Patient Safety Horizon Scanning Volume 6 Issue 6

June 24, 2015

Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients

June 24, 2015

Source:  Annals of Surgery 261/5 pp. 831-8

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Date of publicationMay 2015

Publication type:  Journal article

In a nutshell: This review aims to systematically risk assess and analyse the escalation of care process in surgery to identify problems and provide recommendations for intervention. It discusses Healthcare-Failure-Mode-Effects-Analysis (HFMEA), a methodology adapted from safety-critical industries, which allows for hazardous process failures to be prospectively identified and solutions to be recommended. Failures in the escalation process amenable to intervention were systematically identified in this review. The authors say that the mapping of the escalation process will allow tailored interventions to enhance surgical training and patient safety.

Length of Publication:  8 pages


Effectiveness of interventions to improve patient handover in surgery: A systematic review

June 24, 2015

Source:  Surgery 158/1 pp. 85-95

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Date of publication:  May 2015

Publication type:  Journal article

In a nutshell:  The authors of this study examined interventions to improve handover in surgery. The interventions included paper and computerised checklists, forms and standardised operating protocols for handover. All studies found some degree of improvement in handover processes. Checklists or forms can be used to improve information transfer during surgery handovers. The process of implementation is poorly described in the literature however.

Length of Publication:  11 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


Common contra-indications and interactions of drugs in orthopaedic practice

June 24, 2015

Source:  The Bone & Joint Journal 97-B/4 pp. 434-41

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Date of publicationApril 2015

Publication type:  Journal article

In a nutshell: Many medicines for orthopaedic conditions can produce serious adverse reactions if prescribed inappropriately, either alone or in combination with other drugs. Often these hazards are not appreciated. The European Union has issued legislation regarding safety measures which member states must adopt to minimise the risk of errors of medication. A number of initiatives in the UK and the United States have highlighted the importance of informing and educating clinicians. In this article, common drug interactions and contra-indications in orthopaedic practice are discussed.

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


Effect of the World Health Organization checklist on patient outcomes: a stepped wedge cluster randomized controlled trial

June 24, 2015

Source:  Annals of Surgery 261/5 pp. 821-8

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Date of publicationMay 2015

Publication type:  Journal article

In a nutshell: There have been reports of reductions of morbidity and mortality after implementation of the World Health Organization’s Surgical Safety Checklist (SSC) in pre-/post designed studies without controls. The authors of this study report a randomized controlled trial of the SSC. They concluded that implementation of the WHO SSC was associated with robust reduction in morbidity and length of in-hospital stay and some reduction in mortality.

Length of Publication:  8 pages


Clinical governance: The formula for a safer hospital

June 24, 2015

Source:  Health Service Journal 18 May, 2015

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Date of publicationMay 2015

Publication type:  News item

In a nutshell: Giles Thorpe, a registered nurse and deputy director of clinical governance at Basildon and Thurrock University Hospitals FT,  looks at how a radical overhaul of its corporate governance structure has significantly improved patient safety at Basildon Hospital.

Length of Publication:  1 web page


Safety guideline: reducing the risk from cemented hemiarthroplasty for hip fracture 2015

June 24, 2015

Source:  Anaesthesia 70/5 pp. 623-6

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Date of publicationMay 2015

Publication type:  Journal article/Guidelines

In a nutshell: This is a consensus document produced by a Working Party established by the Association of Anaesthetists of Great Britain and Ireland, with representatives from the British Orthopaedic Association and British Geriatric Society. The guideline is presented for the preparation and conduct of anaesthesia and surgery in patients undergoing cemented hemiarthroplasty for hip fracture. The Working Party analysed recent publications highlighting complications occurring during the peri-operative period. The advice presented is based on previously published advice and clinical studies.

Length of Publication:  4 pages