Current awareness suts may 2016 by Musgrove Park Hospital Library

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Current Awareness Sign Up To Safety This monthly Current Awareness Bulletin is produced by the Library Team, Musgrove Park Academy to provide staff with a range of resources to support Sign Up To Safety. It includes recently published guidelines and research articles, news and policy items.

This guide provides a selection of relevant resources and is not intended to be a comprehensive list. All websites have been evaluated and details are correct at the time of publications. Details correct at time of going to print. Please note that resources are continuously updated. For further help or guidance, please contact a member of library staff.

This guide has been compiled by: Carol-Ann Regan Musgrove Park Hospital Library Service Carol-ann.regan@tst.nhs.uk @musgrovesompar

ď&#x20AC;şď&#x20AC; http://librarymph.wordpress.com/ Issue 6 May 2016

Contents Click on a section title to navigate contents Page Recent journal articles

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UpToDate and Dynamed Plus Reports, publications and resources

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RECENT JOURNAL ARTICLES BACK TO TOP Some articles are available in the library or on-line via an OpenAthens password by following the fulltext link. If you would like an article which is not available as full-text then please contact library staff. Please note that abstracts are not always available for articles.

FALLS Title: Does vibration training reduce the fall risk profile of frail older people admitted to a rehabilitation facility? A randomised controlled trial. Citation: Disability and rehabilitation, Jun 2016, vol. 38, no. 11, p. 1082-1088, 1464-5165 (June 2016) Author(s): Parsons, J, Mathieson, S, Jull, A, Parsons, M Abstract: To determine the effect of Vibration Training (VT) on functional ability and falls risk among a group of frail older people admitted to an inpatient rehabilitation unit in a regional hospital in New Zealand. A randomized controlled trial of 56 participants (mean 82.01 years in the intervention group and 81.76 years in the control group). VT targeting lower limb muscles with a frequency 30-50 Hz occurred three times per week until discharge. Amplitude progressively increased from 2 to 5 mm to allow the programme to be individually tailored to the participant. The control group received usual care physiotherapy sessions. Outcome measures were: Physiological profile assessment (PPA); and Functional Independence measure (FIM) and Modified Falls Efficacy Scale (MFES). There was a statistically significant difference observed between the two groups in terms of FIM score (F = 5.09, p = 0.03) and MFES (F = 3.52, p = 0.007) but no difference was observed in terms of PPA scores (F = 0.96, p = 0.36). Among older people admitted to an inpatient rehabilitation facility there may be some beneficial effect to the use of VT in conjunction with usual care physiotherapy in terms of improved functional ability. The study design and the small dosage of VT provided may have precluded any change in falls risk among participants. Implications for Rehabilitation Vibration training (VT) may assist in reducing the risk of falling among at risk older people. Current pressures on health systems (ageing population, reduced hospital length of stay) necessitate the development of innovative strategies to maximise the rehabilitation potential of older people. Among older people admitted to an inpatient rehabilitation facility there may be some beneficial effect to the use of vibration training in conjunction with usual care physiotherapy in terms of improved functional ability. Source: Medline

Title: Anatomy of Inpatient Falls: Examining Fall Events Captured by Depth-Sensor Technology. Citation: Joint Commission journal on quality and patient safety / Joint Commission Resources, May 2016, vol. 42, no. 5, p. 225-232, 1553-7250 (May 2016) Author(s): Potter, Patricia, Allen, Kelly, Costantinou, Eileen, Klinkenberg, Dean, Malen, Jill, Norris, Traci, O'Connor, Elizabeth, Roney, Wilhelmina, Tymkew, Heidi Hahn Abstract: Sensor technology offers a new way to identify patient movement, detect falls, and automatically alert health care staff when falls occur. The information gained from analyzing actual fall

events can be beneficial in developing individualized fall prevention strategies, informing nursing staff about the nature of falls, and identifying opportunities to make the patient care environment safer. A six-month performance improvement pilot was conducted at Barnes-Jewish Hospital (St. Louis) to assess the ability of a depth-sensor system to capture inpatient fall events within patient hospital rooms. Depth sensors were installed on two inpatient medicine units with a history of high fall rates. The depth sensors captured actual fall events on video. Video clips were reviewed and analyzed to identify the characteristics of patient falls, staff response times, and environmental conditions contributing to falls. A total of 16 falls involving 13 patients were recorded by depth sensors. Six of the 13 patients who fell were classified as high risk on the basis of the hospital's fall rating tool. Common contributing factors included difficulty rising from their bed, weakened lower extremities, and unsteady or slow gait. Eleven of the falls involved patients reaching for objects in their path in an effort to achieve stability. Nurses had less than two minutes from the time a patient began to exit a bed to the time a fall occurred. Patients expressed few complaints with depth sensors installed in rooms. Falldetection sensor systems offer valuable data for analyzing the nature of patient falls, with the potential promise of prescribing specific fall interventions for patients and to identify staff development opportunities. Hospitals should understand these devices' benefits and limitations and how they affect nursing practice. Source: Medline

