Qual Saf Health Care
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Qual Saf Health Care · Oct 2008
An educational and audit tool to reduce prescribing error in intensive care.
To reduce prescribing errors in an intensive care unit by providing prescriber education in tutorials, ward-based teaching and feedback in 3-monthly cycles with each new group of trainee medical staff. ⋯ Prescriber education and feedback reduce manual prescribing errors in intensive 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.