Making patients safer: nurses’ responses to patient safety alerts

Abstract

Title. Making patients safer: nurses' responses to patient safety alerts. Aim. This paper is a report of a study to determine whether action required by patient safety alerts was effectively taken. Background. Over the last 10 years, there has been a growing awareness of the number of patients unintentionally harmed in the course of their treatment. Safety alerts are designed to reduce the incidence of adverse events by removing these predisposing factors. Method. A multi-method study was carried out in 20 acute, two mental health, four ambulance and 15 primary care provider organizations in the United Kingdom in 2006-2007 using surveys, interviews with senior managers and front-line staff, collection of documentary evidence and equipment audit. The implementation of three safety alerts for nursing action is reported. Findings. Most staff were aware of the dangers posed by gloves to staff with latex allergy, but only 20% were aware of the types of common equipment that posed a danger to sensitive patients. Almost 40% of nurses were unable to give a correct acidity value to allow nasogastric feeding to commence. One alert, on needle-free intravascular connectors, was distributed in only a few organizations as the term used was unfamiliar at all levels of the organization. Conclusion. Healthcare providers have succeeded in setting up successful systems to disseminate alerts to middle management level, but there is evidence that implementation of recommendations by nurses is sub-optimal.

An assessment of the quality and impact of NPSA medication safety outputs issued to the NHS in England and Wales

“…A recent report issued by the Association of Victims of Medical Accidents (AVMA)10 led to allegations that alerts were being ignored by a significant proportion of NHS organisations, but although we have previously9 expressed some concern about the management of alerts these current findings suggest that at least some of the delay in signing them off (the basis of the AVMA's reported non-compliance) may lie in the complexity of the requirements themselves. Many of the trusts in our study reported fierce levels of activity combined with a rigorous interpretation of the challenging criteria for signing off the alert as complete.…”

A national incident reporting and learning system in England and Wales, but at what cost?

“…For this, one hypothesis we consider is that the benefits from alerts and guidelines are proportional to the degree of their implementation; there is particularly limited evidence on the latter. A search of the literature finds one publication, which describes good compliance with feedback report implementation [11], whereas two publications report mixed awareness and implementation effort across NHS organisational levels [12,13]. The equivocal evidence on implementation steers the choice of study design, as we now discuss.…”

 Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents reported to a national database of errors

“…However, most of these solutions seem reactive 31. At present, the lesson from national PSRS is limited; some of the information is lost in translation 32. Local systems of risk management opt for root cause analyses to develop local solutions to mitigate against harm to the patient.…”