738 Lessons from the National Patient Safety Agency Alerts

Aim The National Patient Safety Agency (NPSA) reviews incident reports from all NHS trusts, and reports deemed critical are issued as NPSA alerts. We aim to highlight important learning points from NPSA alerts to facilitate wider dissemination and prevent similar incidents, and overall improve patient safety. Method All patient safety alerts obtained from NPSA since inception (2008) till June 2020 were screened. We identified safety alerts that could be relevant to surgical practice, and further details of each alert were obtained from the Central Alerting System (CAS) website. Information obtained from CAS website was reviewed by consultant surgeons to identify specific learning points. Results 1857 alerts were reported by NPSA of which 94 were relevant to surgical practice. Alerts were grouped into four themes: pre-operative(N = 4), intra-operative(N = 34), post-operative(N = 29), others(N = 8), and no specific learning point identified(N = 19). Pre-operative alerts focused on safety checks to avoid errors and improve patient safety e.g., WHO checklist. Majority of the intra-operative alerts were due to difficulty with use of specific equipment(n = 22) e.g., advanced haemostatic devices. Post-operative alerts highlighted specific issues with implants especially in breast and orthopaedic surgery(N = 23), and patient review following procedures(N = 6). Conclusions In spite of alerts occurring in a specific speciality, there is wider applicability to all surgical specialities e.g., pre-operative risk assessment in elderly patients requiring urgent surgery or confirming pregnancy status in immediate pre-operative period. Emphasis should be laid on staff training on using specialist equipment including troubleshooting. Raising awareness of these NPSA alerts may help prevent similar incidents.

PENGARUH PERAWAT TERHADAP KEJADIAN MEDICATION ERROR DI RUMAH SAKIT

Saat ini medication error menjadi salah satu permasalahan kesehatan yang banyak menimbulkan berbagai dampak bagi pasien mulai dari resiko ringan bahkan resiko yang paling parah yaitu menyebabkan suatu kematian. Di Indonesia, prevalensi medication error berdasarkan data nasional kesalahan pemberian obat menduduki peringkat pertama sebesar 24,8% dari 10 besar insiden di rumah sakit yang pernah dilaporkan. Tahap dispensing adalah urutan pertama kesalahan dalam proses penggunaan obat. Pada penelitian di ruang perawatan pasien di RS Charitas Palembang (Simamora, 2011). Kejadian Tidak Diinginkan yang berhubungan dengan penggunaan obat sebanyak 76 kasus (26%) dan dari seluruh kejadian ini medication error yang paling sering terjadi adalah pada fase administration 81,32%, fase prescribing 15,88 % dan fase transcribing 2,8%.5 . Menurut National Patient Safety Agency (2004), medication error pada tahap administration error adalah jenis kesalahan yang paling sering terjadi dan menimbulkan dampak yang paling parah dibandingkan jenis kesalahan lainnya. Pihak yang paling bertanggung jawab dalam tahap drug administration adalah perawat, sebab perawat berkewajiban dalam tindakan pemberian obat.

PENERAPAN LANGKAH-LANGKAH KESELAMATAN PASIEN DI RUMAH SAKIT

Rumah sakit adalah organisasi pelayanan yang serba padat; yaitu padat usaha, padat modal, padat kecanggihan teknologi, padat SDM dan profesi; karena itu lah menjadikan rumah sakit menjadi organisasi yang padat masalah. Apabila kompleksitas di rumah sakit tidak dikelola dengan baik maka dapat menimbulkan peluang untuk terjadinya kesalahan pelayanan yang dapat berakibat buruk bagi keselamatan pasien. Menurut NPSA atau National Patient Safety Agency (2004) menyatakan bahwa untuk meningkatkan keselamatan pasien ada beberapa langkah yang dapat dilakukan, dikenal dengan “Seven Steps Patient Safety” yaitu: Langkah awal untuk menuju keselamatan pasien yang diharapkan agar dapat mencegah terjadinya KTD dan KNC dengan cara membangun budaya keselamatan pasien. Berdasarkan hasil penelitian, belum semua langkah dalam ‘Tujuh Langkah Menuju Keselamatan Pasien’ dilakukan oleh RSISA terutama untuk langkah ke lima, yaitu komunikasi terbuka kepada pasien dan keluarga tentang insiden. Sudah dilakukan berbagai upaya untuk mencapai langkah yang lain, namun upaya yang dilakukan masih belum optimal.

