Reducing patient harm following inadvertent endobronchial placecement of nasogastric tubes in patients with SARS-COV-2

Clinical handover – the transfer between clinicians of responsibility and accountability for patients and their care (AMA 2006) – is a pivotal and high-risk communicative event in hospital practice. Studies focusing on critical incidents, mortality, risk and patient harm in hospitals have highlighted ineffective communication – including incomplete and unstructured clinical handovers – as a major contributing factor (NSW Health 2005; ACSQHC 2010). In Australia, as internationally, Health Departments and hospital management have responded by introducing standardised handover communication protocols. This paper problematises one such protocol – the ISBAR tool – and argues that the narrow understanding of communication on which such protocols are based may seriously constrain their ability to shape effective handovers. Based on analysis of audio-recorded shift-change clinical handovers between medical staff, we argue that handover communication must be conceptualised as inherently interactive and that attempts to describe, model and teach handover practice must recognise both informational and interactive communication strategies. By comparing the communicative performance of participants in authentic handover events we identify communication strategies that are more and less likely to lead to an effective handover and demonstrate the importance of focusing close up on communication to improve the quality and safety of healthcare interactions.

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Clinical Cybersecurity Training Through Novel High Fidelity Simulations (Preprint)

10.2196/preprints.9853 ◽

2018 ◽

Author(s):

Christian Dameff ◽

Jordan Selzer ◽

Jonathan Fisher ◽

James Killeen ◽

Jeffrey Tully

Keyword(s):

Patient Safety ◽

Patient Care ◽

Medical Devices ◽

Healthcare Systems ◽

High Fidelity ◽

Protected Health Information ◽

Patient Harm ◽

Security Vulnerabilities ◽

Clinical Simulations ◽

Medical Infrastructure

BACKGROUND Cybersecurity risks in healthcare systems have traditionally been measured in data breaches of protected health information but compromised medical devices and critical medical infrastructure raises questions about the risks of disrupted patient care. The increasing prevalence of these connected medical devices and systems implies that these risks are growing. OBJECTIVE This paper details the development and execution of three novel high fidelity clinical simulations designed to teach clinicians to recognize, treat, and prevent patient harm from vulnerable medical devices. METHODS Clinical simulations were developed which incorporated patient care scenarios with hacked medical devices based on previously researched security vulnerabilities. RESULTS Clinician participants universally failed to recognize the etiology of their patient’s pathology as being the result of a compromised device. CONCLUSIONS Simulation can be a useful tool in educating clinicians in this new, critically important patient safety space.

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A bedside rescue method for retrieving retained guidewires: The ‘Suck Out’ technique

The Journal of Vascular Access ◽

10.1177/1129729820943457 ◽

2020 ◽

pp. 112972982094345

Author(s):

Maryanne Z A Mariyaselvam ◽

Vikesh Patel ◽

Adam Sawyer ◽

James A Richardson ◽

Jonathan Dean ◽

...

Keyword(s):

Central Venous Catheter ◽

Venous Catheter ◽

Central Venous Catheters ◽

Patient Harm ◽

Central Venous ◽

Exact Test ◽

The United Kingdom ◽

Catheter Tip ◽

Never Event ◽

Benchtop Model

Background: Central venous catheter guidewire retention is classed as a ‘never event’ in the United Kingdom, with the potential for significant patient harm. If the retained guidewire remains within the central venous catheter lumen, bedside techniques may facilitate guidewire retrieval. However, these techniques may be ineffective if the guidewire has already passed below skin level. We investigated a novel ‘suck out’ technique for bedside guidewire retrieval and compared this against traditional retrieval methods. Methods: Simulation 1: in a benchtop model, seven different central venous catheters had their corresponding guidewire placed in the last 2 cm of the catheter tip which was immersed horizontally in fluid. A 50-mL syringe was attached to the distal lumen central venous catheter hub and suction applied for 5 s, and the distance of guidewire retraction was recorded. Simulation 2: a central venous catheter guidewire was intentionally retained within the catheter at either 5 cm above or below skin level in a pigskin model. Simple catheter withdrawal, catheter clamping withdrawal and the ‘suck out’ method were compared for efficacy using Fisher’s exact test. Results: Simulation 1: retained guidewires were retracted by 13 cm on average. Simulation 2: when guidewires were retained 5 cm above skin level, all retrieval methods were 100% effective; however, when retained 5 cm below skin level, simple catheter withdrawal was ineffective, clamping and withdrawal was only 10% effective and the ‘suck out’ technique was 90% effective (p < 0.001). Conclusion: The ‘suck out’ technique can effectively retract guidewires retained within central venous catheter lumens and demonstrates superiority over traditional methods of retained guidewire extraction in simulated models.