Title: Intentional rounding: facilitators, benefits and barriers. Citation: Journal of clinical nursing, May 2016, vol. 25, no. 9-10, p. 1346-1355, 1365-2702 (May 2016) Author(s): Flowers, Kelli, Wright, Kylie, Langdon, Rachel, McIlwrath, Maureen, Wainwright, Craig, Johnson, Maree Abstract: To describe the implementation, practice and sustainability of Intentional Rounding (IR) within two diverse settings (aged care and maternity). The profile of patients in hospitals has changed over time, generally being more severe, placing heavy demands on nurses' time. Routine non-urgent care is often provided only when there is time. IR has been found to increase both patient and staff satisfaction, also resulting in improved patient outcomes such as reduced falls and call bell use. IR is also used as a time management tool for safe and reliable provision of routine care. This descriptive qualitative research study comprised of three focus groups in a metropolitan hospital. Fifteen nurses participated in three focus groups. Seven main themes emerged from the thematic analysis of the verbatim transcripts: implementation and maintenance, how IR works, roles and responsibilities, context and environment, benefits, barriers and legal issues. IR was quickly incorporated into normal practice, with clinicians being able to describe the main concepts and practices. IR was seen as a management tool, facilitating accountability and continuity of management support being essential for sustainability. Clinicians reported increases in patient and staff satisfaction, and the opportunity to provide patient education. While patient type and acuity, ward layout and staff experience affected the practice of IR, the principles of IR are robust enough to allow for differences in the ward specialty and patient type. However, care must be taken when implementing IR to reduce the risk of alienating experienced staff. Incorporation of IR charts into the patient health care record is recommended. Engaging all staff, encouraging ownership and stability of management are key factors in the successful implementation and maintenance of IR. IR is flexible and robust enough to accommodate different patient types and acuity. ÂŠ 2016 John Wiley & Sons Ltd. Source: Medline

Title: Do Falls Experienced During Inpatient Stroke Rehabilitation Affect Length of Stay, Functional Status, and Discharge Destination? Citation: Archives of physical medicine and rehabilitation, Apr 2016, vol. 97, no. 4, p. 561-566, 1532821X (April 2016)

Author(s): Wong, Jennifer S, Brooks, Dina, Mansfield, Avril Abstract: To compare length of stay, functional status, and discharge destination between individuals who fell during inpatient stroke rehabilitation and those who did not fall. Retrospective cohort study. Rehabilitation hospital. Individuals who fell during inpatient stroke rehabilitation (n=106; fallers group; mean age, 67.8±12.9y; mean time poststroke, 26.4±28.3d) were matched to individuals who did not fall (n=106; nonfallers group; mean age, 67.3±13.6y; mean time poststroke, 21.9±28.8d) on age and functional status (N=212). Not applicable. Total length of stay, FIM assessed at discharge, and discharge destination. The mean length of stay for fallers was 11 days longer than nonfallers (P=.0017). Nonfallers and fallers did not differ on discharge total FIM scores (P=.19), and both groups were discharged home after inpatient rehabilitation (nonfallers: 77%; fallers: 74%; P=.52). This study suggests that falls experienced during inpatient stroke rehabilitation may have contributed to a longer length of stay; however, falls did not affect discharge functional status or discharge destination. Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved. Source: Medline

