Patient Safety Horizon Scanning Volume 5 Issue 11

November 26, 2014

Application of the WHO surgical safety checklist outside the operating theatre: medicine can learn from surgery

November 26, 2014

Source:  Clinical Medicine 14/5 pp. 468-74.

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Date of publication:  October 2014

Publication type:  Journal article

In a nutshell: Use of the World Health Organization (WHO) safety checklist for invasive medical procedures is not yet routine. These procedures are becoming ever more complex and involve higher-risk patients, with the need for general anaesthesia on occasion. The potential for error is increasing and the need for a safety checklist is more apparent. The checklist can be modified to provide a framework for specialty-specific safety checks, enhanced team-working and communication for invasive medical procedures. The authors carried out an audit on use of the WHO checklist in 20 cases under general anaesthesia in the quaternary referral cardiac catheterisation laboratory. They discovered use of the safety tool was poor and identified two ‘near miss’ incidents within the audit period. The authors developed and implemented a modified WHO checklist for the specific challenges faced in the cardiac catheterisation laboratory. Following a staff education programme, a subsequent audit of 34 cases demonstrated improvement in all sections with no patient safety incidents during the post-intervention audit period.

Length of Publication:  7 pages


Airline style patient safety film set to land in hospitals

November 26, 2014

Source:  Salford Royal NHS Foundation Trust

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Date of publication:  October 2014

Publication type:  News item

In a nutshell: A new ‘airline style’ film to give patients advice on how to stay safe in hospital has been created with the help of staff at Salford Royal. The film has been developed by Haelo in partnership with Guys’ and St Thomas’ Hospitals NHS Foundation Trust. The film aims to reduce avoidable complications such as blood clots, pressure ulcers or falls. Patients will also be provided with an information card with advice on looking after themselves during their hospital stay. The safety advice is being supported by Health Secretary, Jeremy Hunt, and the national Sign up to Safety campaign. The film can be easily incorporated into Trust websites so patients can watch it before they come into hospital. Hospitals with the Hospedia patient media system are also able to have the film uploaded free of charge to show patients once in hospital.

Length of Publication:  1 web page


5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors

November 26, 2014

Source:  British Journal of Anaesthesia 113/4 pp. 549-59.

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Date of publication:  October 2014

Publication type:  Journal article

In a nutshell: This paper presents the main findings of the 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia (AAGA). It is one of a series of papers. The authors recommend that an anaesthetic checklist, to be an integral part of the World Health Organization Safer Surgery checklist, is introduced as an aid to preventing accidental awareness.

Length of Publication:  1 web page


A simple flashcard: big impact for junior doctors!

November 26, 2014

Source:  The Clinical Teacher 11/6 pp. 454-60.

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Date of publication:  October 2014

Publication type:  Journal article

In a nutshell:  Reducing prescribing errors is crucial for ensuring patient safety. Many studies have reported that foundation-year doctors (FYs) have been found to be major contributors to prescribing errors; however, few studies have introduced meaningful interventions. Questionnaires were sent to FY2s to find the 15 most commonly prescribed medications on call. The medications and instructions were incorporated into a flashcard that was disseminated to new FY1s at a hospital in the UK. The FY1s were asked to complete a pre- and post-flashcard questionnaire, giving instructions for 10 medications and their confidence in prescribing these medications. A control group at another hospital were given the same questionnaires, but not the flashcard. No significant difference in confidence was seen in FY1s at either hospital before the flashcard was issued. At week 4, 93% of FY1s still used the flashcard 2.2 times per day, claiming that it saved time on call. The authors say they have introduced an inexpensive and simple prescribing aid, which has been statistically shown to improve prescribing confidence in FY1s.

Length of Publication:  7 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


Mentorship for newly appointed physicians: a strategy for enhancing patient safety?

November 26, 2014

Source:  Journal of Patient Safety 10/3 pp. 59-67.

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Date of publication:  September 2014

Publication type:  Journal article

In a nutshell:  Health-care services are applying mentorship in their settings, learning from business and industry where it is a popular innovation. This article looks at the concept of mentorship for newly appointed physicians in their first substantive senior post and in particular at its deployment to enhance patient safety. Semi-structured interviews were conducted with Medical Directors, Deputy Medical Directors and Clinical Directors from 9 acute NHS Trusts in the Yorkshire and Humber region in the north of England. A number of beneficial outcomes were found, including greater personal and professional support, organisational commitment, and general well-being. Providing newly appointed senior physicians with support through mentorship was considered to enhance the safety of patient care.

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


Learning from preventable deaths: exploring case record reviewers’ narratives using change analysis

November 26, 2014

Source: Journal of the Royal Society of Medicine 107/9 pp. 365-75.

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Date of publication:  September 2014

Publication type:  Journal article

In a nutshell: The authors set out to determine if applying change analysis to the narrative reports made by reviewers of hospital deaths in acute NHS Trusts in 2009 increases the utility of this information in the systematic analysis of patient harm. The change analysis approach enabled explicit characterisation of multiple problems in care, both across the admission and also at the boundary between primary and secondary care, and illuminated how these problems accumulate to cause harm. The method was straightforward to apply to multiple records and achieved good inter-rater reliability. Analysis of case narratives using change analysis provided a richer picture of healthcare-related harm than the traditional approach.

Length of Publication:  11 pages