scholarly journals Safer use of anticoagulants: the NPSA patient safety alert

Prescriber ◽  
2007 ◽  
Vol 18 (10) ◽  
pp. 17-24 ◽  
Author(s):  
Steve Chaplin
Keyword(s):  
Patient Safety ◽  
Safety Alert

scholarly journals P13 Optimising paediatric intravenous fluid management plans: a quality improvement project

2020 ◽  
Vol 105 (9) ◽  
pp. e12.2-e13
Author(s):  
Jenny Gray ◽  
Susie Gage
Keyword(s):  
Patient Safety ◽  
Nursing Staff ◽  
Fluid Balance ◽  
Medical Staff ◽  
Fluid Management ◽  
Management Plan ◽  
Intravenous Fluid ◽  
Safety Alert ◽  
Management Plans ◽  
National Patient

IntroductionIntravenous (IV) maintenance fluids are often prescribed post-surgery when enteral routes are contraindicated. Serious consequences have been documented when poor fluid management has occurred, as highlighted in the National Patient Safety Alert (NPSA) 22; reducing the risk of hyponatraemia; when administering IV fluids to children.1 In response to this, the National Institute for Health and Care Excellence (NICE) published their guidance in December 2015 regarding IV fluids in children.2 Based on NICE recommendations, a pan hospital fluid guidance was produced. Within the NICE and hospital’s own guideline it states that there should be a daily fluid management plan documented. It has been well recognised that this daily fluid management plan was not routinely been completed; hence showing non-adherence to our hospital policy and NICE recommendations.AimsPrimary aim was to improve the documentation of the daily fluid management plan; aimed at the medical staff and the secondary aim was to improve the monitoring requirements of IV fluids and documentation of these; largely aimed at the nursing staff.MethodsA simple sticker was designed and attached to continuous sheets for medical notes which had a checklist of monitoring requirements and a section for fluid balance. Additionally, 2 posters were produced; one aimed at medical staff for documenting a fluid management plan and one aimed at the nursing staff with the monitoring requirements. These posters were displayed on the paediatric surgical ward.ResultsA total of 22 patients who were prescribed IV fluids were identified for a baseline measurement, an equal number of patients were compared after the intervention. Neonates and children receiving total parenteral nutrition were excluded from the data collection. There were 41% of daily fluid management plans completed pre intervention and post intervention there were 56% completed; showing a 15% increase in completion. As regards the monitoring indications; there were increases for nursing fluid balance completed from 19% to 46%, blood glucose taken and recorded from 64% to 83% and the daily weight documented from 10% to 49%.ConclusionsThis short QI project shows that implementation of an intervention did improve outcomes across all indications investigated. The results are not as dramatic as first hoped, but this is largely due to the short time scale of 4 weeks to introduce our change and it coincided with the change-over month of junior medical staff. With further education and champions within the medical and nursing teams; further improvement is very much possible, with the main aim in reducing risk and improving patient safety.ReferencesNational Patient Safety Alert: Reducing the risk of hyponatraemia when administering intravenous infusions to neonates 2007. Available at https://www.sps.nhs.uk/articles/npsa-alert-reducing-the-risk-of-hyponatraemia-when-administering-intraveneous-infusions-to-neonates/ [Accessed 12th June 2019]NICE guidance: Intravenous fluid therapy in children and young people in hospital. Available at https://www.nice.org.uk/guidance/ng29 [Accessed 12th June 2019]

Assessment of the implementation of a national patient safety alert to reduce wrong site surgery

2008 ◽  
Vol 17 (6) ◽  
pp. 409-415 ◽  
Author(s):  
P Rhodes ◽  
S J Giles ◽  
G A Cook ◽  
A Grange ◽  
R Hayton ◽  
...  
Keyword(s):  
Patient Safety ◽  
Wrong Site Surgery ◽  
Safety Alert ◽  
National Patient ◽  
Wrong Site

scholarly journals 498 Patient safety alert: Medical image manipulation as a safety hazard for wrong-site procedures

2020 ◽  
Vol 140 (7) ◽  
pp. S67
Author(s):  
J.S. Taylor ◽  
P.L. Bailin ◽  
A.T. Vidimos ◽  
J. Lucas ◽  
A. Vij ◽  
...  
Keyword(s):  
Patient Safety ◽  
Medical Image ◽  
Image Manipulation ◽  
Safety Hazard ◽  
Safety Alert ◽  
Wrong Site

Standardizing the Early Identification of Acute Kidney Injury: The NHS England National Patient Safety Alert