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Medical device error and failure reporting: Learning from the car industry

Journal of Patient Safety and Risk Management ◽

10.1177/25160435211008273 ◽

2021 ◽

pp. 251604352110082

Author(s):

Arkeliana Tase ◽

Peter Buckle ◽

Melody Z Ni ◽

George B Hanna

Keyword(s):

Reporting System ◽

Current System ◽

Learning System ◽

Healthcare Sector ◽

Patient Harm ◽

Car Industry ◽

Root Cause ◽

Incident Investigation ◽

Initiating Factors ◽

Failure Reporting

Background Improving the design of technology relies in part, on the reporting of performance failures in existing devices. Healthcare has low levels of formal reporting of performance and failure of medical equipment. This paper examines methods of reporting in the car industry and healthcare and aims to understand differences and identify opportunities for improvement within healthcare. Methods A literature search was carried out in Pubmed, Medline, Embase, Engineering Village, Scopus. NHS England and MHRA publications and guidelines were also reviewed. Focus was placed on the current system of reporting in both industries, known degree of patient harm, initiating factors, barriers, quality and methods of incident investigation and their validity. The findings were used to compare error reporting system in the two industries. Results Derivation of healthcare incident data from different sources means the full extent of patient harm is not known. For example, in 2012 there were 13,549 and 38,395 incidents reported by MHRA and NRLS (National Reporting and Learning System) respectively leading to uncertainties on the extent of the problem. The car industry emphasises the role of reporting source in ensuring data quality. Utilising some aspects of this approach might benefit healthcare reporting. These include a specific reporting system that stresses the importance of organisational learning in improving safety and recognises the limitations of root cause analysis. Conclusions Learning from reporting systems within the car industry may help the healthcare sector improve its own reporting, aiding healthcare performance.

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Gastrostomy for infants with severe epidermolysis bullosa simplex in neonatal intensive care

Orphanet Journal of Rare Diseases ◽

10.1186/s13023-021-01896-0 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

M. Marro ◽

S. De Smet ◽

D. Caldari ◽

C. Lambe ◽

S. Leclerc-Mercier ◽

...

Keyword(s):

Intensive Care ◽

Epidermolysis Bullosa ◽

Neonatal Intensive Care ◽

Nutrition Support ◽

Epidermolysis Bullosa Simplex ◽

Withdrawal Time ◽

Multicentric Study ◽

Nasogastric Tubes ◽

Mucosal Involvement ◽

Enteral Nutrition Support

Abstract Introduction Severe epidermolysis bullosa simplex (EBS sev) is a rare genodermatosis characterized by congenital generalized blistering and mucosal involvement. Increased needs and decreased intake quickly lead to nutritional imbalance. Enteral nutrition support is proposed, but classical nasogastric tubes are not well tolerated in these patients and gastrostomy is preferred. Objective and methods To report the experience with EBS sev in neonatal units of French reference centers for gastrostomy. In this retrospective multicentric study, we included all patients with EBS sev who had gastrostomy placement before age 9 months during neonatal care hospitalization. Results Nine infants (5 males/4 females) with severe skin and mucosal involvement were included. A gastrostomy was decided, at an early age (mean 3.7 months, range 1.4 to 8 months) in infants with mean weight 4426 g (range 3500 to 6000 g). Techniques used were endoscopy with the pull technique for 5 infants and surgery under general anesthesia for 4. Main complications were local but resolved after treatment. All infants gained weight after gastrostomy. The mean withdrawal time (n = 7) for the gastrostomy was 35.8 months (range 10.5 months to 6.5 years). Seven children had persistent oral disorders. Conclusions Gastrostomy in infants with EBS sev can be necessary in neonatal intensive care units. Both surgical and endoscopic pull techniques seem efficient, with good tolerance.

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