Alcohol hand sanitisers on mental health wards safety risk educational and QI poster

AimsTo provide awareness of safety concerns around use of alcohol hand sanitiser on a mental health ward, and to consider ways of improving how learning for a serious adverse incident in one trust can better be communicated to other trustsBackgroundDD a male patient with history of paranoid schizophrenia alongside historic illicit drug use and current alcohol dependency admitted detained to Bluestone hospital following bizarre behaviour at a wake. Had been non-compliant with medication. Transferred to PICU due to going AWOL and returning under influence of alcohol.2nd April overnight staff noted him to become over-sedated, presenting with slurred speech and appeared under influence of alcohol – transferred to A + E due to deteriorating GCS – was intubated, and transferred to ICU. Blood alcohol level was 373. Several empty bottles of hand sanitiser from dispensers on ward found in his room and he later disclosed he had accessed further alcohol hand sanitiser in sluice while washing clothesSAI learning outcomes from one healthcare trust in Northern Ireland not currently routinely shared with other trustsMethodLiterature review carried out to search for reports of similar incidents – 1 previous review article suggesting one death and 11 other major complications from consumption of alcohol hand sanitiser over 5 year period 2005-2009.Quality improvement steps implemented to address this riskWard policy was reviewed to ensure patients no longer had unsupervised access to wash clothesLiaised with Infection Control to assess the need for alcohol hand sanitiser to be available to patients given the ward is effectively a community settingIntoxication policy reviewed and education sessions on this provided to all medical and nursing staffRegional regular PICU staff update seminar launched for purpose of bringing PICU staff from across Northern Ireland together to share learning from SAIs and casesResultInfection control agreed alcohol hand sanitiser dispensers could be removed from wards and kept only in locked nursing office with use of visitors.Learning from this case shared with other trusts locally at newly launched regional PICU update seminarNo further incidents to dateConclusionPatient access to alcohol hand sanitisers found to be a significant safety risk in PICU settingFollowing implementation of quality improvement steps no further incidents of patients swallowing alcohol hand sanitiserImproved awareness of risk of alcohol intoxication on ward with nursing staff escalating concerns to on-call doctor more frequently

Plasma methylglyoxal levels are associated with amputations and mortality in severe limb ischemia patients with and without diabetes

<b>Introduction</b> <p>Diabetes is a risk factor for severe limb ischemia (SLI), a condition associated with high mortality, morbidity and limb loss. The reactive glucose-derived dicarbonyl methylglyoxal (MGO) is a major precursor for advanced glycation endproducts (AGEs) and potential driver of cardiovascular disease. We investigated whether plasma MGO levels are associated with poor outcomes in SLI.</p> <p><b>Methods</b> <b></b></p> <p>We measured plasma levels of MGO, free AGEs, and D-lactate, the detoxification endproduct of MGO, with ultra-performance liquid chromatography tandem mass spectrometry at baseline in 160 patients (64.8±13.3years, 67.5% male, 37.5% diabetes) with no-option SLI and recorded major adverse outcomes (n=86, containing death n=53 or amputations n=49 (First event counted)) over 5-year follow-up. Data were analyzed with linear or Cox regression, after Ln-transformation of the independent variables, adjusted for sex, age, trial arm, diabetes, eGFR, systolic blood pressure, cholesterol levels and BMI. Associations are reported per 1SD plasma marker. </p> <p><b>Results</b></p> <p>Higher plasma MGO levels were associated with more adverse outcomes (RR: 1.44; 95%CI: 1.11-1.86) and amputations separately (1.55; 1.13-2.21). We observed a similar, but weaker trend for mortality (1.28; 0.93-1.77). The MGO derived AGE N^ε-(carboxyethyl)lysine was also associated with more adverse outcomes (1.46; 1.00-2.15) and amputations (1.71; 1.04-2.79). D-lactate was not associated with adverse incident outcomes. Higher plasma MGO levels were also associated with more inflammation and white blood cells and fewer progenitor cells. </p> <p><b>Conclusion</b></p> <p>Plasma MGO levels are associated with adverse outcomes in SLI. Future studies should investigate whether MGO-targeting therapies improve outcomes in SLI.<br> </p>

Plasma methylglyoxal levels are associated with amputations and mortality in severe limb ischemia patients with and without diabetes

