Evaluating the effect of distractions in the operating room on clinical decision-making and patient safety

March 23, 2016

Source: Surgical Endoscopy [Epub ahead of print]

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Date of publication: February 2016

Publication type:  Journal article

In a nutshell:  Answering telephone calls and pagers is common distraction in the operating room. This study sought to evaluate the impact of distractions on patient care by (1) assessing the accuracy and safety of responses to clinical questions posed to a surgeon while operating and (2) determining whether pager distractions affect simulation-based surgical performance.

The study found that distractions in the operating room may have a profound impact on patient safety on the wards. While multitasking in a simulated setting, the majority of residents made at least one unsafe clinical decision. Pager distractions also hindered surgical residents’ ability to complete a simulated laparoscopic task in the allotted time without affecting other variables of surgical performance.

Length of publication:  6 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


Our approach to changing the culture of caring for the acutely unwell patient at a large UK teaching hospital: A service improvement focus on Early Warning Scoring tools

May 22, 2015

Source: Intensive & Critical Care Nursing 31/2 pp. 106-15

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Date of publication:  April 2015

Publication type:  Journal article

In a nutshell:  Early Warning Scoring tools have been in place in Nottingham University Hospitals NHS Trust for over five years but compliance has been low. A service improvement project commenced across all admission wards in 2013. Prior to the project, only one out of five clinical care targets set were achieved. An established framework for service improvement was used to guide delivery. Since introduction of the service improvement team, consistent signs of improvement have been visible across the admission areas in four out of five of the clinical care targets. The first 12 months of the project has seen benefits in patient care and staff experience.

Length of Publication:  10 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


A strategy to maintain safety in clinical incidents

October 29, 2014

Source:  Nursing Times 2/110 (34-35) pp.16-8.

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Date of publication:  August 2014

Publication type:  News item

In a nutshell:  Team leaders in the NHS are often in a position where they have to manage and control a clinical situation. They can also be actively involved in delivering patient care because of low staffing levels or inappropriate skill mixes, which can lead to the potential for loss of situational awareness and risk to patient and staff safety. “Inner and outer circles” is an approach that could reduce risks and increase patient safety. It is used in pre-hospital and industrial environments and could be adapted to suit inpatient and other settings.

Length of Publication:  3 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


Leading the way on patient safety.

March 27, 2013

Source:  The Scottish Government

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Date of publication:  March 2013

Publication type:  Press release

In a nutshell:  The world’s first patient safety programme for primary care is being launched in Scotland. There are about 100,000 GP visits every day in Scotland so the programme will see safety measures performed where most of the NHS care is supplied. Safety surveys and case note reviews will be undertaken by GPs and their staff to increase awareness and to incorporate patient safety into their work to reduce avoidable harm. For the first time almost all patient care will be covered by the Scottish Patient Safety Programme with initiatives now up and running in GP surgeries, hospitals, mental health and maternity services.

Length of Publication:  1 web page


CCGs already improving patient care

August 31, 2012

Source: Kings Fund

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Date of publication: July 2012

Publication type:  Article

In a nutshell:  This article looks at Clinical Commissioning Groups and the impact they are already making in the area of improving patient care.


Raising and acting on concerns about patient safety

April 30, 2012

Source:  General Medical Council

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Date of publication: Jan 2012

Publication type:  Guidance

In a nutshell:  This guidance focuses how doctors should act where there are concerns regarding patient care, dignity and safety.  It also provides guidance on putting into practice the advice contained in ‘Good Medical Practice’.  The guidance came into effect at the end of March 2012.

Length of publication:  18 pages


Misidentification

August 29, 2011

Source: Nursing Times  Volume 107 Issue 25 pp20

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Date of publication: June 2011

Publication type: Journal Article

In a nutshell: Part three of four articles on changes to the Department of Health’s extended ‘never events’ list. Focuses on the use and checking of wristbands to avoid errors arising from wrongly-identified patients. A case study is used to illustrate a ‘nearly never event’ of a patient who almost underwent an invasive procedure intended for another person with the same name, because protocols were not followed correctly.

Length of publication: 1 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

Acknowledgement: British Nursing Index from NHS Evidence


Understanding patient safety culture, part 1.

August 29, 2011

Source: J Perianesthesia Nursing Volume 26 Issue 3 pp170-2

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Date of publication: June 2011

Publication type: Journal Article

In a nutshell: This is the first in a series exploring factors influencing patient safety in healthcare. The impact of the working environment on nurses’ perceptions of patient safety and the concept of a culture of patient safety are discussed.

Length of publication: 3 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

Acknowledgement: British Nursing Index Database from NHS Evidence


Creating safety by strengthening clinicians’ capacity for reflexivity

May 28, 2011

Source: BMJ Quality & Safety  Volume 20 Issue 4 pp83-86

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Date of publication: April 2011

Publication type: Journal Article

In a nutshell: The article looks at two techniques which will help clinicians look reflectively at what they do to highlight areas of where a change of practice can improve safety.  These two techniques include filming real-time clinical practice and asking clinician’s feedback on their own footage, and reflection on the questions asked by patients, carers and family.

Length of publication: 3 pages

Some important notes: This article is available in full text to all NHS Staff using Athens, for more information about accessing full text follow this link to find your local NHS Library

Acknowledgement: NHS Institute Alert from the NHS Institute of Innovation and Improvement


Can teaching medical students to investigate medication errors change their attitudes towards patient safety?

May 28, 2011

Source: BMJ Quality & Safety  2011;20:319-325

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Date of publication: February 2011

Publication type: Journal Article

In a nutshell: This article considers if giving medical students a basic knowledge of common medication errors before they start to see patients in hospital can reduce the chance of them making mistakes. The study was  carried out during a paediatric rotation at the Johns Hopkins Children’s Center.

Length of publication: 8 pages

Some important notes: This article is available in full text to all NHS Staff using Athens, for more information about accessing full text follow this link to find your local NHS Library

Acknowledgement: The British Journal of Healthcare Computing & Information Management


Best practice in the management of epidural analgesia in the hospital setting

January 28, 2011

Source: NHS Evidence Health Management

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Date of publication: November 2010

Publication type: Guidelines

In a nutshell: These guidelines look at best practice in the use of epidural analgesia within hospitals.  The main subjects focused on are continuous influsions, intermittent top-up injections and patient-controlled epidural analgesia (PCEA).  They also look at the features of epidural pain management services.

Length of publication: 15 pages


QIPP: Patient safety will drive cash savings

July 22, 2010

Source:  http://www.healthexec.tv

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Date of publication:  July 2010

Publication type:  Interview

In a nutshell:  An interview with Maxine Power, National Improvement Lead for Quality and Efficiency who explains how the Department of Health is putting safety at the centre of improvement programmes by  engaging with 100 boards, thereby making savings which can be reinvested into patient care.

Some important notes:  You will need to register to view the video.  Registration is free.