Use of a safe procedure checklist in the cardiac catheterisation laboratory.

BACKGROUND: The use of the WHO safe surgery checklist has been shown to reduce morbidity and mortality from surgical procedures. However, whether a WHO-style safe procedure checklist can improve safety in the cardiac catheterisation laboratory (CCL) has not previously been investigated. OBJECTIVES: The authors sought to design and implement a safe procedure checklist suitable for all CCL procedures, and to assess its impact over the course of 1 year. METHODS: In the first 3 months, weekly PDSA cycles (Plan-Do-Study-Act) were used to optimise the design of the checklist through testing and staff feedback, and team briefing sessions were introduced before each procedure list. The impact of the checklist and team briefs was assessed by analysing in-house procedural data subsequently submitted to national audit databases. Staff and patient questionnaires were performed throughout the year. RESULTS: Introduction of the checklist was associated with a significant reduction of 3 min in average turnaround time (95% CI 25 s to 6 min, p=0.027). Similarly, an initial reduction in patient radiation exposure was recorded (dose area product reduction of 641.5 cGy/cm2; 95% CI 255.9 to 1027.1, p=0.002). The rate of reported complications from all procedures fell significantly from 2.0% in 2012/2013 (95% CI 1.6% to 2.4%) to 0.8% in 2013/2014 (95% CI 0.6% to 1.1%, p≤0.001). Staff climate questionnaires showed that technicians and radiographers gave more positive responses at the end of the study period compared with the beginning (p=0.001). CONCLUSIONS: The use of a team brief and WHO-derived safe procedure checklist in the CCL was associated with decreased radiation exposure, fewer procedural complications, faster turnarounds and improved staff experience.

How to undertake a root cause analysis investigation to improve patient safety.

RATIONALE AND KEY POINTS: Root cause analysis is a tool that can be used when determining how and why a patient safety incident has occurred. Incidents that usually require a root cause analysis include the unexpected death of a patient, serious pressure ulcers, falls that result in injury, and some infections and medication errors. This article outlines the stages of the investigation process for undertaking a root cause analysis. REFLECTIVE ACTIVITY: 'How to' articles can help update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of.

Mitigating Latent Threats Identified through an Embedded In Situ Simulation Program and Their Comparison to Patient Safety Incidents: A Retrospective Review.

OBJECTIVE: To assess the impact of service improvements implemented because of latent threats (LTs) detected during in situ simulation. DESIGN: Retrospective review from April 2008 to April 2015. SETTING: Paediatric Intensive Care Unit in a specialist tertiary hospital. INTERVENTION: Service improvements from LTs detection during in situ simulation. Action plans from patient safety incidents (PSIs). MAIN OUTCOME MEASURES: The quantity, category, and subsequent service improvements for LTs. The quantity, category, and subsequent action plans for PSIs. Similarities between PSIs and LTs before and after service improvements. RESULTS: 201 Simulated inter-professional team training courses with 1,144 inter-professional participants. 44 LTs were identified (1 LT per 4.6 courses). Incident severity varied: 18 (41%) with the potential to cause harm, 20 (46%) that would have caused minimal harm, and 6 (13%) that would have caused significant temporary harm. Category analysis revealed the majority of LTs were resources (36%) and education and training (27%). The remainder consisted of equipment (11%), organizational and strategic (7%), work and environment (7%), medication (7%), and systems and protocols (5%). 43 service improvements were developed: 24 (55%) resources/equipment; 9 (21%) educational; 6 (14%) organizational changes; 2 (5%) staff communications; and 2 (5%) guidelines. Four (9%) service improvements were adopted trust wide. 32 (73%) LTs did not recur after service improvements. 24 (1%) of 1,946 PSIs were similar to LTs: 7 resource incidents, 7 catastrophic blood loss, 4 hyperkalaemia arrests, 3 emergency buzzer failures, and 3 difficulties contacting staff. 34 LTs (77%) were never recorded as PSIs. CONCLUSION: An in situ simulation program can identify important LTs which traditional reporting systems miss. Subsequent improvements in workplace systems and resources can improve efficiency and remove error traps.

Thinking differently about complaints in the NHS.