<b>Introduction</b> <p>Diabetes is a risk factor for severe limb ischemia (SLI), a condition associated with high mortality, morbidity and limb loss. The reactive glucose-derived dicarbonyl methylglyoxal (MGO) is a major precursor for advanced glycation endproducts (AGEs) and potential driver of cardiovascular disease. We investigated whether plasma MGO levels are associated with poor outcomes in SLI.</p> <p><b>Methods</b> <b></b></p> <p>We measured plasma levels of MGO, free AGEs, and D-lactate, the detoxification endproduct of MGO, with ultra-performance liquid chromatography tandem mass spectrometry at baseline in 160 patients (64.8±13.3years, 67.5% male, 37.5% diabetes) with no-option SLI and recorded major adverse outcomes (n=86, containing death n=53 or amputations n=49 (First event counted)) over 5-year follow-up. Data were analyzed with linear or Cox regression, after Ln-transformation of the independent variables, adjusted for sex, age, trial arm, diabetes, eGFR, systolic blood pressure, cholesterol levels and BMI. Associations are reported per 1SD plasma marker. </p> <p><b>Results</b></p> <p>Higher plasma MGO levels were associated with more adverse outcomes (RR: 1.44; 95%CI: 1.11-1.86) and amputations separately (1.55; 1.13-2.21). We observed a similar, but weaker trend for mortality (1.28; 0.93-1.77). The MGO derived AGE N^ε-(carboxyethyl)lysine was also associated with more adverse outcomes (1.46; 1.00-2.15) and amputations (1.71; 1.04-2.79). D-lactate was not associated with adverse incident outcomes. Higher plasma MGO levels were also associated with more inflammation and white blood cells and fewer progenitor cells. </p> <p><b>Conclusion</b></p> <p>Plasma MGO levels are associated with adverse outcomes in SLI. Future studies should investigate whether MGO-targeting therapies improve outcomes in SLI.<br> </p>

The effects of hospital-physician financial integration on adverse incident rate: An agency theory perspective

Background Patient safety is an important aspect of quality of care. Physicians’ alignment with hospitals by means of financial integration may possibly help hospitals achieve their quality goals. Most research examines the effects of financial integration on financial performance. There is a need to understand whether financial integration has an effect on quality and safety. Purpose The aim of this study is to examine the association between hospital physician financial integration (employment, joint ventures, and ownership) and Adverse Incident Rate. Methodology: A longitudinal panel study design was used. A random effects model with hospital, year, and state effects was used. Our sample contained 3,528 hospitals observations within U.S. from 2013–2015. Findings Contrary to our hypotheses, hospital physician financial integration does not influence AIR. Besides financial integration, hospitals need to have a high commitment towards quality and safety to influence a lower AIR.

P31 Improving paracetamol safety in a tertiary paediatric hospital

AimsMedication errors are perhaps the most common threat to patient safety.1 Children are particularly at risk because of variations in age and weight necessitating individual dose calculation for each patient; doses that are ten times the correct amount are occasionally given and can be life-threatening.2 Since 2015 the hospital has been seeking, as part of a Regional Quality initiative, to improve safety related to paracetamol.MethodsPrevious work involved clarification of IV paracetamol dosing for neonates and children under 10 kg with procurement of 100 mg in 10 ml vials, as well as introduction of a ‘ready-reckoner’ reference chart for prescribing, preparation and administration inserted into each BNFC across the hospital. In September 2018, we implemented a new prescribing aide sticker into kardexes in an effort to reduce IV administration errors. We then audited whether these interventions had led to an overall reduction in adverse incidents related to paracetamol.ResultsWe demonstrated a progressive reduction in adverse incidents over the past four years; it has now been more than 1000 days since the last reported serious adverse incident related to paracetamol. A snapshot audit of prescribing showed that 100% of patients were prescribed a safe dose of paracetamol by either age or weight. There was however considerable variation in dosing for enteral prescribing (8.2–18.8 mg/kg), with the majority of children (74%) being dosed according to age, despite weight being available at time of prescription. Introduction of the paracetamol prescribing aide sticker received overwhelmingly positive feedback from both medical and nursing staff, and has now been implemented for all children requiring regular IV paracetamol.ConclusionsAnaesthetics were the most commonly implicated specialty in paracetamol errors in our institution. Enteral dosing by age banding in hospital carries the potential for some children to be significantly under-dosed leading to sub-therapeutic drug levels, or even inadvertently over-dosed for more complex children who are underweight for age. We would therefore recommend dosing of enteral paracetamol by weight, when available, in hospital. Substantial improvement in paracetamol safety can be achieved through implementation of prescribing and administration aides to reduce likelihood of human error.ReferencesEyers S, Fingleton J, Perrin K, Beasley R. Proposed MHRA changes to UK children’s paracetamol dosing recommendations: modelling study. J R Soc Med 2012;105:263–9.Kaufmann J, Laschat M, Wappler F. Medication Errors in Paediatric Emergencies: A Systematic Analysis. Dtsch Arztebl Int 2012;109:609–616.

