1507 Prospective Audit of Vascular Handover List

Introduction Good handover is paramount for orientating on-call teams coming onto shift and maintaining patient safety. In our tertiary referral centre a pre-prepared list on our shared drive is used to handover vascular patients in the hospital. It was felt that there was insufficient information on the list and that inconsistencies / inaccuracies could compromise patient safety. Method We performed a full-cycle prospective audit using GMC/ RCSEng guidance as standards. Our list was audited over a period of 10 days 4/2/20-14/2/20. In addition, a questionnaire was sent around doctors of all grades to highlight areas of improvement and to gather ideas. The second cycle (17/2/20- 27/2/20) was then performed after introduction of a new list, which allowed more comprehensive information to be collected in a shared drive. Junior doctors on the team were briefed, and results collected with a second questionnaire. Results The new list showed statistically significant improvements in inclusion of key information as set out in the standards. These included presenting complaint ’92% from 57%,’ Diagnosis ’98% from 89%, clinical history 91% from 35%, significant results 86% from 13% and outstanding tasks 80% from 6.2%. (These were all significant p = 0.001 Mann-Whitney U.) Further information including antibiotics and VTE was included after feedback from department. 85% found the new list easier to navigate and 76% felt it reduced risk to patient safety. Conclusions Introduction of a revised handover list in a vascular tertiary referral centre resulted in significant improvements in adherence to RCSEng/ BMA standards and staff perceived benefit to patient safety.

Patient safety in Neonatal Intensive Care Units: Neonatal patient safety

Introduction: Patient Safety in a Neonatal Intensive Care Unit is to reduce as little as possible the risk of causing harmful acts in the course of care. Objective: This study aimed to search together with the scientific literature which factors compromise patient safety in the neonatal care unit. Methods: For this an integrative review was performed on the Pubmed and Scielo platforms, using a combination of the descriptors “Patient Safety” or “Patient Safety” and “Neonatology” or “Neonatology” and “Hospital” and “Infection” or “Infection”. 27 articles that after the inclusion and exclusion criteria were analyzed and totaled in 7 manuscripts for the study. Results: The results showed that patient safety is compromised by factors related to multiprofessional work and the treatment received. Conclusion: Proposals include the elaboration of tools (protocols, checklists, among others) that could effectively help the establishment of a safety culture and promote the theme.

Classification of Failures in the Perception of Conversational Agents (CAs) and Their Implications on Patient Safety

The use of Conversational agents (CAs) in healthcare is an emerging field. These CAs seem to be effective in accomplishing administrative tasks, e.g. providing locations of care facilities and scheduling appointments. Modern CAs use machine learning (ML) to recognize, understand and generate a response. Given the criticality of many healthcare settings, ML and other component errors may result in CA failures and may cause adverse effects on patients. Therefore, in-depth assurance is required before the deployment of ML in critical clinical applications, e.g. management of medication dose or medical diagnosis. CA safety issues could arise due to diverse causes, e.g. related to user interactions, environmental factors and ML errors. In this paper, we classify failures of perception (recognition and understanding) of CAs and their sources. We also present a case study of a CA used for calculating insulin dose for gestational diabetes mellitus (GDM) patients. We then correlate identified perception failures of CAs to potential scenarios that might compromise patient safety.

Promoting health and wellbeing across community nursing teams: role of the specialist practitioner district nurse

There is a growing concern around the health and wellbeing of community nurses due to the high complexities of and demand on district nursing services. It is well recognised that district nursing services have no limits to their capacity, and they have been dealing with an increasing caseload, with no increases in resources or staff. Consequently, this has left community nurses feeling exhausted and experiencing burnout, which, in the long term, can lead to compassion fatigue, which can in turn compromise patient safety. Specialist practitioner qualified district nurses (SPQDN) require the skills and knowledge to promote health and wellbeing, in order to provide a positive work environment and limit work-related stress and burnout despite the challenges encountered. This article explores possible strategies to promote health and wellbeing among community nurses and the barriers that SPQDNs encounter in doing so.

