “Never Events”. BAPEN has provided the following advice: An overview of opinions on nasogastric tubes as aerosol generating procedures during the Covid-19 crisis COVID-19 & enteral tube feeding safety
  3. Content Article
    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.
  4. Community Post
    Hi 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?
  5. News Article
    The Association for Perioperative Practice (AfPP) is calling for action to be taken after a recent report suggests little progress has been made to prevent errors within the perioperative environment. The patient safety charity made the call following the release of NHS Improvement’s latest Never Event report; Provisional publication of Never Events reported as occurring between 1 April and 31 December 2019, which revealed an alarming 81% (284) of the never events recorded happened while a patient was on the operating table. Lindsay Keeley, patient safety and quality lead at AfPP said: “The survey highlighted that there’s a need to take action now if we are to support the healthcare profession in reducing the occurrence of never events. It has become clear that receptive team culture, a strong leadership team and better support for staff is what will help to reduce the risk of a never event occurring. It’s vital that those in leadership positions begin to understand the contributory factors in the recurrence of never events and the challenges faced by staff." She went on to highlight some of the recent initiative taking place: “What is promising is that there are practitioners who are developing new, practical and simple solutions every day that can support other team members and can be used within theatres across the country." "One example is Rob Tomlinson’s introduction of the 10,000 Feet initiative – a safety initiative designed to cut through noise and distraction within the theatre environment, particularly at critical points of the patient’s journey. If correctly implemented, initiatives like this can cut through the hierarchies that stop people feeling unable to speak up when they see something that shouldn’t be happening, thus reducing the occurrence of never events" “We of course need to be mindful that there will always be challenges within perioperative practice in the form of interruptions and distractions, but the key is how as practitioners we engage with this to recognise and reduce never events.” Read full story Source: Clinical Services Journal, 25 February 2020
  6. Content Article
    The patient was a 62-year-old man who underwent hip replacement surgery. During his surgery, incompatible prostheses made by different manufacturers were used. The error was identified when data from the procedure was recorded in the National Joint Registry several days later. The investigation centred on how the error occurred and what safety recommendations we could make to reduce the risk of a similar event happening again. The investigation focuses on hip replacement surgery but the findings are applicable to all orthopaedic joint replacements.
  7. News Article
    One of the country’s smallest trusts recorded 277 serious incidents over a two-year period, HSJ can reveal. Delays in treatment, missed diagnoses, adverse media coverage and “suboptimal” care were among the hundreds of serious incidents reported at the struggling Isle of Wight Trust from the start of 2018 and up to November 2019. There were also two never events in 2019 — a “wrong site” surgery and an incident in which a patient was mistakenly connected to an air flow meter, rather than an oxygen supply. The trust said the level of incidents did not neccessarily reflect poor care, and did not mean patients had come to harm. The trust was placed in special measures in April 2017 after it was rated “inadequate” by the Care Quality Commission due to “significant” concerns over patient safety. It was upgraded to “requires improvement” in September 2019, but remains in special measures. Read full story (paywalled) Source: HSJ, 22 January 2020
  8. Content Article
    Key findings The study findings suggest that the designation of a NE as a NE is dependent on the individual/type of NE and that NEs were reportedly rare. Although GPs were more likely to disagree with the NE label for the more frequently occurring NEs, this was not in proportion to their increased frequency of occurrence. Most GPs remained unconvinced that the risk can be eliminated for any of the NEs. GPs do, however, seem to take the actual and potential occurrence of such events seriously given that 99% stated an intention to undertake a significant event analysis after a NE. Opinions varied widely with some GPs commenting that the risk of serious harm was extremely low, whereas other GPs suggested that the NE should be more stringent. Some GPs felt that the NE description was placing a burden of responsibility on them that was not intended by the description of the NE; for example, that they should be responsible for the actions of a laboratory or the ambulance service. There were differences in opinion about the level of responsibility a GP should take for the actions of non-medical staff.
  9. News Article
    A young woman was left with a retained foreign object, after surgery in an India hospital. A checklist could have avoided her death. The response from the health officials was: “We have issued a show-cause notice to the staff seeking an explanation. We will initiate departmental action based on their replies and finding of our inquiry.” In the fields of healthcare quality and patient safety, such punitive measures of “naming and shaming” have not worked. T.S. Ravikumar, President, AIIMS Mangalagiri, Andhra Pradesh, moved back to India eight years ago with the key motive to improve accountability and safety in healthcare delivery. He believes that we have a long way to go in reducing “preventable harm” in hospitals and the health system in general. "We need to move away from fixing blame, to creating a 'blame-free culture' in healthcare, yet, with accountability. This requires both systems design for safe care and human factors engineering for slips and violations". "Providing safe care without harm is a 'team sport', and we need to work as teams and not in silos, with mutual respect and ability to speak up where we observe any deviation or non-compliance with rules, says Ravikumar. Basic quality tools and root-cause analysis for adverse events must become routine. Weekly mortality/morbidity conferences are routine in many countries, but not a routine learning tool in India. He proposes acceleration of the recent initiative of the DGHS of the Government of India to implement a National Patient Safety Framework, and set up an analytical “never events” or sentinel events reporting structure. Read full story Source: The Hindu, 12 January 2020
  10. Content Article
    The study achieved its aim of beginning a consensus building process to develop and validate a preliminary list of candidate never events for primary care dentistry. Consensus was achieved on a list of nine candidate never events covering a range of potentially serious system wide issues, most of which relate to patient safety checking procedures. At the time of publication, this was one of a small number of dental studies with an explicit focus in terms of developing a tool to help improve patient safety related work practices and performance in this setting, potentially reducing risks to practitioners and practices alike.
  11. Content Article
    For fires to occur, heat, fuel and oxygen must be present. Oxygen was a factor in half of the surgical fire cases reviewed, usually when the concentration of oxygen being delivered for ventilation wasn’t reduced sufficiently during electro- or laser surgery on the head, neck or upper chest. Most of the burns that weren’t caused by fire involved heat from equipment. These cases included surgeons using the wrong device or settings, as well as issues with the maintenance, malfunction or positioning of devices. Cases involving fuel were usually caused by the unsafe use of alcohol-based antiseptics, including allowing it to pool under patients, using the wrong concentration, or failing to let it dry before placing drapes. To reduce the risk of fires and burns, CMPA recommends that surgical teams “identify, separate and manage the elements of the fire triangle” before procedures. This involves ensuring that “ignition sources should not come into contact with fuels, and oxygen should be reduced to the minimum required concentration.” The association also recommends that surgical teams ensure that antiseptic has time to dry and doesn’t pool, follow device instructions, and run simulations to practice responding to fires.
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