Title: One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs. Citation: BMJ quality & safety, Apr 2016, vol. 25, no. 4, p. 241-256, 2044-5423 (April 2016) Author(s): Maben, Jill, Griffiths, Peter, Penfold, Clarissa, Simon, Michael, Anderson, Janet E, Robert, Glenn, Pizzo, Elena, Hughes, Jane, Murrells, Trevor, Barlow, James Abstract: There is little strong evidence relating to the impact of single-room accommodation on healthcare quality and safety. We explore the impact of all single rooms on staff and patient experience; safety outcomes; and costs. Mixed methods pre/post 'move' comparison within four nested case study wards in a single acute hospital with 100% single rooms; quasi-experimental before-and-after study with two control hospitals; analysis of capital and operational costs associated with single rooms. Two-thirds of patients expressed a preference for single rooms with comfort and control outweighing any disadvantages (sense of isolation) felt by some. Patients appreciated privacy, confidentiality and flexibility for visitors afforded by single rooms. Staff perceived improvements (patient comfort and confidentiality), but single rooms were worse for visibility, surveillance, teamwork, monitoring and keeping patients safe. Staff walking distances increased significantly post move. A temporary increase of falls and medication errors in one ward was likely to be associated with the need to adjust work patterns rather than associated with single rooms per se. We found no evidence that single rooms reduced infection rates. Building an all single-room hospital can cost 5% more with higher housekeeping and cleaning costs but the difference is marginal over time. Staff needed to adapt their working practices significantly and felt unprepared for new ways of working with potentially significant implications for the nature of teamwork in the longer term. Staff preference remained for a mix of single rooms and bays. Patients preferred single rooms. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/ Source: Medline Full Text: Available from Highwire Press in BMJ Quality and Safety Title: Development and evaluation of an automated fall risk assessment system. Citation: International journal for quality in health care : journal of the International Society for Quality in Health Care / ISQua, Apr 2016, vol. 28, no. 2, p. 175-182, 1464-3677 (April 2016) Author(s): Lee, Ju Young, Jin, Yinji, Piao, Jinshi, Lee, Sun-Mi

Abstract: Fall risk assessment is the first step toward prevention, and a risk assessment tool with high validity should be used. This study aimed to develop and validate an automated fall risk assessment system (Auto-FallRAS) to assess fall risks based on electronic medical records (EMRs) without additional data collected or entered by nurses. This study was conducted in a 1335-bed university hospital in Seoul, South Korea. The Auto-FallRAS was developed using 4211 fall-related clinical data extracted from EMRs. Participants included fall patients and non-fall patients (868 and 3472 for the development study; 752 and 3008 for the validation study; and 58 and 232 for validation after clinical application, respectively). The system was evaluated for predictive validity and concurrent validity. The final 10 predictors were included in the logistic regression model for the riskscoring algorithm. The results of the Auto-FallRAS were shown as high/moderate/low risk on the EMR screen. The predictive validity analyzed after clinical application of the Auto-FallRAS was as follows: sensitivity = 0.95, NPV = 0.97 and Youden index = 0.44. The validity of the Morse Fall Scale assessed by nurses was as follows: sensitivity = 0.68, NPV = 0.88 and Youden index = 0.28. This study found that the Auto-FallRAS results were better than were the nurses' predictions. The advantage of the Auto-FallRAS is that it automatically analyzes information and shows patients' fall risk assessment results without requiring additional time from nurses. ÂŠ The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved. Source: Medline Full Text: Available from Highwire Press in International Journal for Quality in Health Care Title: Protecting Patient Safety: Can Video Monitoring Prevent Falls in High-Risk Patient Populations? Citation: Journal of nursing care quality, Apr 2016, vol. 31, no. 2, p. 131-138, 1550-5065 (2016 AprJun) Author(s): Sand-Jecklin, Kari, Johnson, Jennifer Ray, Tylka, Sharon Abstract: Despite implementation of many prevention strategies, patient falls in hospitals continue to be a significant safety problem, causing nursing staff and administrators to seek innovative means to further reduce falls among hospitalized patients. This article describes the feasibility and impact of implementing centralized video monitoring on the safety of patients identified as high risk for falls, as well as implications of video monitoring in the acute care setting. Source: Medline

Title: Open visiting reduces the number of inpatient falls. Citation: Nursing older people, Mar 2016, vol. 28, no. 3, p. 7. 1472-0795 (March 31, 2016) Author(s): Kleebauer, Alistair Abstract: THE INTRODUCTION of open visiting has led to a drop in inpatient falls at a large NHS trust. There were 259 fewer falls recorded after open visiting was introduced in April last year at Heart of England NHS Foundation Trust, which runs Heartlands, Good Hope and Solihull Hospitals. Source: Medline Full Text: Available from Royal College of Nursing in Nursing Older People; Note:; Notes: Click on 'Sign in' to top right, then choose OpenAthens option Available from RCN Publishing in Nursing Older People; Note: ; Notes: Click on 'Sign in' to top right, then choose OpenAthens option

