The systems approach to error reduction: factors influencing inoculation injury reporting in the operating theatre

cutter j. & jordan s. (2012) Journal of Nursing Management
The systems approach to error reduction: factors influencing inoculation injury reporting in the operating theatre Aim To examine the frequency of, and factors influencing, reporting of mucocutaneous and percutaneous injuries in operating theatres. Background Surgeons and peri-operative nurses risk acquiring blood-borne viral infections during surgical procedures. Appropriate first-aid and prophylactic treatment after an injury can significantly reduce the risk of infection. However, studies indicate that injuries often go unreported. The ‘systems approach’ to error reduction relies on reporting incidents and near misses. Failure to report will compromise safety. Methods A postal survey of all surgeons and peri-operative nurses engaged in exposure prone procedures in nine Welsh hospitals, face-to-face interviews with selected participants and telephone interviews with Infection Control Nurses. Results The response rate was 51.47% (315/612). Most respondents reported one or more percutaneous (183/315, 58.1%) and/or mucocutaneous injuries (68/315, 21.6%) in the 5 years preceding the study. Only 54.9% (112/204) reported every injury. Surgeons were poorer at reporting: 70/133 (52.6%) reported all or >50% of their injuries compared with 65/71 nurses (91.5%). Conclusions Injuries are frequently under-reported, possibly compromising safety in operating theatres. Implications for nursing management A significant number of inoculation injuries are not reported. Factors influencing under-reporting were identified. This knowledge can assist managers in improving reporting and encouraging a robust safety culture within operating departments.     

Distal stent delivery with guideliner catheter: First in man experience

Failure to deliver stents is one of the commonest causes of procedural failure in contemporary PCI practice. We describe successful use of the Guideliner Catheter, the first purpose designed FDA and CE marked device delivery catheter in 13 complex cases in native coronary vessels and bypass grafts performed via the radial route to enable distal stent delivery following failure of conventional techniques. We discuss how the Guideliner catheter may be used to facilitate difficult radial cases. © 2010 Wiley‐Liss, Inc.     

Rhinocerebral mucormycosis due to absidia corymbifera

Summary We report two cases of rhinocerebral mucormycosis due toAbsidia corymbifera, an extremely uncommon causal agent. Both occurred in patients with haematological disorders and both had a fatal outcome, despite antemortem diagnosis and aggressive treatment. We discuss the factors which generally contribute to the poor prognosis in this group of patients and suggest another possible mechanism which may contribute to the high mortality.

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Rhinozerebrale Mucormykose durch Absidia corymbifera

Zusammenfassung Wir berichten über zwei Fälle von rhinozerebraler Mukormykose durchAbsidia corymbifera, einen extrem seltenen Erreger. Bei beiden Patienten lag eine hämatologische Grunderkrankung vor, beide Fälle verliefen tödlich, obwohl die Diagnose gestellt und eine aggressive Therapie eingeleitet worden war. Die bei dieser Patientengruppe für eine schlechte Prognose verantwortlichen allgemeinen Faktoren werden diskutiert, wir stellen außerdem einen möglichen Pathomechanismus vor, der die hohe Letalität der Infektion mit verursachen kann.

     

The Total Health Care Audit System: a systematic methodology for clinical practice evaluation and development in NHS provider organizations

Writing in Medical Education in 1982, Fowkes (1982) noted the lack of general agreement within the medical profession on methods of audit, a deficiency previously articulated by Shaw (1980) and later emphasized by McIntyre (1985). More recently, a study by Black & Thompson (1993) of consultant and junior medical staff in four London district general hospitals revealed that 'many doctors did not understand how to undertake audit', and major research by both Hopkins (1993, 1994) and Buttery et al. (1994) described a multiplicity of methodological deficiencies in the general approaches to audit adopted by clinicians since the promulgation of the White Paper definition in 1989. Soundness of methodological approach is fundamental to securing the success of clinical audit within Provider organizations and is thus central to the generation of measurable improvements in the quality of clinical care being delivered to patients. It is therefore disturbing that methodological deficiencies may still be observed in general approaches to audit (Buttery et al. 1994), with no author yet recommending a formal system for critical inquiry into clinical practice. It was the recognition of the unsatisfactory nature of this situation which led us to develop a system aimed at assessing, in a critical fashion, the quality of the totality of care dispensed within NHS provider organizations. The system is presented here for the first time.     

Comparison of Sonography and Magnetic Resonance Imaging for Spring Ligament Abnormalities

Objective. The purpose of this study was to determine whether sonography is as accurate as magnetic resonance (MR) imaging for depicting abnormalities of the spring ligament in patients with symptomatic posterior tibial tendon (PTT) dysfunction. Methods. Sixteen patients (18 ligaments) with symptomatic PTT dysfunction were prospectively evaluated with sonography and MR imaging. Results. Magnetic resonance imaging showed spring ligament tears in 8 of 18 feet, including 6 incomplete tears and 2 complete tears. Sonography showed spring ligament tears in 7 of 18 feet, including 6 incomplete tears and 1 complete tear. The findings of sonography and MR imaging were concordant in 17 of 18 feet (94%). Six of the 8 spring ligament tears on MR imaging were associated with posterior tibial tendinosis or tears. Conclusions. Sonography is an effective imaging option in assessing spring ligament abnormalities in patients with symptomatic PTT dysfunction.     

USE OF SOLVENTS TO DISPERSE EAR WAX

SUMMARY In this test a course of 4 drops twice a day for 5 days of ear wax solvents, a cerumenolytic, sodium bicarbonate, or sterile water significantly increased the clearance of wax from ears by natural expulsion and eliminated the requirement for ear syringing in 50% of cases.