"PENTINGNYA PENGETAHUAN PERAWAT DALAM MENINGKATKAN KESELAMATAN PASIEN"

Perawat adalah mereka yang memiliki kemampuan dan kewenangan melakukan tindakan keperawatan berdasarkan ilmu yang dimiliki dan diperoleh melalui pendidikan keperawatan. Budaya keselamatan pasien merupakan pondasi utama dalam menuju keselamatan pasien. Penerapan ini sejalan dengan National Patient Safety Agency dan KKPRS dalam tujuh langkah keselamatan pasien yang menekankan bahwa langkah awal menuju keselamatan pasien adalah dengan menerapkan budaya keselamatan pasien Perawat yang memiliki pengetahuan yang baik tentu akan memberikan asuhan keperawatan yang tepat terhadap pasien. metode yang digunakan adalah literatur review. Literatur review ini menganalisis jurnal, text book, dan e-book yang relevan dan berfokus pada bagaimana tentang pengaruh budaya patient safety terhadap kesembuhan pasien. Pada hasil saya membandingkan beberapa penelitian dari jurnal ilmiah yang memuat dan membuktikan bahwa betapa pentingnya pengetahuan perawat dalam peningkatan patient safety. Yang saya cantumkan membuktikan bahwa kelalaian perawat dan kurangnya pengetahuan perawat tentang keselamatan pasien akan berakibat fatal.

"PENTINGNYA PENGETAHUAN PERAWAT DALAM MENINGKATKAN KESELAMATAN PASIEN"

Perawat adalah mereka yang memiliki kemampuan dan kewenangan melakukan tindakan keperawatan berdasarkan ilmu yang dimiliki dan diperoleh melalui pendidikan keperawatan. Budaya keselamatan pasien merupakan pondasi utama dalam menuju keselamatan pasien. Penerapan ini sejalan dengan National Patient Safety Agency dan KKPRS dalam tujuh langkah keselamatan pasien yang menekankan bahwa langkah awal menuju keselamatan pasien adalah dengan menerapkan budaya keselamatan pasien Perawat yang memiliki pengetahuan yang baik tentu akan memberikan asuhan keperawatan yang tepat terhadap pasien. metode yang digunakan adalah literatur review. Literatur review ini menganalisis jurnal, text book, dan e-book yang relevan dan berfokus pada bagaimana tentang pengaruh budaya patient safety terhadap kesembuhan pasien. Pada hasil saya membandingkan beberapa penelitian dari jurnal ilmiah yang memuat dan membuktikan bahwa betapa pentingnya pengetahuan perawat dalam peningkatan patient safety. Yang saya cantumkan membuktikan bahwa kelalaian perawat dan kurangnya pengetahuan perawat tentang keselamatan pasien akan berakibat fatal.

P044 Can an electronic prescribing system ensure clear anticoagulation discharge communication?

