Errors in the management of cardiac arrests: An observational study of patient safety incidents in England

January 28, 2015

Source:  Resuscitation 85/12 pp.1759–1763

Follow this link for abstract

Date of publication:  December 2014

Publication type:  Journal article

In a nutshell: This study aimed to gain a better understanding of the types of error that occur during the management of cardiac arrests that lead to a death. The reviewers identified a main shortfall in the management of each cardiac arrest and this resulted in 12 different factors being documented. These were then grouped into four themes: miscommunication involving crash number, shortfalls in staff attending the arrest, equipment deficits, and poor application of knowledge and skills. No firm conclusion could be drawn about how many deaths would have been averted if the emergency had been managed to a high standard.

Length of Publication:  5 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

Keeping patients safe when they transfer between care providers

July 28, 2011

Source: Royal Pharmaceutical Society

Follow this link for fulltext

Date of publication: July 2011

Publication type: Guidance

In a nutshell: This guidance looks at the one of the risks to patient care when the patient is transferred between health care providers.   This risk is the miscommunication or unintended change to medications.  The guidance looks at ways to reduce this risk and reduce preventable incidences.

Length of publication: 11 pages

Acknowledgements:  Kings Fund blog