scholarly journals 738 Lessons from the National Patient Safety Agency Alerts

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
Rachel Lee ◽  
Jacob Hatt ◽  
Kamal Mahawar ◽  
Mohit Bansal ◽  
Amit Goyal ◽  
...  
Keyword(s):  
Patient Safety ◽  
Improve Patient Safety ◽  
Surgical Practice ◽  
National Patient Safety Agency ◽  
Urgent Surgery ◽  
National Patient ◽  
Who Checklist ◽  
Improve Patient ◽  
Learning Points ◽  
Specific Learning

Abstract Aim The National Patient Safety Agency (NPSA) reviews incident reports from all NHS trusts, and reports deemed critical are issued as NPSA alerts. We aim to highlight important learning points from NPSA alerts to facilitate wider dissemination and prevent similar incidents, and overall improve patient safety. Method All patient safety alerts obtained from NPSA since inception (2008) till June 2020 were screened. We identified safety alerts that could be relevant to surgical practice, and further details of each alert were obtained from the Central Alerting System (CAS) website. Information obtained from CAS website was reviewed by consultant surgeons to identify specific learning points. Results 1857 alerts were reported by NPSA of which 94 were relevant to surgical practice. Alerts were grouped into four themes: pre-operative(N = 4), intra-operative(N = 34), post-operative(N = 29), others(N = 8), and no specific learning point identified(N = 19). Pre-operative alerts focused on safety checks to avoid errors and improve patient safety e.g., WHO checklist. Majority of the intra-operative alerts were due to difficulty with use of specific equipment(n = 22) e.g., advanced haemostatic devices. Post-operative alerts highlighted specific issues with implants especially in breast and orthopaedic surgery(N = 23), and patient review following procedures(N = 6). Conclusions In spite of alerts occurring in a specific speciality, there is wider applicability to all surgical specialities e.g., pre-operative risk assessment in elderly patients requiring urgent surgery or confirming pregnancy status in immediate pre-operative period. Emphasis should be laid on staff training on using specialist equipment including troubleshooting. Raising awareness of these NPSA alerts may help prevent similar incidents.

Open to scrutiny: incident reporting and transparency in the NHS

2010 ◽  
Vol 92 (3) ◽  
pp. 82-83
Author(s):  
Suzette Woodward
Keyword(s):  
Patient Safety ◽  
Management System ◽  
Improve Patient Safety ◽  
Incident Reporting ◽  
National Patient Safety Agency ◽  
National Patient ◽  
Reduce Risk ◽  
A Priority ◽  
Set Up ◽  
Improve Patient

The National Patient Safety Agency (NPSA) has been set up to improve patient safety for all NHS patients, wherever they are treated. An important part of the work of the NPSA is to learn from incidents that are reported nationally to provide sound, representative guidance and recommendations to reduce risk and harm in healthcare. Incident reporting should not be seen as a management system but as a culture in which patient safety is a priority.

scholarly journals Writing’s on the wall: improving the WHO Surgical Safety Checklist

2021 ◽  
Vol 10 (1) ◽  
pp. e001086
Author(s):  
Claire Cushley ◽  
Tom Knight ◽  
Helen Murray ◽  
Lawrence Kidd
Keyword(s):  
Patient Safety ◽  
Online Survey ◽  
Improve Patient Safety ◽  
Surgical Safety Checklist ◽  
Surgical Safety ◽  
Time Out ◽  
Mandatory Requirement ◽  
Who Checklist ◽  
Improve Patient ◽  
Theatre Team

Background and problemThe WHO Surgical Safety Checklist has been shown to improve patient safety as well as improving teamwork and communication in theatres. In 2009, it was made a mandatory requirement for all NHS hospitals in England and Wales. The WHO checklist is intended to be adapted to suit local settings and was modified for use in Gloucestershire Hospitals NHS Foundation Trust. In 2018, it was decided to review the use of the adapted WHO checklist and determine whether improvements in compliance and engagement could be achieved.AimThe aim was to achieve 90% compliance and engagement with the WHO Surgical Safety Checklist by April 2019.MethodsIn April 2018, a prospective observational audit and online survey took place. The results showed compliance for the ‘Sign In’ section of the checklist was 55% and for the ‘Time Out’ section was 91%. Engagement by the entire theatre team was measured at 58%. It was proposed to move from a paper checklist to a wall-mounted checklist, to review and refine the items in the checklist and to change the timing of ‘Time Out’ to ensure it was done immediately prior to knife-to-skin.ResultsFollowing its introduction in September 2018, the new wall-mounted checklist was reaudited. Compliance improved to 91% for ‘Sign In’ and to 94% for ‘Time Out’. Engagement by the entire theatre team was achieved 100% of the time. Feedback was collected, adjustments made and the new checklist was rolled out in stages across all theatres. A reaudit in December 2018 showed compliance improved further, to 99% with ‘Sign In’ and to 100% with ‘Time Out’. Engagement was maintained at 100%.ConclusionsThe aim of the project was met and exceeded. Since April 2019, the new checklist is being used across all theatres in the Trust.