AimThe National Patient Safety Agency (NPSA)1 identified heparin as a major cause of adverse events associated with adverse incidents, including some fatalities. By ensuring good communication, this should be associated with risk reduction.1 The aim of this study was to ensure there is clear anticoagulation communication on discharge, from the paediatric intensive care unit (PICU) electronic prescribing system (Philips), to the paediatric cardiac high dependency unit and paediatric cardiac ward. To investigate whether the heparin regimen complies with the hospital’s anticoagulant guidelines and if there is any deviation; that this is clearly documented. To find out if there is an indication documented for the heparin regimen chosen and if there is a clear long term plan documented for the patient, after heparin cessation.MethodsA report was generated for all patients who were prescribed a heparin infusion on PICU, between 1st January 2018 and 30th June 2018, from the Philips system. All discharge summaries from the PICU Philips system were reviewed. Only paediatric cardiac patients were included that had a heparin infusion prescribed on discharge, all other discharge summaries were excluded from the study. Each discharge summary was reviewed in the anticoagulant section; for the heparin regimen chosen, whether it complies with the hospital’s anticoagulant guidelines and if there was any deviation whether this was documented. The indication documented of which heparin regimen was chosen and whether a clear long term plan was documented after heparin cessation; for example if the patient is to be transferred onto aspirin, clopidogrel, warfarin or enoxaparin.Results82 discharge summaries were reviewed over the 6 month period between 1st January 2018 and 30th June 2018; 16 were excluded as were not paediatric cardiac, leaving 66 paediatric cardiac discharge summaries that were reviewed. 45 out of 66 (68%) complied with the hospital’s heparin anticoagulation guidelines. Of the 32% that deviated from the protocol; only 33% (7 out of 21) had a reason documented. Only 50% (33) of the summaries reviewed had an indication for anticoagulation noted on the discharge summary and 91% of discharge summaries had a long term anticoagulant plan documented.ConclusionThe electronic prescribing system can help to ensure a clear anticoagulation communication as shown by 91% of the anticoagulation long term plan being clearly documented; making it a more seamless patient transfer. On the Philips PICU electronic prescribing system there is an anticoagulant section on the discharge summary that has 3 boxes that need to be completed; heparin regimen, indication and anticoagulation long term plan. However, despite these boxes; deviations from the anticoagulant protocol were poorly documented as highlighted by only 33% having the reason highlighted in the discharge summary, only 50% of the indications were documented. Despite having prompts for this information on the discharge summary, the medical staffs needs to be aware to complete this information, in order to reduce potential medication errors and risk.ReferenceThe National Patient Safety Agency (NPSA). Actions that make anticoagulant therapy safer. NPSA; March 2007.

5 Standard iv infusion concentration in paediatric and neonatal units: a national survey

AimThe National Patient Safety Agency in the UK has advocated the use of standard concentration (SC) infusions to improve patient safety and care.1 National standards have been adopted for infusions in the adult critical care setting however practice in paediatric and neonatal settings still varies and presents a challenge.2,3 This study is part of a multi-professional collaborative working towards a national consensus on SC infusions in paediatric and neonatal care. The study aims to explore the practice of standardised concentration usage for Intravenous (IV) infusions in paediatric and neonatal units in the UK, specifically:How many units use standardised concentration for IV infusions.Evaluate the variation and overlap of continuous IV infusion concentrations in practice.Assess what devices are used to administer these infusions.How standardised infusions are provided.MethodThe study used a quantitative descriptive survey design via an online self-administered questionnaire. Paediatric and neonatal intensive care units in the UK were surveyed through pharmacy, nursing, and medical networks to describe current practice. Data was collected for 25 days and analysed using SPSS.ResultA total of 194 NICUs and 39 PICUs were surveyed. Responses were received from 71 units: NICU 46 (65%); PICU 17 (24%) and 8 other (11%), giving an overall response rate of 30.5%.Twenty-eight units (40%) have established SC for IV infusions, 18 units provided information on presentation of SC infusions. Forty-six different medication infusions were standardised. Considering the differences in concentration, weight-bands, diluents, volume and presentation, there were 273 variations for these drugs. Taking only the concentration into account, there were 137 variations presented. The average number of variations per medication was 3 (range 1 to 14).15 units (53.6%) use ‘smart’ pumps for administration of SC infusions and 3 (10.7%) use other computer software for infusion rate calculations. Infusions are most commonly prepared on wards (81.3%) or in pharmacy (12.3%).ConclusionThe study is limited by the response rate; however the results suggest that 59% of paediatric and neonatal units in the UK use conventional weight-based methods for IV infusions. A third of units have established some SC with a wide variation of concentrations in this sample. Just over half of the units use ‘smart’ pump technology and over three quarters of SC infusions are prepared on the ward.Further data collection is required to acquire a fuller picture of SC infusions used in UK PICUs and NICUs. This data can then be used as the basis of a national consensus statement on SC infusion, facilitating adoption across the NHS.ReferencesNPSA Patient Safety Alert 20: Promoting safer use of injectable medicines2007. London: The National Patient Safety Agency.MacKay MW, Cash J, Farr F, et al. Improving paediatric outcomes through intravenous and oral medication standardisation. J Pediatr Pharmacol Ther2009;14:226–35.Phillips MS, Standardising IV. Infusion concentrations: National survey results. Am J Health Syst Pharm2011;68:2176–82.

