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Boston Scientific Recalls Obsidio Conformable Embolic for Increased Bowel Ischemia Risk When Used for Lower GI Bleeding
Recall of Certain Saline and Sterile Water Medical Products Associated with Nurse Assist: FDA Safety Communication
Abbott/Thoratec Corp. Recalls HeartMate II and HeartMate 3 Left Ventricular Assist System (LVAS) due to Long-term Buildup Causing an Obstruction
Medline Industries, LP Issues a Nationwide Recall of Convenience Kits Containing Nurse Assist 0.9% Sodium Chloride Irrigation USP and Sterile Water for Irrigation USP
Aruba Aloe Balm N.V. Issues Voluntary Nationwide Recall of Aruba Aloe Hand Sanitizer Gel Alcohol 80% and Aruba Aloe Alcoholada Gel Due to Presence of Methanol
Honeywell Safety Products USA, Inc. Issues Voluntary Worldwide Recall of Honeywell Fendall 2000 Non-Sterile Eyewash Cartridges # 32-002050-0000 used with the Fendall 2000 Eyewash Station Due to a Lack of Appropriate Policies and Procedures by Honeywell...
Medos International Sàrl Recalls Cerenovus CEREBASE DA Guide Sheath due to Cracking of the Distal Catheter Shaft
Smiths Medical ASD Recalls PneuPac ParaPAC Plus 300 and 310 Ventilator Kits for a Malfunction Causing Non-Cycling, Continuous Positive Gas Flow and Preventing Proper Ventilation
Teleflex and Arrow International Recall ARROW QuickFlash Radial Artery and Radial Artery/Arterial Line Catheterization Kits for Increased Resistance That May Lead to Vessel Injuries, Narrowing, or Blockage
AvKARE, LLC. Issues Voluntary Nationwide Recall of Atovaquone Oral Suspension, USP 750 mg/5 mL Due to Potential Bacillus Cereus Contamination
Eugia US LLC (f/k/a AuroMedics Pharma LLC) Issues Voluntary Nationwide Recall of Methocarbamol Injection, USP 1000 mg/10 mL (100mg/mL) (Single Dose Vial) Due to Presence of White Particles
Amneal Pharmaceuticals, LLC. Issues a Nationwide Voluntary Recall of Vancomycin Hydrochloride for Oral Solution USP, 250mg/5mL, Due to the Potential for Some Bottles to be Super Potent Which May be Harmful
2023 Safety Communications
Lost in translation: does measuring 'adherence to the Surgical Safety Checklist indicate true implementation fidelity?
The use of checklists in surgery is a best practice.1 There is a plethora of evidence that suggests using the WHO Surgical Safety Checklist (SSC) reduces complications such as pneumonia,2 intraoperative blood loss,2 3 sepsis,2 unplanned intubation,2 urinary tract infections,2 wound infections,2–4 30-day readmissions and 30-day mortality.2–4 The SSC has three components, which need to be carried out for each phase of a surgical procedure, including sign-in, timeout and sign-out.5 The SSC serves as an aide memoir that includes vital information to prompt team discussions and actions that may otherwise be overlooked or forgotten, thereby promoting clear, consistent and timely communications among team members that prevents errors and enhances patient safety.6 Importantly, the SSC is more than merely a...
Elusive but hopefully not illusive: coordinating care for patients with heart failure with preserved ejection fraction
Depending on your perspective, a unicorn could be either a magical horned creature or a billion-dollar start-up. Alternatively, it could represent coordinated care for patients with heart failure with preserved ejection fraction (HFpEF), as it does for Brooman-White et al.1 In their accompanying paper on coordination of care for patients with HFpEF, which included an analysis of 12 clinical guidelines and secondary analysis of qualitative interviews with patients and healthcare professionals in the UK’s National Health Service, the authors describe the apparent illusiveness of securing coordinated specialist and generalist care for this complex patient group. However, by explicating when and why problems arise, Brooman-White et al offer hope that the pursuit of coordinated care is not really as illusive as the unicorn they describe it as, but rather an elusive challenge which requires renewed focus and strategies designed around the needs of patients who use these services....
Effective use of interdisciplinary approaches in healthcare quality: drawing on operations and visual management
Thinkers from the broad field of quality management, such as Edwards Deming, have influenced the more focused field of healthcare quality including international organisations such as the Institute for Healthcare Improvement and The Health Foundation. Quality management was initially established for industrial settings but has since been applied in many other sectors such as education, travel and, in this context, healthcare. Quality management encompasses quality assurance, control and improvement. Healthcare practitioners and researchers have applied aspects of these in examples such Benneyan et al1 who in their much-cited text apply statistical process control in healthcare quality improvement using standard techniques developed in quality management. Other industrial research fields such as change management and organisational culture have also been adopted by the healthcare quality field. The value of learning from these fields was summarised by Davies et al2 who noted that ‘there is a rich literature...
