A safer place for patients: learning to improve patient safety

1 Every day over one million people are treated successfully by National Health Service (NHS) acute, ambulance and mental health trusts. However, healthcare relies on a range of complex interactions of people, skills, technologies and drugs, and sometimes things do go wrong. For most countries, patient safety is now the key issue in healthcare quality and risk management. The Department of Health (the Department) estimates that one in ten patients admitted to NHS hospitals will be unintentionally harmed, a rate similar to other developed countries. Around 50 per cent of these patient safety incidentsa could have been avoided, if only lessons from previous incidents had been learned. 2 There are numerous stakeholders with a role in keeping patients safe in the NHS, many of whom require trusts to report details of patient safety incidents and near misses to them (Figure 2). However, a number of previous National Audit Office reports have highlighted concerns that the NHS has limited information on the extent and impact of clinical and non-clinical incidents and trusts need to learn from these incidents and share good practice across the NHS more effectively (Appendix 1). 3 In 2000, the Chief Medical Officer’s report An organisation with a memory 1 , identified that the key barriers to reducing the number of patient safety incidents were an organisational culture that inhibited reporting and the lack of a cohesive national system for identifying and sharing lessons learnt. 4 In response, the Department published Building a safer NHS for patients3 detailing plans and a timetable for promoting patient safety. The goal was to encourage improvements in reporting and learning through the development of a new mandatory national reporting scheme for patient safety incidents and near misses. Central to the plan was establishing the National Patient Safety Agency to improve patient safety by reducing the risk of harm through error. The National Patient Safety Agency was expected to: collect and analyse information; assimilate other safety-related information from a variety of existing reporting systems; learn lessons and produce solutions. 5 We therefore examined whether the NHS has been successful in improving the patient safety culture, encouraging reporting and learning from patient safety incidents. Key parts of our approach were a census of 267 NHS acute, ambulance and mental health trusts in Autumn 2004, followed by a re-survey in August 2005 and an omnibus survey of patients (Appendix 2). We also reviewed practices in other industries (Appendix 3) and international healthcare systems (Appendix 4), and the National Patient Safety Agency’s progress in developing its National Reporting and Learning System (Appendix 5) and other related activities (Appendix 6). 6 An organisation with a memory1 was an important milestone in the NHS’s patient safety agenda and marked the drive to improve reporting and learning. At the local level the vast majority of trusts have developed a predominantly open and fair reporting culture but with pockets of blame and scope to improve their strategies for sharing good practice. Indeed in our re-survey we found that local performance had continued to improve with more trusts reporting having an open and fair reporting culture, more trusts with open reporting systems and improvements in perceptions of the levels of under-reporting. At the national level, progress on developing the national reporting system for learning has been slower than set out in the Department’s strategy of 2001 3 and there is a need to improve evaluation and sharing of lessons and solutions by all organisations with a stake in patient safety. There is also no clear system for monitoring that lessons are learned at the local level. Specifically: a The safety culture within trusts is improving, driven largely by the Department’s clinical governance initiative 4 and the development of more effective risk management systems in response to incentives under initiatives such as the NHS Litigation Authority’s Clinical Negligence Scheme for Trusts (Appendix 7). However, trusts are still predominantly reactive in their response to patient safety issues and parts of some organisations still operate a blame culture. b All trusts have established effective reporting systems at the local level, although under-reporting remains a problem within some groups of staff, types of incidents and near misses. The National Patient Safety Agency did not develop and roll out the National Reporting and Learning System by December 2002 as originally envisaged. All trusts were linked to the system by 31 December 2004. By August 2005, at least 35 trusts still had not submitted any data to the National Reporting and Learning System. c Most trusts pointed to specific improvements derived from lessons learnt from their local incident reporting systems, but these are still not widely promulgated, either within or between trusts. The National Patient Safety Agency has provided only limited feedback to trusts of evidence-based solutions or actions derived from the national reporting system. It published its first feedback report from the Patient Safety Observatory in July 2005

