Charles Vincent Essentials of Patient Safety 2012

This paper presents the case for a practical approach for developing the workforce, to safeguard patients and to improve the quality of the patient pathway across health, social care and beyond. Central to this is the inclusion of Crew Resource Management (CRM) (RAeS, 1999) skills learned from the aviation industry, to enhance interprofessional teamwork development and collaborative practice.

Source: The Journal of Practice Teaching and Learning (The Journal of Practice Teaching  in Health and Social Work), Volume 10, Number 2, 2010 , pp. 4-27(24)

Symposium title: Medicines Safety Symposium – making Great Britain a safer place to take medicines
Venue: The Royal Institute of British Architects
Date: 17 June 2012

For more information and to book your place please follow this link.

Raising and acting on concerns about patient safety (2012)

http://www.rcseng.ac.uk/museums/exhibitions

The programme offers stimulating speaker sessions from human factors specialists in both healthcare and non-healthcare related industries, and multiple opportunities to network with fellow CHFG supporters.  An extended ‘Marketplace’, where individuals and organisations will share and showcase their human factors based innovations, experiences and designs will also be a feature of the day.   If you would like to contribute to the Marketplace, please email us as soon as possible outlining your showcase idea.

The response to news of this forthcoming Seminar has been overwhelming, with record registrations, which is of course  excellent news; we are however compiling a waiting list as there are usually cancellations prior to the event so if  you would like to attend this free event simply complete our online registration form, and we will let you know if/when a place becomes available.

We hope you are able to join us at what promises to be a powerful and thought-provoking learning event.

There is no charge to attend this event, due to the generous support of our sponsors the Medical Protection Society, The Health Foundation, Nottingham University Hospitals NHS Trust and the Institute of Ergonomics and Human Factors.

In this article, Gordon Caldwell argues that tardy access to core clinical information systems may be close to paralysing clinical care processes for doctors, nurses and other health professionals to the detriment of safe high quality patient care.

In order to inform the Department of Health’s Human Factors Reference Group, we conducted a rapid on-line survey asking CHFG supporters about the top priority areas which in their view, if standardised, would make a positive contribution to improving patient safety as well as making their work easier and more effective overall.

A textual and content analysis was conducted to produce “categories” of priorities.

Respondents[1]

The majority of respondents:

• describe their primary role as ‘Medical’ (73%) with the next largest group being ‘Patient Safety / Improvement Specialist’ (7%)
• describe themselves as working for / within NHS Acute Providers  (79%)
• are based in England (85%) with an even spread across regions. The next largest groups are from Scotland and Wales both at nearly 6% of respondents.

 Summary of Standardisation priorities

In summary, three main priorities stood out in the analysis:

1. Protocols – this relates to all comments associated with what might otherwise be called “standard operating procedures” for a range of specific clinical circumstances.

Category examples include standardisation of:

• Consent processes
• Protocol-driven management of a wide range of clinical presentations and interventions – specific mentions included sepsis, trauma management, chemotherapy, difficult airways, commencement of surgery
• Screening procedures
• Management of deteriorating patients including vital signs measurement and montioring, escalation protocols etc.

A significant number of comments also related to standardisation of the documentation associated with these protocols.

2.  Medicines handling – this relates to all comments associated with prescription, storage and administration of medicines but excludes drug labelling which has been treated as a separate category. (NB If combined this would elevate “Medicines” to first position)

Category examples include standardisation of:

• Drug / Fluids / Anticoagulation / Insulin chart layouts
• Intravenous drug doses and concentrations including prefilled labelled syringes
• Drug infusions for use in Critical Care / Theatres / Emergency Care
• Drug cupboards, packaging, ampoules
• National prescription chart
• Electronic prescribing – avoiding incorrect prescriptions, drug interactions and incorrect administration.

3.     Equipment – this relates to all comments associated with commonly used monitoring, treatment and other specialist equipment.

Category examples include standardisation of:

• Pumps & Infusion devices
• Monitoring equipment
• Difficult Airway Trolley – NOTE this piece of equipment also had its own category as it had 8 mentions in the respondents’ number 1 priority for standardisation, and 18 in total across all five priority listings
• Equipment packs for CVC insertion
• Operating tables.

 Comments

A number of caveats should be considered when examining the results of this survey.

•  Medically qualified practitioners working in surgical and/or anaesthetics practice were very strongly represented in the sample
• Respondents offered more than fifty additional free text comments. Within these responses there was a wide variation in how the term “standardisation” was being used
• A significant number of respondents suggest “whole NHS” implementation approaches and treat the NHS as a single organisation rather than a federation of semi-independent bodies with their own systems of governance and control.