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

Source:  Resuscitation 85/12 pp.1759–1763

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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

Development of a knowledge, skills, and attitudes framework for training in laparoscopic cholecystectomy

Source:  The American Journal of Surgery 207/5 pp. 790-6

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Date of publication:  May 2014

Publication type:  Journal article

In a nutshell:  Resident education and training has been changed by the implementation of duty-hour restrictions and a heightened awareness of patient safety. The authors of this article discuss the development of a training framework for knowledge, skills, and attitudes, and the design of a surgical simulation curriculum. A successful framework for curriculum development was implemented using laparoscopic cholecystectomy as the example. This curriculum developed a structured framework for surgical training, a method that can be applied to any procedure.

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.

Managing Clostridium difficile infection in hospitalised patients

Source:  Nursing Standard 28/33 pp. 37-43

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Date of publication:  April 2014

Publication type:  Journal article

In a nutshell:  Checklists are used commonly in health care to improve patient safety. The development and integration of a daily review checklist process to support the care and management of patients with Clostridium difficile infection in one NHS trust hospital are described in this article. The objective of the checklist is to assist staff in early recognition of disease severity, identification of potential complications and prevention of cross-transmission of C.difficile.

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.

Exploring error in team-based acute care scenarios: an observational study from the United Kingdom

Source:  Academic Medicine

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Date of publication:  June 2012

Publication type:  Article

In a nutshell:  This article follows 38 junior doctors, in their first year after medical qualification, in NHS Lothian.  It looks at the errors made by these doctors and investigates whether there was a single cause. The article reasons that identifying a single cause for each error could identify which knowledge and skills which are most vulnerable to specific errors and enable specially tailored educational strategies to be developed to try to prevent them.

Acknowledgements:  Kings Fund

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.