PRESSURE ULCERS Title: Measuring hospital-acquired pressure injuries: A surveillance programme for monitoring performance improvement and estimating annual prevalence. Citation: International journal of nursing studies, Jun 2016, vol. 58, p. 71-79, 1873-491X (June 2016) Author(s): Jull, Andrew, McCall, Elaine, Chappell, Matt, Tobin, Sam Abstract: To describe a surveillance approach for monitoring the effect of improvement initiatives on hospital-acquired pressure injuries and findings arising from that surveillance. Random sampling of patients on the same day of each successive month from a campus of child and adult hospitals using a standard audit tool to identify presence of hospital-acquired pressure injury. Where multiple pressure injuries were present, the most severe grade injury contributed to prevalence. Statistical process control charts were used to monitor monthly performance and Maximum Likelihood Estimation to determine timing of step change. 8274 patients were assessed over 3 years from an eligible population of 32,259 hospitalised patients. 517 patients had hospital-acquired pressure injuries giving an overall prevalence of 6.2% (95% CI 5.7-6.8%). Annual prevalence was 8.4% (95% CI 7.4-9.5%) in the first year, falling to 5.6% (95% CI 4.7-6.4%) in the second year and 4.8% (95% CI 4.0-5.6%) in the third year. A step change was signalled with mean prevalence up to July 2013 being 7.9% (95% CI 7.1-8.8%) and mean prevalence thereafter 4.8% (95% CI 4.2-5.4%). Hospital-acquired pressure injuries were found in all age ranges, but were more frequent in children up to 14 years (17.4%) and those aged 75 years or older (38.7%). Monthly random sampling of patients within clinical units can be used to monitor performance improvement. This approach represents a rational alternative to cross-sectional prevalence surveys especially if the focus is on performance improvement. Copyright © 2016 Elsevier Ltd. All rights reserved. Source: Medline

Title: Prevention of heel pressure ulcers among older patients - from ambulance care to hospital discharge: A multi-centre randomized controlled trial. Citation: Applied nursing research: ANR, May 2016, vol. 30, p. 170-175, 1532-8201 (May 2016) Author(s): Bååth, Carina, Engström, Maria, Gunningberg, Lena, Muntlin Athlin, Åsa Abstract: The aim was to investigate the effect of an early intervention, a heel suspension device boot, on the incidence of heel pressure ulcers among older patients (aged 70+). Pressure ulcers are a global healthcare issue; furthermore, the heel is an exposed location. Research indicates that preventive nursing interventions starting during the ambulance care and used across the acute care delivery chain are seldom used. A multi-centre randomized control study design was used. Five ambulance stations, two emergency departments and 16 wards at two Swedish hospitals participated. Altogether, 183 patients were transferred by ambulance to the emergency department and were thereafter admitted to one of the participating wards. Significantly fewer patients in the intervention group (n=15 of 103; 14.6%) than the control group (n=24 of 80; 30%) developed heel pressure ulcers during their hospital stay (p=0.017). Pressure ulcer prevention should start early in the acute care delivery chain to increase patient safety. Copyright © 2015 Elsevier Inc. All rights reserved. Source: Medline

Title: Evaluation of the internal and external responsiveness of the Pressure Ulcer Scale for Healing (PUSH) tool for assessing acute and chronic wounds. Citation: Journal of advanced nursing, May 2016, vol. 72, no. 5, p. 1134-1143, 1365-2648 (May 2016)

Author(s): Choi, Edmond P H, Chin, Weng Yee, Wan, Eric Y F, Lam, Cindy L K Abstract: To examine the internal and external responsiveness of the Pressure Ulcer Scale for Healing (PUSH) tool for assessing the healing progress in acute and chronic wounds. It is important to establish the responsiveness of instruments used in conducting wound care assessments to ensure that they are able to capture changes in wound healing accurately over time. Prospective longitudinal observational study. The key study instrument was the PUSH tool. Internal responsiveness was assessed using paired t-testing and effect size statistics. External responsiveness was assessed using multiple linear regression. All new patients with at least one eligible acute or chronic wound, enrolled in the Nurse and Allied Health Clinic-Wound Care programme between 1 December 2012 - 31 March 2013 were included for analysis (N = 541). Overall, the PUSH tool was able to detect statistically significant changes in wound healing between baseline and discharge. The effect size statistics were large. The internal responsiveness of the PUSH tool was confirmed in patients with a variety of different wound types including venous ulcers, pressure ulcers, neuropathic ulcers, burns and scalds, skin tears, surgical wounds and traumatic wounds. After controlling for age, gender and wound type, subjects in the 'wound improved but not healed' group had a smaller change in PUSH scores than those in the 'wound healed' group. Subjects in the 'wound static or worsened' group had the smallest change in PUSH scores. The external responsiveness was confirmed. The internal and external responsiveness of the PUSH tool confirmed that it can be used to track the healing progress of both acute and chronic wounds. ÂŠ 2016 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd. Source: Medline

