Update on the National Patient Safety Goals — Changes for 2006

2005 ◽  
Vol 12 (3) ◽  
pp. 83-85 ◽  
Author(s):  
&NA;
Keyword(s):  
Patient Safety ◽  
National Patient

scholarly journals P044 Can an electronic prescribing system ensure clear anticoagulation discharge communication?

2019 ◽  
Vol 104 (7) ◽  
pp. e2.49-e2
Author(s):  
Susie Gage
Keyword(s):  
Patient Safety ◽  
Discharge Summary ◽  
Electronic Prescribing ◽  
List Type ◽  
Heparin Infusion ◽  
National Patient Safety Agency ◽  
High Dependency ◽  
National Patient ◽  
Discharge Summaries

AimThe National Patient Safety Agency (NPSA)1 identified heparin as a major cause of adverse events associated with adverse incidents, including some fatalities. By ensuring good communication, this should be associated with risk reduction.1 The aim of this study was to ensure there is clear anticoagulation communication on discharge, from the paediatric intensive care unit (PICU) electronic prescribing system (Philips), to the paediatric cardiac high dependency unit and paediatric cardiac ward. To investigate whether the heparin regimen complies with the hospital’s anticoagulant guidelines and if there is any deviation; that this is clearly documented. To find out if there is an indication documented for the heparin regimen chosen and if there is a clear long term plan documented for the patient, after heparin cessation.MethodsA report was generated for all patients who were prescribed a heparin infusion on PICU, between 1st January 2018 and 30th June 2018, from the Philips system. All discharge summaries from the PICU Philips system were reviewed. Only paediatric cardiac patients were included that had a heparin infusion prescribed on discharge, all other discharge summaries were excluded from the study. Each discharge summary was reviewed in the anticoagulant section; for the heparin regimen chosen, whether it complies with the hospital’s anticoagulant guidelines and if there was any deviation whether this was documented. The indication documented of which heparin regimen was chosen and whether a clear long term plan was documented after heparin cessation; for example if the patient is to be transferred onto aspirin, clopidogrel, warfarin or enoxaparin.Results82 discharge summaries were reviewed over the 6 month period between 1st January 2018 and 30th June 2018; 16 were excluded as were not paediatric cardiac, leaving 66 paediatric cardiac discharge summaries that were reviewed. 45 out of 66 (68%) complied with the hospital’s heparin anticoagulation guidelines. Of the 32% that deviated from the protocol; only 33% (7 out of 21) had a reason documented. Only 50% (33) of the summaries reviewed had an indication for anticoagulation noted on the discharge summary and 91% of discharge summaries had a long term anticoagulant plan documented.ConclusionThe electronic prescribing system can help to ensure a clear anticoagulation communication as shown by 91% of the anticoagulation long term plan being clearly documented; making it a more seamless patient transfer. On the Philips PICU electronic prescribing system there is an anticoagulant section on the discharge summary that has 3 boxes that need to be completed; heparin regimen, indication and anticoagulation long term plan. However, despite these boxes; deviations from the anticoagulant protocol were poorly documented as highlighted by only 33% having the reason highlighted in the discharge summary, only 50% of the indications were documented. Despite having prompts for this information on the discharge summary, the medical staffs needs to be aware to complete this information, in order to reduce potential medication errors and risk.ReferenceThe National Patient Safety Agency (NPSA). Actions that make anticoagulant therapy safer. NPSA; March 2007.

Examining the new NHS National Patient Safety Syllabus

2021 ◽  
Vol 30 (11) ◽  
pp. 682-683
Author(s):  
John Tingle
Keyword(s):  
Patient Safety ◽  
Law School ◽  
National Patient ◽  
Recent Patient

John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, introduces the recently published NHS National Patient Safety Syllabus and some recent patient safety reports

Recommendations from the British Committee for Standards in Haematology and National Patient Safety Agency

2007 ◽  
Vol 136 (1) ◽  
pp. 26-29 ◽  
Author(s):  
T. P. Baglin ◽  
D. Cousins ◽  
D. M. Keeling ◽  
D. J. Perry ◽  
H. G. Watson
Keyword(s):  
Patient Safety ◽  
National Patient Safety Agency ◽  
National Patient ◽  
British Committee

Update on the National Patient Safety Goals-Changes for 2005

AORN Journal ◽  
2005 ◽  
Vol 81 (2) ◽  
pp. 335-341 ◽  
Author(s):  
Kathleen Catalano
Keyword(s):  
Patient Safety ◽  
National Patient

scholarly journals Audit of compliance with WHO surgical safety checklist (modified for electroconvulsive therapy including NPSA advice)