NHS complaints have been both the precipitant and subject of numerous recent reports, inquiries and investigations. They are viewed and treated as a wholly negative aspect of NHS activity and consume significant resource and time in addition to the emotional impact on both patients and staff. Currently the stance taken by NHS providers is defensive and process-driven with little attention to the subject of the complaint and how this might provide useful and constructive information (delivery model). With much focus on patient experience and how this can be improved, complaints, if incorporated into a much bigger framework encompassing patient feedback, satisfaction and experience, could be used to constructively develop and shape healthcare delivery. Use of complaints to inform experience based co-design and collaboration could transform some healthcare services for the benefit of patients and healthcare professionals (relational model). The NHS must learn how to effectively harness patient feedback, including complaints through all available channels: written, verbal and via electronic media. Limited resources mean not everyone can have the treatment they want or need when and where they want or need it and in building an anticipatory approach to complaints by making it easy for patients by inviting feedback, good and bad, training staff to act appropriately and thinking differently by seeing complaints as an opportunity rather than a threat, could contribute to driving improvement across healthcare and making the NHS the high performing organisation it aspires to be.

Managing futility in critically ill patients with cardiac disease.

Despite extraordinary innovations in cardiology and critical care, cardiovascular disease remains the leading cause of death globally, and heart failure has one of the highest disease burdens of any medical condition in the Western world. The lethality of many cardiac conditions, for which symptoms and prognoses are worse than for many malignancies, is widely under-recognized. A number of strategies have been developed within specialties such as oncology to improve the care of patients with life-threatening conditions. For reasons that are multifactorial, these options are often denied to critically ill patients with cardiac disease. Cardiologists and intensivists often regard death as failure, continuing to pursue active treatment while potentially denying patients access to alternatives such as symptom control and end-of-life care. Patient autonomy is central to the delivery of high-quality care, demanding shared decision-making to ensure patient preferences are acknowledged and respected. Although many cardiologists and intensivists do provide thoughtful and patient-centred care, the pressure to intervene can lead to physician-centric care focused around the needs and wishes of medical staff to the detriment of patients, families, health-care workers, and society as a whole.

Minimización del riesgo en el laboratorio de cateterismo cardiaco / Minimizing risk in the cardiac catheterization laboratory

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Chronic stable ischaemia protects against myocyte damage during beating heart coronary surgery.

OBJECTIVES: Many patients with coronary artery disease demonstrate chronic resting ischaemic myocardial dysfunction. We have investigated whether this ischaemia influences the myocardial damage caused by the period of coronary occlusion involved in beating heart surgery. METHODS: Thirty-three patients with chronic stable angina and normal left ventricular ejection fraction were studied. To make our model clinically appropriate, we included patients with a wide range of ischaemic times, ages and in a subset of 10 patients a surgical preconditioning protocol. Myocyte injury was assessed from venous Troponin T release measured on days 1, 2, and 3. We used intraoperative transoesophageal M mode echocardiograms and simultaneous high-fidelity left ventricular pressure to assess whether patients were demonstrating the functional effects of ischaemia (asynchronous regional contraction with reduced mechanical function). RESULTS: Patients demonstrated the functional effects of resting ischaemia and 17 did not. Patients with resting ischaemia had lower preoperative values of regional peak power and work and all three variables increased significantly with surgery. Venous Troponin T levels at 48 and 72 h postoperatively were lower in those with preoperative resting ischaemia (median (interquartile range) 0.13 (0.08-0.20) vs 0.21 (0.13-0.69) for 48 h and 0.10 (0.08-0.19) vs 0.26 (0.12-0.51) for 72 h). Stepwise multiple linear regression of total postoperative troponin release (measured as the area under the curve of troponin release) demonstrated two independent determinants (R squared for model 0.40): longer ischaemic time, and increasing values of cycle efficiency. The surgical ischaemic preconditioning protocol and preoperative collaterals were not independent determinants. CONCLUSIONS: In patients with chronic coronary artery disease, stable preoperative ischaemia may thus represent a naturally occurring form of myocardial protection, whose presence reduces Troponin T release after beating heart surgery. This protection is different in nature from classical ischaemic preconditioning.

Sedation, anaesthesia and monitoring for bronchoscopy.

Management of the airway for paediatric bronchoscopy requires joint planning and constant communication between the bronchoscopist and the anaesthetist. At all times maintenance of an effective airway must be the first priority. All sedative drugs compromise the patency of the airway to some extent in addition to effective ventilation by the patient. Thus, a specific individual must be dedicated to ensure adequacy of airway and ventilation throughout the procedure. Since sedation and anaesthesia are merely two points on a continuum of reduced central nervous system activation, an anaesthetist most appropriately performs this role. There is a range of drugs that may be utilised to induce sedation and a variety of airway adjuncts, which will be described. Any individual using them should be familiar with their advantages and disadvantages and be capable of managing any predictable or unusual complications.