Title: A retrospective analysis of the findings of pressure ulcer investigations in an acute trust in the UK. Citation: Journal of tissue viability, May 2016, vol. 25, no. 2, p. 91-97, 0965-206X (May 2016) Author(s): Greenwood, Clare, McGinnis, Elizabeth Abstract: The root cause analysis (RCA) process has been applied in this organisation since 2010 to investigate all severe pressure ulcers. A previous analysis of the findings from all RCAs completed during 2011-2013 identified actions for practice improvement. The current study reports the results of a further retrospective analysis following implementation of new evidence based investigation process. To analysis the findings from pressure ulcer investigations; compare the results to the previous study and reflect on the new investigation process. Analysis was performed on data from completed RCAs during January-October 2014 to identify key themes and learning points. Thirty two pressure ulcer RCAs were included. Nutrition was the most common contributory factor, highlighting the issue of malnutrition in an acute care setting. The second most common contributory factor was medical conditions that lead to poor tissue perfusion. Severe pressure ulcers rarely occur due to a single root cause, but often due to a sequence of events. Patients frequently have multiple complex needs that increase their susceptibility, when this is in combination with a failure of care, a severe pressure ulcer can occur. The new investigation process had limited success in identifying organisational factors. Further work is needed to support staff in the investigation process. Copyright ÂŠ 2016 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved. Source: Medline

Title: The prevalence of pressure ulcers in the paediatric population. Citation: Journal of tissue viability, May 2016, vol. 25, no. 2, p. 127-134, 0965-206X (May 2016) Author(s): Habiballah, Laila, Tubaishat, Ahmad Abstract: A paucity of research related to the problem of pressure ulcers in paediatrics is found, with a variety of reported prevalence rates. To record the prevalence, location and categories of PU in the

inpatient paediatric wards, and to identify the characteristics of pressure ulcer patients. A descriptive point prevalence study. All paediatric inpatient wards in two hospitals in Jordan. One of which is a university-affiliated hospital and the other a paediatric public hospital. Isolation, burn and emergency units, outpatients' clinics and psychiatric wards were excluded. One sixty six paediatric patients aged from one day up to 18 years from both hospitals. Patients who met the inclusion criteria were included and examined for the existence of pressure ulcers on one day in each hospital by the primary investigator. The European Pressure Ulcer Advisory Panel classification system was used to categorise each identified ulcer. The characteristics of ulcers were collected as well. Sixteen ulcers were identified in 11 patients, giving a prevalence rate of 6.6%.When Category I ulcers were excluded, the prevalence rate dropped to 2.4%. All except one of the PU patients were being treated in critical care units (n = 10, 90.9%), and most of the ulcers were category one (n = 7, 63.6%) and caused by devices (n = 7, 63.6). The face was the most frequently reported location of PUs (n = 6, 54.5%), followed by the occiput (n = 2, 18.2%). Most PU patients were male (n = 6, 54.5%), and less than 12 months old (n = 8, 72.7%). PU patients had experienced longer hospital stays than patients free from PU (U = 499.0, p = 0.02). Jordanian paediatric patients do have pressure ulcers, with a prevalence rate congruent with previously reported international rates. Most of the ulcers found were caused by devices used in critical care units. This should encourage nurses to pay extra attention to their paediatric patients when they are connected to medical devices. Copyright ÂŠ 2016 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved. Source: Medline

Title: Pressure ulcers. Citation: Nursing standard (Royal College of Nursing (Great Britain): 1987), Apr 2016, vol. 30, no. 33, p. 61-62, 2047-9018 (April 13, 2016) Author(s): O'Byrne, Deborah Abstract: My nursing experience is in acute care. Acute medical nurses are well placed to assess skin integrity, identify patients at risk of pressure ulcer development, and commence appropriate interventions to prevent or treat pressure ulcers. Source: Medline Full Text: Available from NURSING STANDARD in Library MPH Title: The lived experience of the wound care nurse in caring for patients with pressure ulcers. Citation: International wound journal, Apr 2016, vol. 13, no. 2, p. 243-251, 1742-481X (April 2016) Author(s): Varga, Marlene A, Holloway, Samantha L Abstract: The aim of the study was to report the lived experience of the wound care nurse (WCN) in caring for patients with pressure ulcers (PU). WCN play an important role in caring for patients with PU, but the effect on caring for individuals with such wounds is poorly understood. A descriptive and interpretative study on the life worlds of spatiality, temporality, relationality and corporeality was carried out. Utilising the hermeneutic Heideggerian phenomenology, data were collected over a 3month period in 2012 using in-depth interviews with five WCN. The interviews revealed eight themes: 'challenge', 'making sense of it all', 'coping and self-care', 'advocate of mine/making a difference', 'knowledge and technology', 'we have seen what can happen', 'holistic caring' and 'frustration'. Twenty-five sub-themes were also identified. WCN experienced a demanding and rewarding role of caring, influenced by the environment and the challenges with individuals living with PU. This study demonstrated an enriching yet challenging role. Recommendations for WCN, health care authorities and education providers include raising awareness of the importance of self-care, greater recognition of the effect of this role on patients with PU and changing education to include reflective practice and

