Reducing risk of overdose with midazolam injection in adults: an evaluation of change in clinical practice to improve patient safety in England

Rationale aims and objectives. This study sought to evaluate potential reductions in risk associated with midazolam injection, a sedating medication, following a United Kingdom National Patient Safety Alert. This alert, ‘Reducing risk of overdose with midazolam injection in adults’, was sent to all National Health Service organisations as a Rapid Response Report detailing actions services should take to minimise risks. Method. To evaluate any potential changes arising from this alert, a number of data sources were explored including reported incidents to a national reporting system for health care error, clinician survey and audit data, pharmaceutical purchasing patterns and feedback from NHS managers. Results. Prior to the Rapid Response Report, 498 incidents were received by the National Patient Safety Agency including 3 deaths. Post implementation of the Rapid Response Report (June 2009), no incidents resulting in death or severe harm had been received. All organisations reported having completed the Rapid Response Report actions. Purchase and use of risk-prone, high-strength sedating midazolam by health care organisations decreased significantly as did the increased use of safer, lower strength doses (as recommended in the Rapid Response Report). Conclusions. Organisations can achieve safer medication practices, better knowledge, awareness and implementation of national safer practice recommendations. Risks from inadvertent overdose of midazolam injection was reduced post implementation of national recommendations. Ongoing monitoring of this particular adverse event will be required with a sustained patient safety message to health services to maintain awareness of the issue and reduction in the number of midazolam related errors

Promoting collaboration in emergency medicine

Background: Collaborative practice between paramedics and medical staff is essential for ensuring the safe handover of patients. Handover of care is a critical time in the patient journey, when effective communication and collaborative practice are central to promoting patient safety and to avoiding medical error. To encourage effective collaboration between paramedic and medical students, an innovative, practice-based simulation exercise, known as Interprofessional clinical skills (ICS) was developed at the University of East Anglia, UK. Emphasising patient safety, effective handover of care and teamwork, within the context of emergency medicine, the ICS promotes collaborative practice amongst health care students through the use of high-and low-fidelity simulation, human factors and values-based practice. Methods: A total of 123 undergraduate students from paramedic (60) and medical backgrounds (63) took part in the ICS. Evaluation data were collected from all students through the completion of an internal feedback/satisfaction questionnaire with 13 statements and one open-ended comment box. Results: The response rate for the questionnaire was 100%. Of the 123 students from paramedic and medical disciplines, 99% agreed or strongly agreed with the statement ‘I enjoyed this session’. Students also felt that the ICS helped them to build mutual respect (98%), enhance understanding of roles (94%) and develop as collaborative practitioners (92%). Conclusion: The ICS is an innovative, enjoyable and meaningful intervention for promoting Interprofessional collaborative practice between paramedic and medical students in a simulated practice setting. It encourages students to gain core training in clinical skills and patient safety, within a safe, supervised environment

Project management techniques to maximise success with research.

Globally, coronary heart disease remains one of the biggest causes of death (World Health Organization (WHO), 2013) and has influenced a vast array of research to ensure that treatments, approaches, prevention strategies and rehabilitation methods are evidence-based. Significantly, the amount of public and private funds used to support research in cardiac care is vast, and funders expect timely, high-quality research to develop and advance care-delivery innovations. Managing research can be complex and fraught with challenges; however, careful consideration of the risks and how these can be avoided or managed can increase your chances of success

What is the nursing time and workload involved in taking and recording patients' vital signs? A systematic review.

AIMS AND OBJECTIVES: To synthesise evidence regarding the time nurses take to monitor and record vital signs observations and to calculate early warning scores. BACKGROUND: While the importance of vital signs' monitoring is increasingly highlighted as a fundamental means of maintaining patient safety and avoiding patient deterioration, the time and associated workload involved in vital signs activities for nurses are currently unknown. DESIGN: Systematic review. METHODS: A literature search was performed up to 17 December 2019 in CINAHL, Medline, EMBASE and the Cochrane Library using the following terms: vital signs; monitoring; surveillance; observation; recording; early warning scores; workload; time; and nursing. We included studies performed in secondary or tertiary ward settings, where vital signs activities were performed by nurses, and we excluded qualitative studies and any research conducted exclusively in paediatric or maternity settings. The study methods were compliant with the PRISMA checklist. RESULTS: Of 1,277 articles, we included 16 papers. Studies described taking vital signs observations as the time to measure/collect vital signs and time to record/document vital signs. As well as mean times being variable between studies, there was considerable variation in the time taken within some studies as standard deviations were high. Documenting vital signs observations electronically at the bedside was faster than documenting vital signs away from the bed. CONCLUSIONS: Variation in the method(s) of vital signs measurement, the timing of entry into the patient record, the method of recording and the calculation of early warning scores values across the literature make direct comparisons of their influence on total time taken difficult or impossible. RELEVANCE TO CLINICAL PRACTICE: There is a very limited body of research that might inform workload planning around vital signs observations. This uncertainty means the resource implications of any recommendation to change the frequency of observations associated with early warning scores are unknown

