ABSTRACT
This article describes two initiatives from the National Patient Safety Agency, which were developed to address important areas of harm to patients. This harm stems from failing to recognise or respond appropriately to deteriorating patients and errors in pre-operative and peri-operative care of surgical patients. Both initiatives used principles of standardisation, reliability and human factors to develop tools and checklists to improve patient safety, with a common approach to supporting implementation. The article describes further advances and developments aimed at increasing and sustaining improvement, including the use of technology to reduce human error.
Subject(s)
State Medicine/organization & administration , Humans , Patients , Reproducibility of Results , Risk Reduction Behavior , Safety , United KingdomABSTRACT
New recommendations are aimed at making blood transfusions safer for patients and less complicated for nurses to administer.
Subject(s)
Blood Transfusion/standards , Medical Errors/prevention & control , Practice Guidelines as Topic , Safety Management/organization & administration , Blood Transfusion/nursing , Clinical Competence/standards , Education, Nursing, Continuing , England , Humans , Medical Errors/nursing , Nursing Staff/education , Patient Identification Systems/standards , Risk Assessment , Transfusion Reaction , WalesABSTRACT
OBJECTIVE: To compare automated interactive screening using the ThinPrep Imaging System with independent manual primary screening of 12,000 routine ThinPrep slides. STUDY DESIGN: With the first 6,000 cases, the Review Scopes (RS) screening results from the 22 fields of view (FOV) only were compared to independent manual primary screening. In the next 6,000 cases, any abnormality detected in the 22 FOV resulted in full manual screening on the cytotechnologist's own microscope. Sensitivity and specificity together with their 95% CIs were calculatedfor each method. RESULTS: In the first set of 6, 000 cases, diagnostic sensitivity and specificity of the imager were 85.19% and 96.67%, respectively. The diagnostic sensitivity and specificity of manual primary screening were 89.38% and 98.42%. This highersensitivity and specificity of manual primary screening were found to be statistically significant. The second set of 6,000 cases demonstrated no significant statistical difference in sensitivity or specificity between the sets of data. CONCLUSION: The results from our study show that the sensitivity and specificity of the imager technology are equivalent to those of manual primary screening. The system is ideally suited to the rapid screening of negative cases, allowing increased laboratory productivity and greater throughput of cases on a daily basis.
Subject(s)
Carcinoma/diagnosis , Cervix Uteri/pathology , Image Cytometry/methods , Pattern Recognition, Automated/methods , Uterine Cervical Neoplasms/diagnosis , Vaginal Smears/methods , Diagnostic Errors/prevention & control , False Negative Reactions , Female , Humans , Image Cytometry/statistics & numerical data , Image Cytometry/trends , Mass Screening/methods , Mass Screening/statistics & numerical data , Mass Screening/trends , Observer Variation , Pattern Recognition, Automated/statistics & numerical data , Pattern Recognition, Automated/trends , Predictive Value of Tests , Reproducibility of Results , Sensitivity and Specificity , Vaginal Smears/statistics & numerical data , Vaginal Smears/trendsABSTRACT
Against a background of ever increasing expenditure on blood safety, less attention has been paid to improving the safety of the transfusion chain within hospitals. Based on reports to the Serious Hazards of Transfusion (SHOT scheme) between 1996 and 2003, the risk of an error occurring during transfusion of a blood component is estimated at 1:16 500, an ABO incompatible transfusion at 1:100 000 and the risk of death as a result of an 'incorrect blood component transfused' (IBCT) is around 1:1 500 000. There are opportunities for error at a number of critical points in the transfusion chain, starting with the decision to transfuse, prescription and request, patient sampling, pretransfusion testing and finally the collection of the component from the blood refrigerator and administration to the patient, consistently the commonest error in successive SHOT reports. Successive 'Better Blood Transfusion' initiatives and the 2003 Annual Report of the Chief Medical Officer for England have drawn welcome attention to the importance of safe and appropriate transfusion and the National Patient Safety Agency has now set a target of reducing the number of ABO incompatible transfusions by 50% over 3-5 years.