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S64-S64
Author(s):  
Faisal Alam ◽  
Rizwan Ashraf ◽  
Kyaw Sein ◽  
Terri Feeney
Keyword(s):  
Patient Safety ◽  
Electroconvulsive Therapy ◽  
Time Pressure ◽  
Clinical Situation ◽  
Surgical Safety Checklist ◽  
Surgical Safety ◽  
National Patient ◽  
Service Standards ◽  
Therapy Treatment

AimsThis audit aims to evaluate the compliance with the WHO surgical safety checklist during the electroconvulsive therapy treatment in ECT clinic at Greater Manchester Mental Health Bolton Directorate. The audit is based on WHO surgical safety checklist modified for ECT including National Patient Safety Agency advice. The goal is to improve the compliance and in turn improve clinical outcomes.BackgroundThe WHO surgical safety checklist (modified for Electroconvulsive therapy including NPSA advice) is devised to promote patient safety, improve teamwork, reduce errors/adverse events and improve overall quality of care. An audit was completed regarding the compliance with the safety checklist at the Bolton ECT clinic and to assess how this could be improved.MethodFollowing approval from the clinical audit department, GMMH NHS Foundation Trust, 20 checklists from randomly selected patient ECT files were included in this audit. We looked at whether the checklists were completed, signed and dated. Our current WHO surgical safety checklist is as per the Electroconvulsive therapy accreditation service standards.ResultA total of 20 WHO surgical safety checklists were reviewed. 95% of the checklists (19/20) were completed by the duty Psychiatrist. 1 form was not completed. 25% (5/20) were not signed rendering them invalid. A total of 75% checklists were complete and valid. Checklists were present in all the case notes.ConclusionCompliance with the WHO surgical safety checklist during the electroconvulsive therapy treatment can be challenging due to various reasons ranging from time pressure to difficult clinical situation. This audit has highlighted that the overall compliance with the set standards (100% completion) was not achieved. A repeat audit will be important to further improve the compliance and overall clinical outcome.

Giving essential content to the National Patient Safety Syllabus and curricula

2021 ◽  
Vol 30 (12) ◽  
pp. 758-759
Author(s):  
John Tingle
Keyword(s):  
Patient Safety ◽  
Law School ◽  
Educational Content ◽  
National Patient

John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses several publications from NHS Resolution that should provide essential educational content for enhanced training on patient safety.

Checking for pregnancy before surgery: summary of a safety report from the National Patient Safety Agency

BMJ ◽  
2010 ◽  
Vol 341 (jul06 2) ◽  
pp. c3402-c3402 ◽  
Author(s):  
T. Lamont ◽  
T. Coates ◽  
D. Mathew ◽  
J. Scarpello ◽  
A. Slater
Keyword(s):  
Patient Safety ◽  
National Patient Safety Agency ◽  
Safety Report ◽  
National Patient

Patient Safety and Error Reduction

2013 ◽  
Author(s):  
Graham Brack ◽  
Penny Franklin ◽  
Jill Caldwell
Keyword(s):  
Patient Safety ◽  
Health Authority ◽  
Healthcare Professionals ◽  
Care Patient ◽  
Error Reduction ◽  
National Patient Safety Agency ◽  
Do No Harm ◽  
National Patient ◽  
Compensation Claims ◽  
Special Health

Most healthcare professionals take up their career because they want to make people better. It is rare—but not unknown—to find nurses deliberately harming patients. It is not always possible to cure a patient’s condition, and readers may be surprised to hear the view of Lord Justice Stuart-Smith that our ‘only duty as a matter of law is not to make the victim’s condition worse’ (Capital and Counties plc v Hampshire CC (1997) 2 All ER 865 at 883). Despite our best intentions, healthcare professionals do sometimes make the patient’s condition worse. There are too many instances of harm caused to patients. Not only does the patient suffer harm, staff will be upset (some may even give up their careers) and large compensation claims may be made which deplete NHS resources. According to the NHS Litigation Authority, in 2010–11 it received 8655 claims of clinical negligence and 4346 claims of non-clinical negligence against NHS bodies, and paid £863 million in connection with clinical negligence claims (NHSLA Annual Report and Accounts, 2011). To put that into perspective, NHS Warwickshire had a budget of £827m for that year, so this amount would fund a mediumsized PCT. For all these reasons, therefore, our first concern must be to do no harm to our patient. If we can improve their condition, so much the better, but at the very least we must leave them no worse off for having put themselves in our care. Patient safety must be everyone’s concern. It is monitored by the NHS Commissioning Board Special Health Authority. Until June 2012 there was a separate agency, the National Patient Safety Agency (NPSA), which produced a report in 2009 entitled Safety in doses: improving the use of medicines in the NHS . There were 811 746 reports to the NPSA in 2007, of which 86 085 were related to medication. The figures for July 2010– June 2011 show an increase to 1.27 million incidents, of which 133 727 were related to medication.

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