Title: Predictive Validity of Pressure Ulcer Risk Assessment Tools for Elderly: A Meta-Analysis. Citation: Western journal of nursing research, Apr 2016, vol. 38, no. 4, p. 459-483, 1552-8456 (April 2016) Author(s): Park, Seong-Hi, Lee, Young-Shin, Kwon, Young-Mi Abstract: Preventing pressure ulcers is one of the most challenging goals existing for today's health care provider. Currently used tools which assess risk of pressure ulcer development rarely evaluate the accuracy of predictability, especially in older adults. The current study aimed at providing a systemic review and meta-analysis of 29 studies using three pressure ulcer risk assessment tools: Braden, Norton, and Waterlow Scales. Overall predictive validities of pressure ulcer risks in the pooled sensitivity and specificity indicated a similar range with a moderate accuracy level in all three scales, while heterogeneity showed more than 80% variability among studies. The studies applying the Braden Scale used five different cut-off points representing the primary cause of heterogeneity. Results indicate that commonly used screening tools for pressure ulcer risk have limitations regarding validity and accuracy for use with older adults due to heterogeneity among studies. © The Author(s) 2015. Source: Medline

Title: Analyses of pressure ulcer point prevalence at the first skin assessment in a Portuguese hospital. Citation: Journal of Tissue Viability, 2016, vol./is. 25/2(75-82), 0965206X Author(s): Sardo, Pedro Miguel Garcez, Simões, Cláudia Sofia Oliveira, Alvarelhão, José Joaquim Marques, Costa, César Telmo de Oliveira e, Simões, Carlos Jorge Cardoso, Figueira, Jorge Manuel Rodrigues, Simões, João Filipe Fernandes Lindo, Amado, Francisco Manuel Lemos, Amaro, António José Monteiro, Melo, Elsa Maria Oliveira Pinheiro de Language: English Publication Type: Academic Journal Source: CINAHL

Title: Using heel protectors for the prevention of hospital-acquired pressure ulcers. Citation: British Journal of Nursing, 2016, vol. /is. 25/6(0-4), 09660461 Author(s): Rajpaul, Kumal, Acton, Claire Language: English Abstract: Pressure ulcers are a frequent, but often preventable, occurrence among patients in acute care facilities, and the heel is one of the anatomical locations most commonly affected. Multiple clinical guidelines recommend the use of robust assessments to identify at-risk patients and the application of heel protection devices to reduce the likelihood of developing heel pressure ulcers. A quality improvement initiative involving robust skin-assessment practices, staff education, and the use of heel protection devices was analysed retrospectively to evaluate the efficacy of current practice

interventions. These analyses revealed that the incidence of heel pressure ulcers was inversely correlated with the number of heel protectors used at two large acute NHS teaching hospitals in inner London, and that the consistent and early use of heel protectors improved patient outcomes and reduced costs of care. Publication Type: Academic Journal Source: CINAHL Full Text: Available from Mark Allen Group in British Journal of Nursing; Note:; Notes: Click on 'Sign in' to top right, then choose OpenAthens option Available from EBSCOhost in British Journal of Nursing Title: USE OF A COMPREHENSIVE PROGRAM TO REDUCE THE INCIDENCE OF HOSPITALACQUIRED PRESSURE ULCERS IN AN INTENSIVE CARE UNIT. Citation: American Journal of Critical Care, 2016, vol. /is. 25/2(152-155), 10623264 Author(s): Swafford, Katie Language: English Publication Type: Academic Journal Source: CINAHL Full Text: Available from EBSCOhost in American Journal of Critical Care Title: A Clinical Nurse Specialist--Led Interprofessional Quality Improvement Project to Reduce Hospital-Acquired Pressure Ulcers. Citation: Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 2016, vol./is. 30/2(110-116), 08876274 Author(s): Fabbruzzo-Cota, Christina, Frecea, Monica, Kozell, Kathryn, Pere, Katalin, Thompson, Tamara, Tjan Thomas, Julie, Wong, Angela Language: English Publication Type: Academic Journal Source: CINAHL

