Patient safety alert – Risk of severe harm or death when desmopressin is omitted or delayed in patients with cranial diabetes insipidus

February 24, 2016

Source:  NHS England

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Date of publication: February 2016

Publication type:  Safety alert

In a nutshell:  A patient safety alert has been issued by NHS England to raise awareness of the risk of severe dehydration and death caused by an omission or delay of desmopressin in patients with cranial diabetes insipidus.

Following reports of patient safety incidents caused by an omission or delay in the provision of desmopressin, providers of NHS care are asked to consider if immediate action needs to be taken locally to raise awareness and reduce the risk of these incidents from occurring. The main themes identified as causes include a lack of awareness of the critical nature of desmopressin amongst medical, pharmacy and nursing staff; and poor availability of the medication within inpatient clinical areas.

Length of publication:   1 webpage


Personal hand gel for improved hand hygiene compliance on the regional anesthesia team

January 27, 2016

Source:  Journal of Anesthesia 29/6 pp. 899-903

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Date of publication: December 2015

Publication type:  Journal article

In a nutshell:  A hospital in the US examined the effect of personal gel dispensers for staff on surgical hand hygiene compliance amongst an anaesthesia team. Before personal gel dispensers were provided compliance was 34% (23% before patient contact and 43% afterwards). After personal dispensers, compliance was 63% (53% before patient contact and 72% afterwards).

Length of publication:  5 pages


The system-wide effect of real-time audio-visual feedback and post-event debriefing for in-hospital cardiac arrest: the Cardiopulmonary Resuscitation Quality Improvement Initiative

December 23, 2015

Source: Critical Care Medicine 43/11 pp. 2321-2331

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Date of publication:  November 2015

Publication type:  Journal article

In a nutshell:  The objective of this multicentre prospective cohort study was to evaluate the effect of implementing real-time audio-visual feedback with and without post event debriefing on survival and quality of cardiopulmonary resuscitation quality at in-hospital cardiac arrest.

The conclusion was that implementation of real-time audio-visual feedback with or without post-event debriefing did not lead to a measured improvement in patient or process-focused outcomes at individual hospital sites. However, there was an unexplained system-wide improvement in return of spontaneous circulation and process-focused outcomes during the second phase of the study.

Length of Publication:  11 pages


Staff’s bright idea implemented to enhance patient safety

October 28, 2015

Source:  Plymouth Hospitals NHS Trust

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Date of publicationSeptember 2015

Publication type:  Trust website

In a nutshell: Three members of Derriford Hospital’s Physiotherapy team have come up with an idea for high visibility tabards to improve patient safety and help reassure patients when they undergo stair assessments. The patients are often very nervous and can be quite unsteady and people pushing past is putting those patients under even more stress which ultimately affects their performance and even their discharge. In an effort to stop this happening, Physiotherapy team members came up with the idea for the high visibility tabards. The tabards display the message ‘Stop. Stair assessment in progress. Please Wait’, in an attempt to highlight to other stair users the need for patience and consideration.

Length of Publication:  1 web page


The Surviving Sepsis Campaign bundles and outcome: results from the International Multicentre Prevalence Study on Sepsis (the IMPreSS study)

October 28, 2015

Source:  Intensive Care Medicine 41/9 pp 1620-8

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Date of publicationAugust 2015

Publication type:  Journal article

In a nutshell: Despite evidence demonstrating the value of performance initiatives, marked differences remain between hospitals in the delivery of care for patients with sepsis. The aims of this study were to improve our understanding of how compliance with the 3-h and 6-h Surviving Sepsis Campaign (SSC) bundles are used in different geographic areas, and how this relates to outcome. Compliance with all of the evidence-based bundle metrics was not high. Patients whose care included compliance with all of these metrics had a 40 % reduction in the odds of dying in hospital with the 3-h bundle and 36 % for the 6-h bundle.

Length of Publication:  9 pages

Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library


Creating spaces in intensive care for safe communication: a video-reflexive ethnographic study

January 28, 2015

Source:  BMJ Quality & Safety 23/12 pp. 1007-13

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Date of publication:  December 2014

Publication type:  Journal article

In a nutshell: This study says that the built environment in acute care settings is a new focus in patient safety research. This was an interventionist video-reflexive ethnographic (VRE) study, exploring how clinicians used the built environment to achieve safe communication in an intensive care unit (ICU) in a hospital in Sydney. The authors found that ICU staff enable safe communication in their wards by creating temporary spaces that are both ‘connected’ and ‘protected’.

Length of Publication:  1 web page

Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library


Methicillin-resistant Staphylococcus aureus screening as a patient safety initiative: using patients’ experiences to improve the quality of screening practices

November 27, 2013

Source:  Journal of Clinical Nursing 2013 Sep 21. [Epub ahead of print]

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Date of publication:  September 2013

Publication type:  Journal article

In a nutshell:  This study aimed to explore the patient experience and acceptability of methicillin-resistant Staphylococcus aureus screening of inpatient admissions to acute hospital settings. The study was conducted in six acute care hospitals in three Scottish regions. The results provide evidence that attitudes were largely positive and responses indicated a belief in the beneficial impact of methicillin-resistant Staphylococcus aureus screening for patients and the wider community. Clinicians should consider the timing, content and effectiveness of information provision.

Length of Publication:  Unknown

Some important notes:  Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library.