Intrapartum electronic fetal monitoring: imperfect technologies and clinical uncertainties--what can a human factors and social science approach add?
For many women, fetal well-being in labour is assessed using continuous electronic fetal monitoring with cardiotocography (CTG), a technique used to monitor the fetal heartbeat and uterine contractions during pregnancy and labour.1 However, problems in the assessment of fetal well-being in labour and delays in escalation and response have been consistently highlighted in maternity care safety inquiries, both in the UK and internationally, causing untold distress to parents and families.2–6
Taking an interdisciplinary perspective, drawing on both human factors/ergonomics and social science, the study from Lamé and colleagues,7 published in this issue of BMJ Quality and Safety, aims to understand the everyday practice of electronic fetal monitoring with CTG and the organisational and work context within which this takes place. Findings are based on ethnographic observations and interviews with midwives and doctors at different levels...
CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity
The WHO Surgical Safety Checklist (SSC) is a communication tool that improves teamwork and patient outcomes. SSC effectiveness is dependent on implementation fidelity. Administrative audits fail to capture most aspects of SSC implementation fidelity (ie, team communication and engagement). Existing research tools assess behaviours during checklist performance, but were not designed for routine quality assurance and improvement. We aimed to create a simple tool to assess SSC implementation fidelity, and to test its reliability using video simulations, and usability in clinical practice.
MethodsThe Checklist Performance Observation for Improvement (CheckPOINT) tool underwent two rounds of face validity testing with surgical safety experts, clinicians and quality improvement specialists. Four categories were developed: checklist adherence, communication effectiveness, attitude and engagement. We created a 90 min training programme, and four trained raters independently scored 37 video simulations using the tool. We calculated intraclass correlation coefficients (ICC) to assess inter-rater reliability (ICC>0.75 indicating excellent reliability). We then trained two observers, who tested the tool in the operating room. We interviewed the observers to determine tool usability.
ResultsThe CheckPOINT tool had excellent inter-rater reliability across SSC phases. The ICC was 0.83 (95% CI 0.67 to 0.98) for the sign-in, 0.77 (95% CI 0.63 to 0.92) for the time-out and 0.79 (95% CI 0.59 to 0.99) for the sign-out. During field testing, observers reported CheckPOINT was easy to use. In 98 operating room observations, the total median (IQR) score was 25 (23–28), checklist adherence was 7 (6–7), communication effectiveness was 6 (6–7), attitude was 6 (6–7) and engagement was 6 (5–7).
ConclusionsCheckPOINT is a simple and reliable tool to assess SSC implementation fidelity and identify areas of focus for improvement efforts. Although CheckPOINT would benefit from further testing, it offers a low-resource alternative to existing research tools and captures elements of adherence and team behaviours.
Informing understanding of coordination of care for patients with heart failure with preserved ejection fraction: a secondary qualitative analysis
Patients with heart failure with preserved ejection fraction (HFpEF) are a complex and underserved group. They are commonly older patients with multiple comorbidities, who rely on multiple healthcare services. Regional variation in services and resourcing has been highlighted as a problem in heart failure care, with few teams bridging the interface between the community and secondary care. These reports conflict with policy goals to improve coordination of care and dissolve boundaries between specialist services and the community.
AimTo explore how care is coordinated for patients with HFpEF, with a focus on the interface between primary care and specialist services in England.
MethodsWe applied systems thinking methodology to examine the relationship between work-as-imagined and work-as-done for coordination of care for patients with HFpEF. We analysed clinical guidelines in conjunction with a secondary applied thematic analysis of semistructured interviews with healthcare professionals caring for patients with HFpEF including general practitioners, specialist nurses and cardiologists and patients with HFpEF themselves (n=41). Systems Thinking for Everyday Work principles provided a sensitising theoretical framework to facilitate a deeper understanding of how these data illustrate a complex health system and where opportunities for improvement interventions may lie.
ResultsThree themes (working with complexity, information transfer and working relationships) were identified to explain variability between work-as-imagined and work-as-done. Participants raised educational needs, challenging work conditions, issues with information transfer systems and organisational structures poorly aligned with patient needs.
ConclusionsThere are multiple challenges that affect coordination of care for patients with HFpEF. Findings from this study illuminate the complexity in coordination of care practices and have implications for future interventional work.