Title: Pressure ulcer and wounds reporting in NHS hospitals in England part 1: Audit of monitoring systems. Citation: Journal of Tissue Viability, 2016, vol./is. 25/1(3-15), 0965206X Author(s): Smith, Isabelle L., Nixon, Jane, Brown, Sarah, Wilson, Lyn, Coleman, Susanne Language: English Publication Type: Academic Journal Source: CINAHL

Title: Pressure ulcer and wounds reporting in NHS hospitals in England part 2: Survey of monitoring systems. Citation: Journal of Tissue Viability, 2016, vol./is. 25/1(16-25), 0965206X Author(s): Coleman, Susanne, Smith, Isabelle L., Nixon, Jane, Wilson, Lyn, Brown, Sarah Language: English Publication Type: Academic Journal Source: CINAHL

SEPSIS Title: Gaps and improvement in management of sepsis Citation: Nursing Times 112(17) p.15-17

Title: The ability of early warning scores (EWS) to detect critical illness in the prehospital setting: A systematic review. Citation: Resuscitation, May 2016, vol. 102, p. 35-43, 1873-1570 (May 2016) Author(s): Williams, Teresa A, Tohira, Hideo, Finn, Judith, Perkins, Gavin D, Ho, Kwok M Abstract: To examine whether early warning scores (EWS) can accurately predict critical illness in the prehospital setting and affect patient outcomes. We searched bibliographic databases for comparative studies that examined prehospital EWS for patients transported by ambulance in the prehospital setting. The ability of the different EWS, including pre-alert protocols and physiologicalbased EWS, to predict critical illness (sensitivity, odds ratio [OR], area under receiver operating characteristic [AUROC] curves) and hospital mortality was summarised. Study quality was assessed using the Newcastle-Ottawa Scale. Eight studies were identified. Two studies compared the use of EWS to standard practice using clinical judgement alone to identify critical illness: the pooled diagnostic OR and summary AUROC for EWS were 10.9 (95%CI 4.2-27.9) and 0.78 (95%CI 0.740.82), respectively. A study of 144,913 patients reported age and physiological variables predictive of critical illness: AUROC in the independent validation sample was 0.77, 95% CI 0.76-0.78. The highrisk patients stratified by the national early warning score (NEWS) were significantly associated with a higher risk of both mortality and intensive care admission. Data on comparing between different EWS were limited; the Prehospital Early Sepsis Detection (PRESEP) score predicted occurrence of sepsis better than the Modified EWS (AUROC 0.93 versus 0.77, respectively). EWS in the prehospital setting appeared useful in predicting clinically important outcomes, but the significant heterogeneity between different EWS suggests that these positive promising findings may not be generalisable. Adequately powered prospective studies are needed to identify the EWS best suited to the prehospital setting. Copyright ÂŠ 2016 Elsevier Ireland Ltd. All rights reserved. Source: Medline

Title: Severe Sepsis and Septic Shock: Timing of Septic Shock Onset Matters. Citation: Shock (Augusta, Ga.), May 2016, vol. 45, no. 5, p. 518-524, 1540-0514 (May 2016)

Author(s): Huang, Chun-Ta, Tsai, Yi-Ju, Tsai, Pi-Ru, Yu, Chong-Jen, Ko, Wen-Je Abstract: Timing of septic shock onset may play a prognostic role in severe sepsis; however, clinical evidence provides contradictory results. This study aimed to investigate possible associations between timing of onset of septic shock and patient outcome. In a university-affiliated hospital, all patients admitted to the intensive care unit (ICU) for severe sepsis or septic shock from November 2007 to March 2011 were included. The primary outcome of interest was the impact of timing of septic shock onset on in-hospital mortality. We also sought to identify potential factors predicting development of septic shock after ICU admission. In total, 772 patients were identified to have severe sepsis; approximately two-thirds (487/772) of them experienced septic shock and overall in-hospital mortality was 57%. Timing of onset of septic shock was an independent predictor of in-hospital outcome, and there was an increasing trend of in-hospital mortality with later onset of septic shock. In addition, timing of septic shock onset provided further mortality risk stratification in patients with APACHE II scores of less than 20 and 20 to 25. We also found that patients who underwent cardiovascular surgery were more likely to experience septic shock after admission and those receiving neurosurgery were at lower risk of developing septic shock. This study showed the significance of timing of septic shock onset in prognosis among ICU patients with severe sepsis. Timing of shock onset further stratified patients with similar disease severity into different mortality risk groups. These findings deliver useful information regarding risk stratification of septic patients. Source: Medline

