Patient safety alert – Risk of death and serious harm by falling from hoists

November 25, 2015

Source: NHS England

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Date of publication: October 2015

Publication type: Safety alert

In a nutshell:  A joint patient safety alert has been issued by NHS England and the Medicines & Healthcare products Regulatory Agency (MHRA) to highlight the risk of falls from hoists.  A National Reporting and Learning System (NRLS) search identified that there have been 15 incidents in a recent four year period where a person has come to harm through falls from hoists, including one death and three severe injuries.  Providers of NHS funded care have been asked to raise awareness of the risk amongst staff and to ensure they have an action plan underway to reduce the risk of these incidents occurring.

Length of Publication: 1 webpage

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Ensuring patient safety blood transfusion

April 26, 2013

Source:  Nurs Times Vol/iss 109/4 pp. 22-3.

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Date of publication:  January-February 2013

Publication type:  Journal article

In a nutshell:  This paper discusses the fact that blood transfusion is a common procedure, that it carries a degree of risk, and that avoidable mistakes can result in serious or fatal consequences. Adverse events are largely associated with human error so current knowledge and skills of the blood grouping system and compatibility, and the ability to identify, respond to and report reactions, are essential for patient safety. An online Nursing Times Learning unit on safe blood transfusion is being launched soon.

Length of Publication:  2 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.


Safe use of oral bowel-cleansing preparations

April 26, 2013

Source:  Nurs Stand Vol/iss 27/22 pp. 35-8.

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Date of publication:  January-February  2013

Publication type:  Journal article

In a nutshell:  An article stating that good bowel preparation enhances detection of lesions and reduces the need for repeat procedures and delayed diagnosis. It says that knowledge of the potential risks associated with oral bowel-cleansing preparations is necessary to improve patient safety and outcomes.

Length of Publication:  4 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.


Perception of patient safety differs by clinical area and discipline.

February 25, 2013

Source:  Br J Anaesth Vol/iss 110/1 pp.107-14

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Date of publication:  January 2013

Publication type:  Journal article

In a nutshell:  The influence of the operating theatre, intensive care unit, and disciplines on ratings of latent risk factors are explored in this study. An understanding of the contribution made by these factors leads to the identification of significant points from which to promote a safe environment. Strategies for improving patient safety should be tailored specifically for various clinical areas and disciplines.

Length of Publication:  8 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.


Identification of risk factors by systematic review and development of risk-adjusted model

September 28, 2011

Source:  Health Technology Assessment  Vol 15, No.3

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Date of publication:  September 2011

Publication type:  Systematic review

In a nutshell: This issue looks at surgical site infections (SSIs), which can lead to patient death.  SSIs are complications from surgery.  This review looks at SSI risk factors, and investigates the importance of postdischarge surveillance (PDS). 

Length of publication:  172 pages

Acknowledgements:  NHS Evidence