P10 To give, or not to give…

Aim‘Between September 2006 and June 2009, the NPSA (National Patient Safety Agency) received reports of 27 deaths, 68 severe harms and 21 383 other patient safety incidents relating to omitted or delayed medicines’.1 The Trust’s Medicines Code states that ‘critical’ medicines should be administered within one hour of the prescribed times, and all other medicines within 90 min.2 ‘Critical’ medicines relevant to NICU (Neonatal Intensive Care Unit) patients include injected antibiotics, anticoagulants, anticonvulsants, aminophylline infusions and strong opioid analgesics. The aim of this audit was to establish what proportion of medicines prescribed for patients on NICU were given outside of this policy.MethodData was downloaded for all NICU inpatients from the electronic prescribing system, ICCA, from 1/4/16 to 30/6/16 inclusive. It was then analysed using Excel. The data shows details of all regular drugs prescribed, the scheduled administration time and the time that the nurses recorded that the drug had been administered. Once only, when required and drug infusions longer than 4 hours were all excluded from this data capture. Scheduled doses of antibiotics that were intentionally delayed whilst awaiting levels, e.g. vancomycin and gentamicin, were excluded before data analysis.ResultsIt was found that over the 3 month period, 137 different patients were administered 10 642 regular doses of 51 different medications. 5.86% of these were classified as ‘delayed’ according to Trust policy. 97.6% of these delayed ‘critical’ medications were antibiotics, accounting for over 45% of the total delayed doses.Meropenem was found to be the antibiotic most frequently delayed, with over one quarter of all doses prescribed being administered more than 1 hour after the scheduled time. The delay in administration ranged from 65 mins to 6 hours. Ceftazidime was the next most frequently delayed, occurring 22.7% of the time, range 2.75 to 3.75 hours.The time of day when most drug delays occurred was between the times of 15:00 and 15:59, accounting for 8.2%. The percentage for each hourly time slot varied from 2.1% to 8.2%. Throughout the week, the percentage of delays on an individual day ranged from the most on Saturdays, 17.9%, to the least on Wednesdays, 9.6%.ConclusionsDelays in administering medicines can have significant detrimental effects for patient safety. Trust policy dictates that ‘critical’ medicines should be administered within 1 hour of the prescribed times.2 It can be seen from the results above that the administration of medications were delayed 5.86% of the time, with antibiotics accounting for over 45% of these delayed doses. The administration of meropenem was delayed over 25% of the time.ReferencesNational Patient Safety Agency. Rapid Response Report 009. Reducing harm from omitted and delayed medicines in hospital2010.Holmes, G. Chapter M09 policy for the administration of medicines [policy document]2016. University Hospitals Bristol NHS Foundation Trust.

Water on the lung: a rare cause of a transudative effusion and new options for palliation

Pleural effusions are very common in clinical practice and can be notoriously difficult to diagnose and a real challenge to manage. There is a large amount of literature on malignant effusions, but no clear guidelines on managing refractory non-malignant pleural effusions. This case examines a rarer cause of a transudative effusion, focussing on the route to diagnosis. The emergence of thoracic ultrasound, in light of the National Patient Safety Agency report in 2008, and the increased safety are reviewed, and, in addition, the options for management are considered, including the tunnelled pleural catheter as a potential long-term solution in this challenging situation.

Variability in local pressures under digital tourniquets

The UK National Patient Safety Agency issued a rapid response report in 2009 following reports of complications related to digital tourniquet use and inadvertent retention. In their guidance, they recommend the use of CE marked digital tourniquets and advise against the use of surgical gloves. There are a number of different commercially available non-pneumatic digital tourniquets, but little clear data relating to their comparable physical properties, clinical efficacy or safety. The aim of this study was to investigate the variability of pressures exerted by non-pneumatic digital tourniquets. A Tekscan FlexiForce® force sensor was used to measure applied force and to calculate the surface pressures under: the Toe-niquet™; T-Ring™ and surgical glove ‘roll down’ tourniquets in finger models. The lowest mean pressures were produced by the larger glove sizes (size 8) (25 mmHg), while the highest pressures were produced by the Toe-niquet (1560 mmHg). There was a significant overall difference in pressures exerted under tourniquets when comparing tourniquet type ( p<0.001) and finger size ( p<0.001) with these techniques. It is difficult to anticipate and regulate pressures generated by non-pneumatic tourniquets. Safe limits for application time and surface pressures are difficult to define. Further work is required to model the pressure effects of commercially available digital tourniquets and to identify which are most effective but safe.