Errors in the management of cardiac arrests: An observational study of patient safety incidents in England

January 28, 2015

Source:  Resuscitation 85/12 pp.1759–1763

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Date of publication:  December 2014

Publication type:  Journal article

In a nutshell: This study aimed to gain a better understanding of the types of error that occur during the management of cardiac arrests that lead to a death. The reviewers identified a main shortfall in the management of each cardiac arrest and this resulted in 12 different factors being documented. These were then grouped into four themes: miscommunication involving crash number, shortfalls in staff attending the arrest, equipment deficits, and poor application of knowledge and skills. No firm conclusion could be drawn about how many deaths would have been averted if the emergency had been managed to a high standard.

Length of Publication:  5 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

East Cheshire implements iPad safety system

October 1, 2014

Source:  Health Service Journal 1, September 2014

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Date of publication:  September 2014

Publication type:  News item

In a nutshell:  An iPad based system funded by the Nursing Technology Fund is being used by nurses at East Cheshire Trust to monitor patient safety. Macclesfield Hospital has begun recording clinical data electronically on handheld devices at the patients’ bedside, replacing the standard practice of recording observations on a paper chart at the end of the bed. Nurses input vital signs and other clinical observations into the devices, and the “VitalPAC” system automatically calculates a risk score which will alert staff immediately to any deterioration and provide advice on an appropriate response. The system is to be rolled out to all inpatient wards at Macclesfield Hospital.

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

Causes of Medication Administration Errors in Hospitals: a Systematic Review of Quantitative and Qualitative Evidence

December 18, 2013

Source:  Drug Safety vol/iss 36/11 pp. 1045-1067

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Date of publication:  November 2013

Publication type:  Journal article

In a nutshell:  The causes of medication administration errors in hospital were examined in this article. Medication lapses were the most commonly reported medication administration errors, followed by mistakes-based on inaccurate knowledge or deliberate violations. Factors potentially leading to medication administration errors included inadequate written communication, problems with medicines supply and storage such as pharmacy dispensing errors and ward stock management, perceived high workload, problems with access to or functioning of ward equipment, patient availability or acuity, fatigue or stress amongst professionals and distractions during drug administration. Medication administration errors are influenced by multiple systems factors so managers and clinicians need to take a system-wide approach to minimise errors.

Length of Publication:  23 pages

Surgical technology and operating-room safety failures: a systematic review of quantitative studies

October 30, 2013

Source:  BMJ Quality and Safety vol/iss 22/9 pp.710-718

Follow this link for abstract

Date of publication:  September 2013

Publication type:  Journal article

In a nutshell:  This systematic review looked at the frequency of equipment-related error in surgery. One quarter of all errors in surgery are a result of equipment or technology. There was usually about one equipment problem per procedure. Using pre-operative checklists could halve the number of equipment errors.

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.

‘Sim Man’ the dummy shortlisted for Patient Safety award for East London NHS Trust

April 26, 2013

Source: The Docklands & East London Advertiser, 29 March 2013

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Date of publication:  March 2013

Publication type: Press release

In a nutshell: Sim Man, a medical device with computer-controlled simulation technology, is being used by the East London NHS Foundation Trust for their ‘dummy run’ medical refresher practice. The dummy lets nurses and other medical staff refresh their skills or learn new ways of doing things without having to practice on real patients. Sim Man has now been shortlisted for a Patient Safety award.

Length of publication: 1 web page

Design for patient safety: A guide to the design of electronic infusion devices

June 9, 2010

Source:  National Reporting and Learning Service

Click here to link to report 

Date of publication:  March 2010

Publication type:  Report

In a nutshell:   Guidance focused on the safe design of infusion pumps and syringe drivers used in hospital and ambulatory care.

Length of publication:  web page

Acknowledgements:   National Patient Safety Agency