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

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The implementation of nice guidance on venous thromboembolism risk assessment and prophylaxis: a before-after observational study to assess the impact on patient safety across four hospitals in England

June 24, 2013

Source:  BMC Health Services Research Vol 13 pp. 203

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Date of publication:  June 2013

Publication type:  Journal article

In a nutshell:  An international major health requirement is the prevention of Venous thromboembolism (VTE) to improve patient safety. In February 2010 NICE issued guidance on assessing patients for risk of VTE on admission to hospital, assessing patients for bleeding risk and evaluating the risks and benefits of prescribing VTE prophylaxis. This study aimed to evaluate the implementation of NICE guidance and its impact on patient safety. The documentation of risk assessment improved following the implementation of NICE guidance; however, it is uncertain whether this led to improved patient safety with respect to prescribing appropriate prophylaxis.

Length of Publication:  14 pages


Simple prompts on drug charts improve prevention.

March 27, 2013

Source: The Health Foundation

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Date of publication:  February 2013

Publication type: Journal article

In a nutshell: Time constraints and other priorities may mean that hospital doctors do not always assess people for their risk of venous thromboembolic events or prescribe preventive measures. Attaching a simple prompting checklist to patients’ drug charts can increase risk assessment and preventive measures.

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.


Clinicans warned of the dangers of loading doses of drugs

December 22, 2010

Source: National Patient Safety Agency

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Date of publication: 25 November 2010

Publication type: News Item

In a nutshell:  The NPSA has issued a new Rapid Response Report (RRR) in a bid to reduce the possibility of harming or causing death through overloading syringes with medicine.   

Length of publication: 1 webpage