Transfusion Error in the Gynecology Patient: A Case Review with Analysis

Fonetik meliputi studi tentang suara. Dalam produksi suara, sebagian besar pembicara yang sama memiliki lafal yang berbeda. Cara pembicara menyadari bahwa fonem tunggal bermacam-macam, ini menyebabkan terjadinya fonetik khas diantara mereka. Fakta ini jelas ditunjukkan oleh orang Amerika, Indonesia, Italia, dan India, karena mereka adalah penutur asli dan non-asli bahasa Inggris. Akibatnya, penelitian ini menjawab masalah apa variasi fonetik dimiliki oleh penutur asli dan non-pribumi dan fonetik komparatif di dua. Penduduk asli dan non-asli penelitian ini adalah karakter dalam film 'Eat, Pray, Love'. Ini adalah film Amerika yang Melibatkan Karakter Bangsa Dari Berbeda negara, Mereka Apakah Inggris dan Indonesia, Italia, India dimana mereka memiliki kinerja fonetik, dengan cara yang berbeda dan tempat suara diartikulasikan sangat menonjol. Tujuan dari penelitian ini adalah untuk menggambarkan fonetik variasi yang digunakan karakter asli, menggambarkan fonetik variasi non karakter asli, dan untuk menemukan perbedaan dan persamaan fonetik variasi antara karakter asli dan non karakter asli. Desain penelitian ini adalah deskriptif kualitatif dan metode komparatif. Sumber data yang didapatnya dari film dalam bentuk suara semua kata yang dihasilkan oleh kedua kelompok, maka hanya suara kata-kata serupa dan suku terpilih sebagai data. Selain itu, proses analisa data memiliki beberap alangkah, menyalin suara, menyortir fonetik, mengklasifikasikan variasi fonetik tertentu, dan merumuskan persamaan dan perbedaan variasi fonetik dari dua jenis karakter. Hasil penelitian menunujukan bahwa fonetik variasi pada karakter asli terdapat voiced Alveolar fricative consonant, half-open back rounded vowel, Voiceless alveolar plosive consonant. Pada fonetik variasi dalam non karakter asli terdapat close front unrounded vowels, voiced alveolar approximant consonant, open front unrounded vowel, open back rounded vowel, open front unrounded vowel, produce open back rounded vowel, close front unrounded vowel, voiceless labiodental fricative, voiced labiodental fricative. Dan fonetik variasi karakter asli dan non karakter asliterdapat6 half open back rounded vowel, 4 half open central vowel, 4 close front unrounded vowel, 7 voiced alveolar fricative consonant, 2 voiced labiodental fricative dan voiceless labiodentals fricative consonant, 3 fricativevoiced alveolar approximant consonant, 1 voiceless velar plosive consonant, 3 voiceless dental fricative consonant, 3 voiceless alveolar plosive consonant yang ditemukanpada kata – kata sama yang diucapkan oleh karakter asli dan non asli dalam film “Eat, Pray, Love”. Saya menyadari bahwa variasi fonetik sangat penting dalam pelafalan bahasa Inggris. Dengan penuh harapan murid dapat mengerti fonetik variasi bagaimana melafalkan sebuah kata, dosen bahasa Inggris dapat mengajari mahasiswa mereka bagaimana melafalkan sebuah kata dengan baik. dan kepada peneliti lain dapat menggunakan penelitian ini untuk referensi lebih lanjut

Transfusion Error in the Gynecology Patient: A Case Review with Analysis

Emergency blood transfusion (EBT) is a life-saving intervention which also carries a significant risk of harm in the event of a transfusion reaction. Our chapter starts with a hypothetical case study of a gynecology patient who underwent emergent hysterectomy with severe hemorrhage managed with an emergency blood transfusion. During the aggressive resuscitation, the patient was inadvertently transfused with blood products that had been allocated for another patient. Through this clinical vignette, we review the operational aspects of an EBT and identify sources of transfusion-related errors. We emphasize best practices that can be implemented with the goal of improved patient safety. This chapter offers a concise, practical review of EBT for our readers

Utilizing Radiofrequency Identification Technology to Improve Safety and Management of Blood Bank Supply Chains

The importance of efficiency in the supply chain of perishable products, such as the blood products used in transfusion services, cannot be overstated. Many problems can occur, such as the outdating of products, inventory management issues, patient misidentification, and mistransfusion. The purpose of this article was to identify the benefits and barriers associated with radiofrequency identification (RFID) usage in improving the blood bank supply chain. Materials and Methods: The methodology for this study was a qualitative literature review following a systematic approach. The review was limited to sources published from 2000 to 2014 in the English language. Sixty-five sources were found, and 56 were used in this research study. Results: According to the finding of the present study, there are numerous benefits and barriers to RFID utilization in blood bank supply chains. RFID technology offers several benefits with regard to blood bank product management, including decreased transfusion errors, reduction of product loss, and more efficient inventory management. Barriers to RFID implementation include the cost associated with system implementation and patient privacy issues. Conclusions: Implementation of an RFID system can be a significant investment. However, when observing the positive impact that such systems may have on transfusion safety and inventory management, the cost associated with RFID systems can easily be justified. RFID in blood bank inventory management is vital to ensuring efficient product inventory management and positive patient outcomes

SPECIMEN LABELING IMPROVEMENT PROJECT: SLIP

Blood specimens are labeled at the time of acquisition in order to identify and match the specimen, label, and order to the patient. While the labeling process is not new, it is frequently laden with errors (Brown, Smith, & Sherfy, 2011). Wrong blood in tube (WBIT) poses significant risk. Multiple factors contribute to mislabeling errors, including lax policies, limited technological solutions, decentralized labeling processes, multi-tasking, distraction from the clinician, and insufficient education and training of staff. To reduce blood specimen labeling errors, a large academic medical center implemented an innovative technological solution for specimen labeling that integrates patient identification, physician order, and laboratory specimen identification through barcode technology that interfaces with the electronic medical record at the point of care. A failure mode, effects and critical analysis (FMECA) were completed to assess for system failure points, and to design workflow prior to training staff. Four failure points were identified and eliminated through workflow adjustments with the new system. Staff training utilizing simulation highlighted system safety points. This quality improvement process applied across adult and pediatric acute and critical care units provided dramatic reductions in blood specimen labeling errors pre/post intervention