Use of a retrospective methodology to examine the process of care surrounding serious medical events in HIV-positive patients: a feasibility study

Introduction: Co-morbidities are increasingly common amongst people living with HIV (PLWH) as they age. There is no evidence regarding models of care. We aimed to assess feasibility of a novel methodology to investigate care processes for serious medical events in PLWH. Method: The method was based on the National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Data were extracted from medical records and questionnaires completed by General Practitioners (GPs), HIV physicians, and non-HIV specialist physicians. A panel reviewed anonymised cases and gave feedback on the review process. Results: Eleven out of 13 patients consented to the study. Questionnaires were completed by 64% of HIV physicians, 67% of non-HIV specialist physicians and 55% of GPs. The IRP advised improvement in the methodology including data presentation and timing. Conclusion: This method was acceptable to patients and secondary care physicians. Further work is needed to the improve GP responses and facilitate IRP

A mixed methods survey to explore views of staff and patients in mental health inpatient wards prior to introduction of a digital early warning system for physical deterioration

Introduction Technological innovation offers opportunities to improve mental health care, however, little evidence exists regarding attitudes of inpatient staff and patients to such changes. We present a survey of staff and patients prior to introduction of a digital version of the National Early Warning Score (eNEWS) system for identifying physical deterioration. Aim To collate views of staff and inpatients related to prospective use of eNEWS, to inform the plan for implementation. Method Paper questionnaires were distributed to both groups in six wards prior to eNEWS implementation. Two discussion groups were then held. Results Eighty two staff and 26 inpatients completed questionnaires. Some inpatients expressed concerns about data confidentiality. Most staff were neutral or positive about the planned change, but raised possible safety risks and the risk of electronic recording being misinterpreted by patients. The implementation plan was modified in response to this information, principally by improving communication processes with patients. Discussion This study adds to the existing evidence by reporting specific staff and patient concerns towards a form of information technology. Further evaluations would help determine the transferability of these findings. Implications for Practice Listening to patient and staff views about planned technological innovation is essential for effective implementation

Exploring the use of high-fidelity simulation training to enhance clinical skills

The use of interprofessional simulation training to enhance nursing students' performance of technical and non-technical clinical skills is becoming increasingly common. Simulation training can involve the use of role play, virtual reality or patient simulator manikins to replicate clinical scenarios and assess the nursing student's ability to, for example, undertake clinical observations or work as part of a team. Simulation training enables nursing students to practise clinical skills in a safe environment. Effective simulation training requires extensive preparation, and debriefing is necessary following a simulated training session to review any positive or negative aspects of the learning experience. This article discusses a high-fidelity simulated training session that was used to assess a group of third-year nursing students and foundation level 1 medical students. This involved the use of a patient simulator manikin in a scenario that required the collaborative management of a deteriorating patient. [Abstract copyright: ©2018 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.

The challenges in monitoring and preventing patient safety incidents for people with intellectual disabilities in NHS acute hospitals: evidence from a mixed-methods study.

BACKGROUND: There has been evidence in recent years that people with intellectual disabilities in acute hospitals are at risk of preventable deterioration due to failures of the healthcare services to implement the reasonable adjustments they need. The aim of this paper is to explore the challenges in monitoring and preventing patient safety incidents involving people with intellectual disabilities, to describe patient safety issues faced by patients with intellectual disabilities in NHS acute hospitals, and investigate underlying contributory factors. METHODS: This was a 21-month mixed-method study involving interviews, questionnaires, observation and monitoring of incident reports to assess the implementation of recommendations designed to improve care provided for patients with intellectual disabilities and explore the factors that compromise or promote patient safety. Six acute NHS Trusts in England took part. Data collection included: questionnaires to clinical hospital staff (n = 990); questionnaires to carers (n = 88); interviews with: hospital staff including senior managers, nurses and doctors (n = 68) and carers (n = 37); observation of in-patients with intellectual disabilities (n = 8); monitoring of incident reports (n = 272) and complaints involving people with intellectual disabilities. RESULTS: Staff did not always readily identify patient safety issues or report them. Incident reports focused mostly around events causing immediate or potential physical harm, such as falls. Hospitals lacked effective systems for identifying patients with intellectual disabilities within their service, making monitoring safety incidents for this group difficult.The safety issues described by the participants were mostly related to delays and omissions of care, in particular: inadequate provision of basic nursing care, misdiagnosis, delayed investigations and treatment, and non-treatment decisions and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders. CONCLUSIONS: The events leading to avoidable harm for patients with intellectual disabilities are not always recognised as safety incidents, and may be difficult to attribute as causal to the harm suffered. Acts of omission (failure to give care) are more difficult to recognise, capture and monitor than acts of commission (giving the wrong care). In order to improve patient safety for this group, the reasonable adjustments needed by individual patients should be identified, documented and monitored