It is estimated that 1:10 patients in health care sustain harm that is potentially avoidable and which often highlight system errors that were not appreciated | Faculty of Intensive Care Medicine
Investigation results in the identification of these system errors and the generation of solutions to prevent future incidents. Sharing and implementing these lessons improves patient safety.
National Patient Safety Alerts relevant to intensive care
National alerts are produced in response to analysis of centrally reported patient safety incidents. Details of all alerts may be found on the Central Alerting System website (https://www.cas.dh.gov.uk/Home.aspx).
Lessons from adverse incidents
Lessons from local incidents may not be shared widely and to improve wider patient safety, the Joint Standards Committee of the Faculty and the Intensive Care Society has created this forum to allow lessons from local investigations into adverse incidents to be disseminated to the intensive care community.
We welcome you to share important safety lessons that have occurred in your own departments that may have general relevance. Please use the form below (or your local form if you would prefer) to submit an anonymised summary of the incident, the learning arising and any changes that have been implemented to prevent future a reoccurrence.
SAFETY MATTERS: Local Incident Lessons
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El-Soussi, A.H. & Asfour, H.I. Intensive and Critical Care Nursing. Published online: 25 January 2017
Background: The Nursing profession is struggling to return to basic nursing care to maintain patients’ safety. “Interventional patient hygiene” (IPH) is a measurement model for reducing the bioburden of both the patient and health care worker, and its components are hand hygiene, oral care, skin care/antisepsis, and catheter site care.
Conclusion: The mean percentage IPH knowledge score is higher than the mean percentage IPH practice score of all IPH items. Barriers for implementing IPH include workload, insufficient resources, and lack of knowledge/training.
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Pfrimmer, D.M. et al. (2017) Dimensions of Critical Care Nursing. 36(1) pp. 45–52
Background: Nursing surveillance has been identified as a key intervention in early recognition and prevention of errors/adverse events. Nursing Intervention Classification (NIC) defines surveillance as “the purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making.” Because nurses are the main staffing constant in the critical care environment, the importance of surveillance as an intervention is fundamental.
Discussion: Surveillance was expressed through nurses’ gathering cues, reflecting on past knowledge, asking questions, verifying, and pulling it all together to find meaning. During handoff, surveillance involved collaborative cognitive work to find meaning in cues.
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