Qual Saf Health Care
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Qual Saf Health Care · Aug 2008
Impact of NICE guidance on rates of haemorrhage after tonsillectomy: an evaluation of guidance issued during an ongoing national tonsillectomy audit.
The National Institute for Health and Clinical Excellence (NICE) issued guidance on surgical techniques for tonsillectomy during a national audit of surgical practice and postoperative complications. ⋯ NICE guidance influenced surgical tonsillectomy technique and in turn produced an immediate fall in postoperative haemorrhage. The ongoing national audit and strong support from the surgical specialist association may have aided its implementation.
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Qual Saf Health Care · Aug 2008
"Every error counts": a web-based incident reporting and learning system for general practice.
Incident reporting systems have been established primarily in the inpatient setting. Their goal is the identification of safety risks in healthcare as a precondition for improvements in the overall quality of care. Knowledge about medical errors in general practice is sparse, as are reporting systems for patient safety in this setting. This article describes the development, structure and initial results of an incident reporting system for general practices in German-speaking countries. ⋯ JFZ is a well-functioning and growing incident reporting system. Future efforts to improve the benefits of incident reporting will concentrate on increasing the utilisation of the system and broadening the spectrum of reported incidents.
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Qual Saf Health Care · Aug 2008
Changes in practice and organisation surrounding blood transfusion in NHS trusts in England 1995-2005.
Between 1996 and 2005 in the UK, the Serious Hazards of Transfusion (SHOT) scheme has reported 105 deaths and 296 patients developing major morbidity due to transfusion. Accurate patient identification and monitoring of patients during blood transfusion are vital in ensuring patient safety, and national guidelines have been in place since 1999. There have been numerous initiatives in the UK in recent years promoting safe and appropriate use of blood and this paper reports the results of the 2005 National Comparative Audit of transfusion practice, and compares this audit with previous audits and survey results. ⋯ This paper document the progress that has been made in the UK in establishing an effective infrastructure for the support of safe transfusion practice, and the measurable improvements in bedside transfusion practice. There remain, however, many areas of poor practice, and the improvements have not been seen across all hospitals. It is still too early to say whether progress made is being translated into a reduction in serious transfusion errors at the bedside. Further progress needs to be made.
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Qual Saf Health Care · Aug 2008
Detection of adverse events in surgical patients using the Trigger Tool approach.
Most studies of healthcare complications identify surgery as a major contributor to the overall burden of complicated care that leads to injury or death. Indeed, surgical adverse events account for one-half to three-quarters of all adverse events in these studies. Despite the intensive current focus on improving medical quality and safety, only a minority of quality improvement efforts are focused on surgery. This study reports on the development and testing of a Trigger Tool to detect adverse events among patients undergoing inpatient surgery. ⋯ The IHI Surgical Trigger Tool may offer a practical, easy-to-use approach to detecting safety problems in patients undergoing surgery; it can be the basis not only for estimating the frequency of adverse events in an organisation, but also determining the impact of interventions that focus on reducing adverse events in surgical patients.
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Qual Saf Health Care · Aug 2008
Analysis of 23 364 patient-generated, physician-reviewed malpractice claims from a non-tort, blame-free, national patient insurance system: lessons learned from Sweden.
In Sweden, patient malpractice claims are handled administratively and compensated if an independent physician review confirms patient injury resulting from medical error. Full access to all malpractice claims and hospital discharge data for the country provided a unique opportunity to assess the validity of patient claims as indicators of medical error and patient injury. ⋯ Patient-generated malpractice claims, as collected in the Swedish malpractice insurance system and adjusted for clinical volumes, have a high validity, as assessed by standardised physician review, and provide unique new information on malpractice risks, preventable medical errors and patient injuries. Systematic collection and analysis of patient-generated quality of care complaints should be encouraged, regardless of the malpractice compensation system in use.