481 Improving the Quality of Pelvic Radiographs - Making A Difference One Picture at A Time

Inadequate pelvic radiographs can lead to missed pathology, necessitate repeat imaging, and subsequently compromise patient safety. The audit conducted aimed to assess and improve the quality of pelvic radiographs at our Trust against local and international guidelines. Retrospective analysis of pelvic radiographs over a one-month period using PACS at Colchester General Hospital was conducted. All pelvic radiographs were assessed according to International Guidelines (EUR 16250EN). Postoperative radiographs were measured against local guidelines. The results were then presented in the departmental meeting and a re-audit was performed in June 2020. A total of 190 pelvic radiographs were collected in September 2019. From the 23 postoperative radiographs, 9 did not include distal end of prosthesis. During the re-audit in June 2020 the same number of pelvic images were collected. Data showed that only 2 out of 29 postoperative images did not include the distal end of the prosthesis. The audit demonstrated need for improvement at our Trust. This was carried out through a presentation in the departmental meeting, highlighting areas that needed improvement. The re-audited results from June 2020 have shown an improvement in the quality of pelvic radiographs and have had direct implications in clinical outcomes.

Abstract P827: W.I.N.G.S. to Acute Stroke Treatment

Background: Nearly 2 million neurons die each minute during an acute ischemic stroke (AIS). Research demonstrates patients receiving timely treatment for AIS can have more favorable outcomes. In 4 th quarter (Q) 2018, a Stroke Center’s average door-to-needle (DTN) time was 54 minutes, acceptable for American Stroke Association’s (AHA/ASA) Get with the Guidelines (GWTG) quality requirement of DTN in 60 minutes or less. Nevertheless, time is brain and decreased DTN times can potentially improve patient outcomes. With this in mind, the emergency department (ED) implemented a quality improvement project (QIP) focused on DTN time reduction. Purpose: Improve the ED workflow by developing standardized roles and task prioritization to reduce DTN times by 20% from 54 minutes to 42 minutes by 4 th Q 2019. Methods: Guidelines and goals were established using AHA/ASA GWTG-Stroke criteria. Included were AIS patients with symptoms occurring prior to ED arrival, met eligibility criteria, and received intravenous tissue plasminogen activator (IV t-PA). Patients with symptoms occurring after ED arrival or during the hospital stay were excluded. An interdisciplinary workgroup collaborated to formulate an evidence-based solution for workflow opportunities identified by simulations, observations, and subjective feedback. Standardized roles, similar to cardiac life support, were created. An innovative acronym, W.I.N.G.S. (weight, IV access, NIHSS, glucose, scan), was developed to strategize adoption and implementation. Education, chart reviews, and timely feedback were given to stakeholders for every stroke intervention to promote engagement. Results: In 4 th Q 2019, average DTN time decreased to 35 minutes (n=16, 35.2% reduction). The average DTN time for 1 st Q 2020 is 31 minutes (n=14, 42.6% reduction). Since QIP implementation, the current DTN record is 12 minutes. Conclusions: W.I.N.G.S. is now a commonly term used in the ED. The multidisciplinary approach was instrumental in implementing a feasible QIP based on evidence and did not compromise patient safety. Sustainability is dependent on continued commitment and engagement of the team to celebrate achievements and reflect, reevaluate, and revise any insufficiencies.

Incidents in Molecular Pathology: Frequency and Causes During Routine Testing

Context.— Errors in laboratory medicine could compromise patient safety. Good laboratory practice includes identifying and managing nonconformities in the total test process. Varying error percentages have been described in other fields but are lacking for molecular oncology. Objectives.— To gain insight into incident causes and frequency in the total test process from 8 European institutes routinely performing biomarker tests in non-small cell lung cancer and colorectal cancer. Design.— All incidents documented in 2018 were collected from all hospital services for pre-preanalytical entries before the biomarker test, as well as specific incidents for biomarker tests. Results.— There were 5185 incidents collected, of which 4363 (84.1%) occurred in the pre-preanalytical phase (all hospital services), 2796 of 4363 (64.1%) related to missing or incorrect request form information. From the other 822 specific incidents, 166 (20.2%) were recorded in the preanalytical phase, 275 (33.5%) in the analytical phase, and 194 (23.6%) in the postanalytical phase, mainly due to incorrect report content. Only 47 of 822 (5.7%) incidents were recorded in the post-postanalytical phase, and 123 (15.0%) in the complete total test process. For 17 of 822 (2.1%) incidents the time point was unknown. Pre-preanalytical incidents were resolved sooner than incidents on the complete process (mean 6 versus 60 days). For 1215 of 5168 (23.5%) incidents with known causes a specific action was undertaken besides documenting them, not limited to accredited institutes. Conclusions.— There was a large variety in the number and extent of documented incidents. Correct and complete information on the request forms and final reports are highly error prone and require additional focus.