Applications of Automated Identification Technology in EHR/EMR

Although both the electronic health record (EHR) and the electronic medical record (EMR) store an individuals computerized health information and the terminologies are often used interchangeably, there are some differences between them. Three primary approaches in Automated Identification Technology (AIT) are barcoding, radio frequency identification (RFID), and biometrics. In this paper, technology intelligence, progress, limitations, and challenges of EHR/EMR are introduced. The applications and challenges of barcoding, RFID, and biometrics in EHR/EMR are presented respectively

Management of cancer-associated anemia with erythropoiesis-stimulating agents: ASCO/ASH clinical practice guideline update.

PURPOSE: To update the American Society of Clinical Oncology (ASCO)/American Society of Hematology (ASH) recommendations for use of erythropoiesis-stimulating agents (ESAs) in patients with cancer. METHODS: PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs in patients with cancer published from January 31, 2010, through May 14, 2018. For biosimilar ESAs, the literature search was expanded to include meta-analyses and RCTs in patients with cancer or chronic kidney disease and cohort studies in patients with cancer due to limited RCT evidence in the cancer setting. ASCO and ASH convened an Expert Panel to review the evidence and revise previous recommendations as needed. RESULTS: The primary literature review included 15 meta-analyses of RCTs and two RCTs. A growing body of evidence suggests that adding iron to treatment with an ESA may improve hematopoietic response and reduce the likelihood of RBC transfusion. The biosimilar literature review suggested that biosimilars of epoetin alfa have similar efficacy and safety to reference products, although evidence in cancer remains limited. RECOMMENDATIONS: ESAs (including biosimilars) may be offered to patients with chemotherapy-associated anemia whose cancer treatment is not curative in intent and whose hemoglobin has declined to \u3c 10 g/dL. RBC transfusion is also an option. With the exception of selected patients with myelodysplastic syndromes, ESAs should not be offered to most patients with nonchemotherapy-associated anemia. During ESA treatment, hemoglobin may be increased to the lowest concentration needed to avoid transfusions. Iron replacement may be used to improve hemoglobin response and reduce RBC transfusions for patients receiving ESA with or without iron deficiency. Additional information is available at www.asco.org/supportive-care-guidelines and www.hematology.org/guidelines

Standardized Blood Transfusion Documentation

The aim of this project was to improve nurse satisfaction through the use of a standardized blood administration documentation template. The goal was to reduce the time that nurses spend charting by offering a structured documentation template and to ensure that the procedure is correctly recorded in the patient’s electronic record. The leadership theme that supported this project is Information Manager, as the clinical nurse leader (CNL) uses information systems and technology at the point of care to improve health care outcomes. The selected microsystem is a medical/surgical/telemetry unit, which has 38 beds with 38 registered nurses (RNs). When surveyed, 39% of the RNs were confident administering blood products and 48% were aware of what is necessary to document regarding blood transfusions. The change theory that was utilized for this project was Kotter’s Change Model. A blood transfusion template was developed to meet the needs of the nurses, providers and patients within the microsystem. Ultimately a delay in releasing the template resulted in pushing the project timeline back. It is expected that having a structured template will result in expedited chart searching, timely display of patient information, better coordination of care among providers, improved patient outcomes and increased nurse confidence when documenting transfusions

Jefferson Digital Commons quarterly report: January-March 2020

This quarterly report includes: New Look for the Jefferson Digital Commons Articles COVID-19 Working Papers Educational Materials From the Archives Grand Rounds and Lectures JeffMD Scholarly Inquiry Abstracts Journals and Newsletters Master of Public Health Capstones Oral Histories Posters and Conference Presentations What People are Saying About the Jefferson the Digital Common

Improving Anesthesia Provider Knowledge and Competence in Patient Blood Management

Background: In the United States, blood transfusions are the most common medical procedure performed in hospitals. When used appropriately, allogeneic blood transfusions are crucial life-saving interventions essential in perioperative management. The use of blood transfusions should be based on safety, efficacy, and quality of treatment. However, a significant volume of evidence has emerged correlating blood transfusions to adverse patient outcomes, increases in cost, increases in morbidity, and mortality in surgical patients. Noting this, current transfusion practices require further evaluation. Patient Blood Management is a novel multidisciplinary approach that mitigate these negative outcomes. Methods: A comprehensive literature search was conducted using CINAHL and MEDLINE databases to identify research studies from 2015 and forward that have evaluated the effectiveness of Patient Blood Management in reducing morbidity, mortality, and excess costs associated with inappropriate allogeneic blood transfusion administration. Results: A total of 8 research studies were identified for review. These studies analyzed various treatment modalities within Patient Blood Management. The articles affirm the reliability and validity of the initiative in reducing the overutilization allogeneic blood transfusions in the perioperative period and thus reducing the associated adverse outcomes and cost