scholarly journals High-risk medications identified from the Danish Patient Safety Database and the challenge of dissemination

2018 ◽  
Vol 24 (1) ◽  
pp. 7-12 ◽  
Author(s):  
Pia Knudsen ◽  
Lena Graversen ◽  
Torsten Larsen
Keyword(s):  
Patient Safety ◽  
High Risk ◽  
Improve Patient Safety ◽  
Healthcare Staff ◽  
Safety Database ◽  
Danish Patient ◽  
National Patient ◽  
Medication Incidents ◽  
Patient Safety Incidents ◽  
Improve Patient

Since 2004, patient safety incidents in Denmark have been reported to a national patient safety reporting system – the Danish Patient Safety Database. The goal of the system is to improve patient safety. In 2011, a decision was made to develop a national list of high-risk medications based on the medication incidents reported to the Danish Patient Safety Database. The high-risk medications are defined as medications that have been involved in medication errors and have caused harm to patients. The purpose is to identify medications that posed a particular and preventable risk for patients. It became clear through updates that there was a group of medications that caused severe harm to the patients more frequently than others. Based on the list, the Danish Patient Safety Authority in 2015 identified seven groups of medications that require special attention from healthcare staff: antidiabetic medications, anticoagulants, low-dose methotrexate, concentrated potassium, opioids, gentamicin and digoxin. Better handling of these seven types of medication could improve patient safety significantly. For many years, Danish Patient Safety Authority has distributed tables and booklets about these high-risk medications. In addition, ‘patient safety warnings’ are issued when it is considered necessary. In spite of this, many patient safety incidents involving these medications still occur. This points to the fact that disseminating knowledge from a government level all the way to frontline healthcare staff poses a challenge. On that background, Danish Patient Safety Authority is exploring new ways to disseminate knowledge to frontline healthcare staff about patient safety incidents.

Outcomes, Regulation, and Quality Improvement

2018 ◽  
Author(s):  
Julia Metzner ◽  
Karen B. Domino
Keyword(s):  
Patient Safety ◽  
Quality Improvement ◽  
Pulse Oximetry ◽  
Operating Room ◽  
Continuous Quality Improvement ◽  
Improve Patient Safety ◽  
Remote Locations ◽  
Continuous Quality ◽  
National Patient ◽  
Improve Patient

To improve the safety of patients undergoing procedures in remote locations, practitioners should be familiar with rigorous continuous quality improvement systems, national and regulatory patient safety efforts, as well as complications related to anesthesia/sedation in out of the operating room (OOOR) settings. This chapter discusses severe outcomes and mechanisms of injury in OOOR locations, national patient safety and regulatory efforts that may be adapted to the OOOR setting, and quality improvement efforts essential to track outcomes and improve patient safety. Patient safety can be improved by adherence to respiratory monitoring (e.g., pulse oximetry and capnography), sedation standards/guidelines and national patient safety and regulatory efforts, and development of vigorous quality improvement systems to measure outcomes and make changes.

Anesthesia and Sedation Outside of the Operating Room: Outcomes, Regulation, and Quality Improvement

2011 ◽  
pp. 62-73
Author(s):  
Julia Metzner ◽  
Karen B. Domino
Keyword(s):  
Patient Safety ◽  
Quality Improvement ◽  
Operating Room ◽  
Continuous Quality Improvement ◽  
Improve Patient Safety ◽  
Anesthesia Care ◽  
Remote Locations ◽  
Continuous Quality ◽  
National Patient ◽  
Improve Patient

Providing anesthesia care in areas outside the operating room (OOOR) has numerous challenges, including an unfamiliar environment; inadequate anesthesia support; deficient resources; cramped, dark, small rooms; and variability of monitoring modalities. In addition, sicker patients are undergoing more complex procedures in areas that may be physically located far from the OR environment. To improve safety of patients undergoing procedures in remote locations, practitioners need to be familiar with development of rigorous continuous quality improvement systems, national and regulatory patient safety efforts, as well as complications related to anesthesia/sedation in OOOR settings. This chapter will identify severe outcomes and mechanisms of injury in these remote locations, national patient safety and regulatory efforts that may be adapted to the OOOR setting, and quality improvement efforts essential to track outcomes and improve patient safety.

