PROSPECTIVE ANALYSIS OF THE CODE BLUE SYSTEM IN A TERTIARY CARE HOSPITAL

BACKGROUND: This study was an analysis done to ascertain the efciency of the code blue system in a tertiary care hospital. All patients on whom a 'Code Blue' has been called in Command Hospital (Eastern Command) Kolkata from January 2017 to July 2018 were analysed using the standardised Code Blue audit form, maintained by the Department of Anaesthesiology & Critical Care and lled in soon after the Code Blue protocol is run. The primary objective was to analyse the factors associated with survival as well as survival rate along with the issues faced by the Code Blue team.METHODS: Data was collected as per the Code Blue audit form and analysed RESULTS: SPSS software version 22 was used. Pearson Chi Square Test and Cox Regression analysis were used to analyse the data. Atotal of 446 code blue calls were initiated during the period. After excluding 40 False calls and 08 Administrative calls, 398 calls were studied and analysed. Overall survival discharge from ICU was 23.37%. But when patients who had a cardiac arrest at the time of code blue were considered, the survival rate dropped to 5.9%. Factors such as Age, Presenting Rhythm and Duration of CPR were found to have signicant effect on overall survival. Four types of problems were faced during the study – technical, equipment related, crash cart related and staff on duty.CONCLUSION: The study concludes that the code blue system and team is useful in managing patients with a cardiac arrest as well as other medical emergencies. However, there are many lacunae that need to be addressed and more studies are required.

P28 Reducing medication errors – a tripartite approach. small steps – better outcomes

AimPaediatric medication errors have everyday potential to cause unintended harm.1 Our aim was to reduce paediatric medication errors on a busy general paediatric medical ward.MethodA prospective audit was undertaken, using an audit form, looking at the number and severity of medication errors from May 2016 to July 2016. The severity of the errors was graded as per the EQUIP study.2 The results were analysed using Microsoft Excel.Action – A study afternoon was arranged in August 2016 to highlight the common themes behind the medication errors followed by a multidisciplinary brainstorming exercise to gather suggestions on reducing medication errors.An education package was introduced:Medical – all trainees were asked to complete a mandatory online module designed by the Royal College of Paediatrics and Child Health, which provides an overview of need for safe prescription practice in children and common themes leading to errors. Further teaching was provided in departmental teaching meetings and the lead paediatric pharmacist undertook targeted teaching.Nursing – an in house competency package was developed based around the principles of the ‘5 rights’ of medication administration, the Health Board controlled drug policy and the All Wales Policy for Medicines Administration, Recording, Review, Storage and Disposal. All staff were encouraged to complete this package. Through one on one sessions with the practice development nurse, staff were coached to follow the five Rs of Right Drug, Right Dose, Right Time, Right Route, and Right Patient.Pharmacy – Lead pharmacist introduced an education tool as advocated by Meds IQ called Druggle3 in the department, where at the end of the safety huddle the pharmacist discusses medication interventions on a daily basis that may have happened on the ward. Through this tool formative education was provided to junior doctors and nurses.Re–audit – After six months of intensive education, a prospective re–audit was undertaken between December 2016 and February 2017 using an audit form. The results were analysed using Microsoft Excel.ResultsThe results showed that 88.6% (141/159) of children admitted had medication errors. 61.2% (87/141) of errors were minor, 34.7% (49/141) significant, 2.8% (4/141) serious and 1.3% (1/141) potentially lethal.The results of the re-audit showed that 12.1% (57/470) of children had medication errors. 77.2% (44/57) of errors were minor and 22.8% (13/57) significant. There were no serious or potentially lethal errors reported.This showed an overall reduction of 76.5% medication errors in the children admitted following the introduction of the education package.ConclusionThe education package through the tripartite approach has achieved a substantial change in the overall rate of prescription errors. We believe medication errors are a significant but preventable cause of harm to children and young people. To ensure this change of practice is sustained we aim to continue the emphasis of education and change management to improve patient safety.ReferencesCass H. Reducing paediatric medication error through quality improvement networks; where evidence meets pragmatism. Arch Dis Child2016;101:414–416.EQUIP final report. http://www.gmc-uk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf [Accessed: 01/08/16].DRUG-gle (Druggle). http://www.medsiq.org/tool/drug-gle-druggle [Accessed: 01/08/2016].

Description of Hand Hygiene’s Compliance on Nurse of Hemodialysis at Haji Hospital Surabaya

Thousands patients around the world die every day because of infections when they get treatment. This is because the transmission of microbacteria from the hands of health workers. Hand hygiene is the most important aspect to prevent the transmission of microbacteria and preventing HAIs. Hand hygiene awareness of health workers is a fundamental behavior to prevent cross-infection. The purpose of this study was to evaluate the hand hygiene compliance of nurse in Unit Hemodialysis of Hajj General Hospital Surabaya. Type of this research is descriptive research and observations by using a qualitative approach. Data retrieval on the research is an interview with nurse and audit hand hygiene. Research instrument using a questionnaire of hand hygiene and BSI knowledge, and hand hygiene audit form made by WHO. The population in this research was all nurses in Hemodialysis Unit General Hospital Surabaya Hajj that add up to 11 people. The results of this research obtained that compliance with hand hygiene Unit Hemodialysis nurse is 35%. The compliance were still less and has not reached the standards established by the PPI Hajj General Hospital Surabaya that is 100% and still has not reach compliance standards of WHO that is 40%. Hand hygiene compliance was low caused by the low participation of PPI base training and the lack of availability of hand hygiene facility in the Hemodialysis Unit General Hospital Surabaya Hajj. Advice from research were conducting on job training about how to perform hand hygiene and improve hand hygiene facilities in Hemodialysis Units. Keywords: hand hygiene, compliance, nurse

Evaluasi Penerapan Audit Mutu Internal Pada STAIN Curup

This study at evaluating the implementation of internal quality audit at STAIN Curup. The data for this study are collected through interview and documentation. Stake or countenance evaluation model is used in this study. Thus, the data analysis involves some following step as: data editing, data coding, tabulating the data, interpreting the data, and drawing conclusion. The result of this study indicates that (1) The Planning internal quality audit is relevant with, attempting to fulfill costumer’s demand, to is relevan with audi vision, audit schedule, the formulation of audit purpose, and the audit form, (2) the implementation of audit is reasonably inappropriate with the purpose and the scope of the audit, and (3) the follow up audit is relevant with the established evaluation standard. As the final thought, this study recommends STAIN Curup conduct well planned and well program internal quality audit continuously so that it can serve as self-reflection for the insitution. Keywords : Evaluation, Internal Quality Audit.

On Quality Control of Settlement Audit and Outsourcing

Internal settlement audit is an important part of our audit of projects, in view of the technical conditions of many units that work with an audit form of outsourcing. Due to the related institutions management, operational capacity, trial data completeness, difficulty of project audits by audit unit with the situation, and other factors, outsourcing is often difficult to guarantee the quality of the audit. Author combines themselves work experience, to a large engineering audit outsourcing for cases, to guarantee audit outsourcing quality for target, on Engineering audit outsourcing management program, and work standard for has summary, while, for audit outsourcing problem, has made standardized, and programmed, and standardization of quality control measures.

Practical Problems in Compiling the Copyright Audit form

This is not intended to be a “how to do it” article as I am sure there are plenty of you out there who could do that, rather it is intended to be a description of the problems I ran into when attempting to complete a copyright audit form and to give you food for thought.