Patient Safety Horizon Scanning Volume 5 Issue 3

March 26, 2014

New recommendations to further improve surgical safety

March 26, 2014

Source:  NHS England

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Date of publication:  February 2014

Publication type:  News item

In a nutshell:  The Surgical Never Events Taskforce has published a report, which makes recommendations for new standards and systems to improve the safety of surgery in hospitals. NHS England has committed to identifying practical ways to take forward the report’s recommendations to eradicate never events from surgical procedures. In the report the taskforce has recommended much greater consistency between different hospitals in all areas of the country. It focuses on standardisation, education and harmonisation. The development and implementation of national standards on the prevention of surgical never events will be key to the taskforce’s recommendations. The full report and summary report can be found on the NHS England website.

Length of Publication:  1 web page


Patient safety alert on addressing rising trends and outbreaks in carbapenemase-producing Enterobacteriaceae

March 26, 2014

Source:  NHS England

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Date of publication:  March 2014

Publication type:  News item

In a nutshell:  An NHS England stage-two ‘resource’ patient safety alert has been issued to signpost providers of NHS care to resources established to avoid the spread of carbapenemase-producing Enterobacteriaceae. A small but increasing number of strains of Enterobacteriaceae have become resistant to carbapenem antibiotics. This patient safety alert is for NHS acute trusts and private hospitals providing NHS funded care and it signposts providers to a toolkit developed by Public Health England to support the NHS to control existing transmission problems and to prevent the further spread of infection.

Length of Publication:  1 web page


Guidelines for routine gastrostomy tube replacement in children

March 26, 2014

Source:  Nursing Children and Young People 25/10 pp. 22-25

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Date of publicationDecember 2013

Publication type:  Journal article

In a nutshell:   The safest method of inserting a gastrostomy in children that require full or supplemental enteral feeding for more than six weeks is by endoscopic placement. The device can be changed to a balloon, button or non-balloon type once a stoma tract has formed successfully following initial placement of a gastrostomy tube. Community nursing teams often support children with gastrostomies and their families. The National Nurses Nutrition Group, the Patient Safety Agency and manufacturers have produced guidance for the safe insertion and replacement of balloon and button gastrostomies, but standardised national guidelines are needed.

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.


The contribution of nurses to incident disclosure: a narrative review

March 26, 2014

Source:  International Journal of Nursing Studies 51/2 pp.334-345

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Date of publication:  February 2014

Publication type:  Journal article

In a nutshell:  Reviewers from England explored how nurses feel about disclosing patient safety incidents to patients and if there are any barriers to disclosure. The findings suggested that nurses have a key role in supporting doctors when disclosing incidents to patients, but that they may not be well prepared to disclose incidents to patients independently. Barriers to nurse involvement in incident disclosure included few opportunities for training and many conflicting roles within nursing. Nurses may have a greater role to play in safety incident error disclosure to patients, but they need better training and support to enable them to do this.

Length of Publication:  12 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.


Predictors of Patients’ Intentions to Participate in Incident Reporting and Medication Safety

March 26, 2014

Source:  Journal of Patient Safety 2014 Feb 11. [Epub ahead of print]

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Date of publication:  February 2014

Publication type:  Journal article

In a nutshell:  Researchers examined aspects that may influence a patient’s willingness to report a safety error to a national reporting system and to bring their medicines into hospital to allow checking. Beliefs about control were the strongest predictors of patients’ intentions. Their expectations about what is ‘normal’ behaviour influence the extent to which they may participate in patient safety initiatives. The researchers concluded that initiatives to improve patient involvement in safety should consider the extent to which people feel in control and capable of performing the behaviour.

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.


Patient safety alert on non-Luer spinal (intrathecal) devices for chemotherapy

March 26, 2014

Source:  NHS England

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Date of publication:  February 2014

Publication type:  News item

In a nutshell: An NHS England patient safety alert to all hospitals in England administering spinal (intrathecal) chemotherapy has been issued to minimise the risk of wrong route administration. Connection with intravenous devices is not permitted, so the alert instructs hospitals to only use syringes and needles, and other devices, with non-Luer connectors when delivering this type of chemotherapy. No incidents of this kind have been reported in England since 2001, but they have happened in Europe and worldwide.

Length of Publication:  1 web page