Improving Opportunities in Healthcare Supply Chain Processes via the Internet of Things and Blockchain Technology

Despite key advances in healthcare informatics and management, little progress to address supply chain process-related problems has been made to date. Specifically, key healthcare supply chain processes include product recalls, monitoring of product supply shortages, expiration, and counterfeits. Implementing and executing these processes in a trusted, secure, efficient, globally accessible and traceable manner is challenging due to the fragmented nature of the healthcare supply chain, which is prone to systemic errors and redundant efforts that may compromise patient safety and impact health outcomes adversely. Blockchain, combined with the Internet of things (IoT), is an emerging technology that can offer a practical solution to these challenges. Accordingly, IoT blockchain offers a superior way to track and trace products via a peer-to-peer distributed, secure, and shared ledger of the blockchain network. This article highlights key challenges related to healthcare supply chains, and illustrates how IoT blockchain technologies can play a role in overcoming these challenges now and in the near future.

Assessing the potential for prevention or earlier detection of on-site monitoring findings from randomised controlled trials: Further analyses of findings from the prospective TEMPER triggered monitoring study

Background/Aims: Clinical trials should be designed and managed to minimise important errors with potential to compromise patient safety or data integrity, employ monitoring practices that detect and correct important errors quickly, and take robust action to prevent repetition. Regulators highlight the use of risk-based monitoring, making greater use of centralised monitoring and reducing reliance on centre visits. The TEMPER study was a prospective evaluation of triggered monitoring (a risk-based monitoring method), whereby centres are prioritised for visits based on central monitoring results. Conducted in three UK-based randomised cancer treatment trials of investigational medicine products with time-to-event outcomes, it found high levels of serious findings at triggered centre visits but also at visits to matched control centres that, based on central monitoring, were not of concern. Here, we report a detailed review of the serious findings from TEMPER centre visits. We sought to identify feasible, centralised processes which might detect or prevent these findings without a centre visit. Methods: The primary outcome of this study was the proportion of all ‘major’ and ‘critical’ TEMPER centre visit findings theoretically detectable or preventable through a feasible, centralised process. To devise processes, we considered a representative example of each finding type through an internal consensus exercise. This involved (a) agreeing the potential, by some described process, for each finding type to be centrally detected or prevented and (b) agreeing a proposed feasibility score for each proposed process. To further assess feasibility, we ran a consultation exercise, whereby the proposed processes were reviewed and rated for feasibility by invited external trialists. Results: In TEMPER, 312 major or critical findings were identified at 94 visits. These findings comprised 120 distinct issues, for which we proposed 56 different centralised processes. Following independent review of the feasibility of the proposed processes by 87 consultation respondents across eight different trial stakeholder groups, we conclude that 306/312 (98%) findings could theoretically be prevented or identified centrally. Of the processes deemed feasible, those relating to informed consent could have the most impact. Of processes not currently deemed feasible, those involving use of electronic health records are among those with the largest potential benefit. Conclusions: This work presents a best-case scenario, where a large majority of monitoring findings were deemed theoretically preventable or detectable by central processes. Caveats include the cost of applying all necessary methods, and the resource implications of enhanced central monitoring for both centre and trials unit staff. Our results will inform future monitoring plans and emphasise the importance of continued critical review of monitoring processes and outcomes to ensure they remain appropriate.

Reform Workplace Practices of Chain Pharmacies to Reduce Medication Errors

Pharmacists employed by chain pharmacies have raised concerns over corporate-mandated practices that compromise patient safety. Harsh working conditions and the pressure to meet mandated quality metrics have increased the likelihood of medication errors. Complications associated with medication errors exceed $40 billion and cause adverse health effects for hundreds of thousands of Americans annually. Despite their ubiquity, chain pharmacies face varying regulations as state pharmacy boards dictate individual statewide policies. There is minimal data collection on pharmacy practices and state pharmacy boards do not require pharmacies to report errors. We recommend Congress pass a bill mirroring the Illinois Pharmacy Practice Act to improve pharmacists’ working conditions and mandate data collection on medication errors nationwide.