Patient Safety Horizon Scanning Volume 6 Issue 11

November 25, 2015

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


Patient safety alert – Support to minimise the risk of distress and death from inappropriate doses of naloxone

November 25, 2015

Source:  NHS England

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Date of publication: October 2015

Publication type: Safety alert

In a nutshell: A patient safety alert has been issued by NHS England to support providers of NHS funded care to minimise the risk of distress and death caused by inappropriate doses of naloxone.  The new ‘Stage 2: Resource’ alert highlights a number of resources now available to help providers ensure their local protocols and training related to naloxone reflect best practice.

Length of Publication: 1 webpage


How sharp are we on safety? An assessment of safer sharps adoption in UK hospitals

November 25, 2015

Source: MindMetre Research

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Date of publication: October 2015

Publication type: Research report

In a nutshell: This report finds that not all NHS trusts are not complying with ‘safer sharps’ rules and, as a result, are continuing to put NHS employees at risk of needle stick injuries and possible blood-borne infections such as hepatitis and HIV.

Length of Publication: 8 pages


Reducing unacceptable missed doses: pharmacy assistant-supported medicine administration

November 25, 2015

Source: International Journal of Pharmacy Practice 23/5 pp. 327-332

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Date of publication: October 2015

Publication type:  Journal article

In a nutshell: The potential harm from omitted and delayed medicines for hospital inpatients was highlighted by the National Patient Safety Agency (NPSA). This study aimed to assess the impact on omitted doses when medicine administration was supported by pharmacy assistants (PAs).  The authors concluded that PA-supported medication rounds can significantly reduce the rate of omitted doses. This study provides evidence for a potential solution to the problem of omitted doses for hospital inpatients.

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


Enhancing surgical safety using digital multimedia technology

November 25, 2015

Source: American Journal of Surgery [Epub ahead of print]

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Date of publication: October 2015

Publication type:  Journal article

In a nutshell: The purpose of this study was to examine whether incorporating digital and video multimedia components improved surgical time-out performance of a surgical safety checklist. A prospective pilot study was designed for implementation of a multimedia time-out, including a patient video. The conclusion of the study was that the multimedia time-out allows improved participation by the surgical team and is preferred to a standard time-out process.

Length of Publication: Unspecified

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 and IT trends

November 25, 2015

Source: Nursing Management 46/11 pp. 24-26

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Date of publication: November 2015

Publication type:  Journal article

In a nutshell: Being able to capture and document patient data at the point of care in an electronic format brings with it many benefits. However, there are inherent risks that come with the use of health information technology that may impact on patient safety and data integrity.  This article discusses how to minimise such risks.

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