Implementing an intervention to improve adverse incident reporting in the hospital setting: A pilot study

Objective: This pilot study evaluated an intervention designed to increase error reporting among physicians. Research was conducted at University Hospital A, where data were collected from April 2017 to March 2019. The intervention began in April 2018 and consisted of the four following steps: define reporting standards, improve the incident reporting system, have the hospital administrators set clear goals and begin a visualized feedback process, and achieve support and appropriate feedback from the hospital administrator. Results: Physicians’ reporting rates were higher in FY 2018 than 2017. Particularly, differences began to occur in November of FY 2018 (p < 0.05, analysed using Fisher’s exact test). Further, the number of reports submitted by non-physicians increased by 900 in FY 2018 compared to those in FY 2017. Based on these results, the intervention effectively increased incident reporting rates among not only physicians, but also other staff members. In this regard, reporting barriers were broken when hospital administrators encouraged employees to submit incident reports.

Lessons learned: using adverse incident reports to investigate the characteristics and causes of prescribing errors

IntroductionPrescribing errors are a principal cause of preventable harm in healthcare. This study aims to establish a systematic approach to analysing prescribing-related adverse incident reports, in order to elucidate the characteristics and contributing factors of common prescribing errors and target multifaceted quality improvement initiatives.MethodsAll prescribing-related adverse incident reports submitted across one NHS board over 12 months were selected. Incidents involving commonly implicated drugs (involved in ≥10 incidents) underwent analysis to establish likely underlying causes using Reason’s Model of Accident Causation.Results330 prescribing-related adverse incident reports were identified. Commonly implicated drugs were insulin (10% of incidents), gentamicin (7%), co-amoxiclav (5%) and amoxicillin (5%). The most prevalent error types were prescribing amoxicillin when contraindicated due to allergy (5%); prescribing co-amoxiclav when contraindicated due to allergy (5%); prescribing the incorrect type of insulin (3%); and omitting to prescribe insulin (3%). Error-producing factors were identified in 86% of incidents involving commonly implicated drugs. 53% of incidents involved error-producing factors related to the working environment; 38% involved factors related to the healthcare team; and 37% involved factors related to the prescriber.DiscussionThis study establishes that systematic analysis of adverse incident reports can efficiently identify the characteristics and contributing factors of common prescribing errors, in a manner useful for targeting quality improvement. Furthermore, this study produced a number of salient findings. First, a narrow range of drugs were implicated in the majority of incidents. Second, a small number of error types were highly recurrent. Lastly, a range of contributing factors were evident, with those related to the working environment contributing to the majority of prescribing errors analysed.

Prehospital neuromuscular blockade post OHCA: UK's first paramedic-delivered protocol

Background: Since 2016, critical care paramedics from the South East Coast Ambulance Service have offered neuromuscular blockade to patients for ventilatory/airway control after cardiac arrest. Aims: To examine the first cases of paramedic-delivered neuromuscular blockade, and evaluate the prevalence of its use and safety. Methods: Retrospective service evaluation of patients receiving post-arrest paralysis during the study period from 1 April 2016 until 31 July 2017. Findings: The study included 127 patients. The mean age of administration was 63 years, mean weight was 80 kg (SD: 19 kg), dose was 1 mg/kg and median time from rocuronium administration to hospital was 32 minutes (IQR 20–43 minutes). Three patients (2.3%) experienced a minor adverse incident. There were no major airway complications, nor other significant adverse incidents. Thirty-seven patients (31%) survived to discharge. Conclusion: From this patient group, paramedic-administered rocuronium in intubated patients who have experienced a cardiac arrest and a return of spontaneous circulation appears to be safe, but further interventional research is required to determine whether this improves patient outcomes.

Police and health operational staff perspectives on managing detainees held under Section 136 of the Mental Health Act: A qualitative study in London

Detention under section 136(1) of the Mental Health Act 1983 allows for the police to detain a person from a public place and “remove [them] to a place of safety” if it is “in the interests of that person or for the protection of other persons in immediate need of care or control.” This study examines the interface between police and health professionals covering the conveyance and transfer of detainees to a place of safety and on completion of the assessment prior to inpatient admission. One hundred ninety-six professionals were interviewed across police (n=38), London Ambulance Service (n=2), Mental Health or Emergency Department staff (n=63), and Approved Mental Health Professionals (AMHPs)/Section 12 doctors (n=93). The data was analyzed thematically using a Framework analysis. The conveyance and transfer of detainees was framed by various elements of detainee risk. Healthcare professionals cited clinical risk, risk associated with substance misuse, professional safety, culture of risk aversion, staffing issues, and fear of certain detainee groups as the main issues. For police, risk was discussed within the context of institutional or professional fear of negligence due to an adverse incident. It is argued that the negative framing of risk at this point of the detention process by all professionals creates a negative therapeutic environment for detainees. Whilst safety is an essential part of the detention process, these distinctions problematize the process for a detainee. The article argues for a more balanced framing of risk to establish a more therapeutic interaction between detainees and police and healthcare providers.