Nephron ◽  
2015 ◽  
Vol 131 (2) ◽  
pp. 113-117 ◽  
Author(s):  
Nicholas M. Selby ◽  
Robert Hill ◽  
Richard J. Fluck ◽  
Keyword(s):  
Acute Kidney Injury ◽  
Patient Safety ◽  
Early Identification ◽  
Kidney Injury ◽  
Safety Alert ◽  
National Patient

scholarly journals P36 Numeta G13% preterm neonatal parenteral nutrition solution – a licensed all-in-one triple chamber, ready to use and terminally sterilised parenteral nutrition for preterm newborn infants

2020 ◽  
Vol 105 (9) ◽  
pp. e25-e25
Author(s):  
Mar Moreno ◽  
Kenny McCormick ◽  
Lindsey Macfarlane ◽  
Alexandra Scrivens
Keyword(s):  
Patient Safety ◽  
Parenteral Nutrition ◽  
Standard Deviation Score ◽  
British Association ◽  
List Type ◽  
Central Administration ◽  
Nursing Time ◽  
Perinatal Medicine ◽  
Improvement Project ◽  
Safety Alert

AimsWe aim to evaluate the efficacy and safety of Numeta G13%E preterm neonatal parenteral nutrition (PN) in our neonatal population.In September 2017 a National Patient Safety Alert (NPSA) highlighted the risk of harm to babies when lipid was mistakenly run at the rate intended for the aqueous component resulting in significant lipid overdose.Although we have worked to implement many of the alert’s recommendations, we feel we can avoid this risk further by using an all-in-one PN solution.1Numeta meets current nutritional guidelines as per British Association of Perinatal Medicine (BAPM) but this project allows comparison of outcomes important to both patient and service between those achieved with our current regimen and those with the all-in-one regimen.2MethodsWe carried out a quality improvement project from April 2018 to April 2019. We collected data from 330 babies in our neonatal unit during six months before (154 babies) and after (176 babies) the adoption of the all-in-one solution.Our previous PN regimen consisted of a ‘menu’ of aqueous bags (starter, maintenance, ‘light’ and bespoke) and a separate lipid solution. All of them were suitable for peripheral or central administration. Numeta came with similar choices: starter, maintenance -for central administration only- and ‘lite’ and Numeta peripheral, suitable for peripheral administration. Bespoke bags were also available if clinically indicated. We set out our desired outcomes and measured parameters accordingly:Patient outcomesMetabolic stability: electrolyte, glucose, bilirubin and lipid measurements summarised by the need to change from standard PN regimen and/or requirement for insulin.Fluid balance summarised by the lowest weight during the first two weeks of life and time taken to regain birth weight.Growth summarised by change of standard deviation score of weight and head circumference between birth and discharge or transfer back to local hospital.Liver tolerance of lipid solutions summarised by incidence of cholestasis (>25 μmol/l conjugated fraction of serum bilirubin)Days and type of PNSepsisService outcomesNursing time taken to prepare PNCostWastageAccess to productResultsAlthough we finished collecting the data in April 2019, we are still in the process of analysing it and evaluating the final results. There have been no cases of lipid overdose and our neonates (including the preterm ones) have so far tolerated well the new parenteral nutrition solution. Average nursing time preparing Numeta went down from 18.5 minutes to 8 minutes and comparison of cost came in favour of Numeta. PN wastage was higher with Numeta (4.7% Maintenance, 10% ‘light’, peripheral 50%) especially in the first month during the transition phase. There was no significant increase of bespoke bags when Numeta was introduced.ConclusionsIn summary, so far we have not identified significant clinical differences between the first six months of the project -using our old standardised nutrition regimen- and the last months -on the new all-in-one solution. We have continued with Numeta preterm solution on the basis of assumed safety.ReferencesRisk of severe harm and death from infusing total parenteral nutrition too rapidly in babies. NHS improvement patient safety alert September 2017.The Provision of Parenteral Nutrition within Neonatal Services – A Framework for Practice. British Association of Perinatal Medicine (BAPM) April 2016 www.bapm.org

Steroid emergency cards: action needed

2020 ◽  
Vol 58 (11) ◽  
pp. 163-163
Keyword(s):  
Patient Safety ◽  
Early Recognition ◽  
Adrenal Crisis ◽  
Safety Alert ◽  
National Patient

AbstractOverview of: NHS England, 2020. National Patient Safety Alert—Steroid Emergency Card to support early recognition and treatment of adrenal crisis in adults.

Sign in / Sign up

Export Citation Format

Share Document