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.

P10 To give, or not to give…

2018 ◽  
Vol 103 (2) ◽  
pp. e2.11-e2
Author(s):  
Zoe Lansdowne
Keyword(s):  
Patient Safety ◽  
Opioid Analgesics ◽  
Time Of Day ◽  
Electronic Prescribing ◽  
Time Range ◽  
List Type ◽  
University Hospitals ◽  
Policy Document ◽  
National Patient Safety Agency ◽  
National Patient

Aim‘Between September 2006 and June 2009, the NPSA (National Patient Safety Agency) received reports of 27 deaths, 68 severe harms and 21 383 other patient safety incidents relating to omitted or delayed medicines’.1 The Trust’s Medicines Code states that ‘critical’ medicines should be administered within one hour of the prescribed times, and all other medicines within 90 min.2 ‘Critical’ medicines relevant to NICU (Neonatal Intensive Care Unit) patients include injected antibiotics, anticoagulants, anticonvulsants, aminophylline infusions and strong opioid analgesics. The aim of this audit was to establish what proportion of medicines prescribed for patients on NICU were given outside of this policy.MethodData was downloaded for all NICU inpatients from the electronic prescribing system, ICCA, from 1/4/16 to 30/6/16 inclusive. It was then analysed using Excel. The data shows details of all regular drugs prescribed, the scheduled administration time and the time that the nurses recorded that the drug had been administered. Once only, when required and drug infusions longer than 4 hours were all excluded from this data capture. Scheduled doses of antibiotics that were intentionally delayed whilst awaiting levels, e.g. vancomycin and gentamicin, were excluded before data analysis.ResultsIt was found that over the 3 month period, 137 different patients were administered 10 642 regular doses of 51 different medications. 5.86% of these were classified as ‘delayed’ according to Trust policy. 97.6% of these delayed ‘critical’ medications were antibiotics, accounting for over 45% of the total delayed doses.Meropenem was found to be the antibiotic most frequently delayed, with over one quarter of all doses prescribed being administered more than 1 hour after the scheduled time. The delay in administration ranged from 65 mins to 6 hours. Ceftazidime was the next most frequently delayed, occurring 22.7% of the time, range 2.75 to 3.75 hours.The time of day when most drug delays occurred was between the times of 15:00 and 15:59, accounting for 8.2%. The percentage for each hourly time slot varied from 2.1% to 8.2%. Throughout the week, the percentage of delays on an individual day ranged from the most on Saturdays, 17.9%, to the least on Wednesdays, 9.6%.ConclusionsDelays in administering medicines can have significant detrimental effects for patient safety. Trust policy dictates that ‘critical’ medicines should be administered within 1 hour of the prescribed times.2 It can be seen from the results above that the administration of medications were delayed 5.86% of the time, with antibiotics accounting for over 45% of these delayed doses. The administration of meropenem was delayed over 25% of the time.ReferencesNational Patient Safety Agency. Rapid Response Report 009. Reducing harm from omitted and delayed medicines in hospital2010.Holmes, G. Chapter M09 policy for the administration of medicines [policy document]2016. University Hospitals Bristol NHS Foundation Trust.

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.

Water on the lung: a rare cause of a transudative effusion and new options for palliation

2017 ◽  
Author(s):  
Lucy Schomberg ◽  
Nick Maskell
Keyword(s):  
Patient Safety ◽  
Pleural Effusions ◽  
Thoracic Ultrasound ◽  
National Patient Safety Agency ◽  
National Patient ◽  
Malignant Effusions ◽  
Pleural Catheter ◽  
Challenging Situation ◽  
Real Challenge

Pleural effusions are very common in clinical practice and can be notoriously difficult to diagnose and a real challenge to manage. There is a large amount of literature on malignant effusions, but no clear guidelines on managing refractory non-malignant pleural effusions. This case examines a rarer cause of a transudative effusion, focussing on the route to diagnosis. The emergence of thoracic ultrasound, in light of the National Patient Safety Agency report in 2008, and the increased safety are reviewed, and, in addition, the options for management are considered, including the tunnelled pleural catheter as a potential long-term solution in this challenging situation.

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

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.

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.

The impact of the National Patient Safety Agency intravenous fluid alert on iatrogenic hyponatraemia in children

2010 ◽  
Vol 95 (Suppl 1) ◽  
pp. A46.1-A46
Author(s):  
S Drysdale ◽  
T Coulson ◽  
N Cronin ◽  
Z-R Manjaly ◽  
C Piyasena ◽  
...  
Keyword(s):  
Patient Safety ◽  
Intravenous Fluid ◽  
National Patient Safety Agency ◽  
National Patient ◽  
The Impact
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