5 Standard iv infusion concentration in paediatric and neonatal units: a national survey

2018 ◽  
Vol 103 (2) ◽  
pp. e2.45-e2
Author(s):  
Nanna Christiansen
Keyword(s):  
Patient Safety ◽  
National Survey ◽  
Response Rate ◽  
Improve Patient Safety ◽  
National Standards ◽  
List Type ◽  
National Patient Safety Agency ◽  
National Patient ◽  
National Consensus ◽  
The Uk

AimThe National Patient Safety Agency in the UK has advocated the use of standard concentration (SC) infusions to improve patient safety and care.1 National standards have been adopted for infusions in the adult critical care setting however practice in paediatric and neonatal settings still varies and presents a challenge.2,3 This study is part of a multi-professional collaborative working towards a national consensus on SC infusions in paediatric and neonatal care. The study aims to explore the practice of standardised concentration usage for Intravenous (IV) infusions in paediatric and neonatal units in the UK, specifically:How many units use standardised concentration for IV infusions.Evaluate the variation and overlap of continuous IV infusion concentrations in practice.Assess what devices are used to administer these infusions.How standardised infusions are provided.MethodThe study used a quantitative descriptive survey design via an online self-administered questionnaire. Paediatric and neonatal intensive care units in the UK were surveyed through pharmacy, nursing, and medical networks to describe current practice. Data was collected for 25 days and analysed using SPSS.ResultA total of 194 NICUs and 39 PICUs were surveyed. Responses were received from 71 units: NICU 46 (65%); PICU 17 (24%) and 8 other (11%), giving an overall response rate of 30.5%.Twenty-eight units (40%) have established SC for IV infusions, 18 units provided information on presentation of SC infusions. Forty-six different medication infusions were standardised. Considering the differences in concentration, weight-bands, diluents, volume and presentation, there were 273 variations for these drugs. Taking only the concentration into account, there were 137 variations presented. The average number of variations per medication was 3 (range 1 to 14).15 units (53.6%) use ‘smart’ pumps for administration of SC infusions and 3 (10.7%) use other computer software for infusion rate calculations. Infusions are most commonly prepared on wards (81.3%) or in pharmacy (12.3%).ConclusionThe study is limited by the response rate; however the results suggest that 59% of paediatric and neonatal units in the UK use conventional weight-based methods for IV infusions. A third of units have established some SC with a wide variation of concentrations in this sample. Just over half of the units use ‘smart’ pump technology and over three quarters of SC infusions are prepared on the ward.Further data collection is required to acquire a fuller picture of SC infusions used in UK PICUs and NICUs. This data can then be used as the basis of a national consensus statement on SC infusion, facilitating adoption across the NHS.ReferencesNPSA Patient Safety Alert 20: Promoting safer use of injectable medicines2007. London: The National Patient Safety Agency.MacKay MW, Cash J, Farr F, et al. Improving paediatric outcomes through intravenous and oral medication standardisation. J Pediatr Pharmacol Ther2009;14:226–35.Phillips MS, Standardising IV. Infusion concentrations: National survey results. Am J Health Syst Pharm2011;68:2176–82.

NPSA infusion device toolkit: a cost‐saving way to improve patient safety

2004 ◽  
Vol 9 (3) ◽  
pp. 195-199 ◽  
Author(s):  
Chris Quinn ◽  
Elaine Stevenson ◽  
Helen Glenister
Keyword(s):  
Patient Safety ◽  
Improve Patient Safety ◽  
Cost Savings ◽  
Significant Cost ◽  
Infusion Device ◽  
National Patient ◽  
Infusion Devices ◽  
User Friendly ◽  
Patient Safety Incidents ◽  
Improve Patient

The National Patient Safety Agency (NPSA) has been established to reduce the risk of patient safety incidents and promote learning across the National Health Service that will improve patient safety and help organisations to learn from the experience of others. One of the first projects has been to look at the way that infusion devices are purchased, stored and used within hospitals. This work has resulted in a number of recommendations centred on simplifying the range of devices available, using a centralised system to maximise use of the equipment and ensuring that staff are properly trained. The work has also involved manufacturers in the hope that future developments in equipment design will result in more user‐friendly devices that will reduce the risk of misuse and any consequent harm to patients. NPSA has just issued its first Safer Practice Notice to Trusts to highlight the issues around infusion devices and offer NHS organisations a toolkit to help them improve patient safety and make significant cost savings.

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