Title: Application of Antibiotic Pharmacodynamics and Dosing Principles in Patients With Sepsis Citation: Critical Care Nurse, Apr 2016, vol. 36, no. 2, p. 22-32, 0279-5442 (April 1, 2016) Author(s): Droege, Molly E., Van Fleet, Suzanne L., Mueller, Eric W. Abstract: Sepsis is associated with marked mortality, which may be reduced by prompt initiation of adequate, appropriate doses of antibiotic. Critically ill patients often have physiological changes that reduce blood and tissue concentrations of antibiotic and high rates of multidrug-resistant pathogens, which may affect patients' outcomes. All critical care professionals, including critical care nurses, should understand antibiotic pharmacokinetics and pharmacodynamics to ensure sound antibiotic dosing and administration strategies for optimal microbial killing and patients' outcomes. Effective pathogen eradication occurs when the dose of antibiotic reaches or maintains optimal concentrations relative to the minimum inhibitory concentration for the pathogen. Time-dependent antibiotics, such as 창 lactams, can be given as extended or continuous infusions. Concentration-dependent antibiotics such as aminoglycosides are optimized by using high, once-daily dosing strategies with serum concentration monitoring. Vancomycin and fluoroquinolones are dependent on both time and concentration above the minimum inhibitory concentration. References Source: BNI Full Text: Available from EBSCOhost in Critical Care Nurse

Title: Development of an e-learning package for sepsis care. Citation: British journal of nursing (Mark Allen Publishing), Mar 2016, vol. 25, no. 6, p. 292-296, 0966-0461 (March 24, 2016) Author(s): Davis, Anna, Henderson, James, Langmack, Gill Abstract: Severe sepsis is a major cause of morbidity and mortality in the UK. This article describes the collaborative development and implementation of an interactive online learning package to

understand the key role nurses have in recognising and then starting to apply the Sepsis Six care bundle in clinical practice. The e-learning package, developed in a UK teaching hospital, uses a case study approach to address the knowledge that is required to be able to recognise sepsis, to understand the processes that occur and the ongoing care and treatment required. The package is relevant to final-year student nurses, newly registered nurses in preceptorship and other health professionals involved in assessing and treating patients who may be developing sepsis. Source: Medline Full Text: Available from Mark Allen Group in British Journal of Nursing; Note: ; Notes: Click on 'Sign in' to top right, then choose OpenAthens option Available from EBSCOhost in British Journal of Nursing Title: Development and Implementation of an Early-Onset Sepsis Calculator to Guide Antibiotic Management in Late Preterm and Term Neonates. Citation: Joint Commission Journal on Quality & Patient Safety, 2016, vol./is. 42/5(232-239), 15537250 Author(s): Kuzniewicz, Michael W., Walsh, Eileen M., Sherian Li, Fischer, Allen, Escobar, Gabriel J. Language: English Publication Type: Academic Journal Source: CINAHL

Title: Immunosuppression and Secondary Infection in Sepsis. Citation: JAMA: Journal of the American Medical Association, 2016, vol./is. 315/14(1457-1459), 00987484 Author(s): Angus, Derek C., Opal, Steven Language: English Publication Type: Academic Journal Source: CINAHL

Title: Incidence, Risk Factors, and Attributable Mortality of Secondary Infections in the Intensive Care Unit After Admission for Sepsis. Citation: JAMA: Journal of the American Medical Association, 2016, vol./is. 315/14(1469-1479), 00987484 Author(s): van Vught, Lonneke A., Klouwenberg, Peter M. C. Klein, Spitoni, Cristian, Scicluna, Brendon P., Wiewel, Maryse A., Horn, Janneke, Schultz, Marcus J., N端rnberg, Peter, Bonten, Marc J. M., Cremer, Olaf L., van der Poll, Tom Language: English Publication Type: Academic Journal Source: CINAHL

Title: Sepsis: a 21st century problem. Citation: British Journal of Hospital Medicine (17508460), 2016, vol./is. 77/4(200-201), 17508460 Author(s): Goodwin, Alexander Language: English Publication Type: Academic Journal Source: CINAHL

Title: The new international sepsis guidelines (Sepsis-3): the central message remains. Citation: British Journal of Hospital Medicine (17508460), 2016, vol./is. 77/4(208-211), 17508460 Author(s): Whittle, John, Walker, David Language: English Publication Type: Academic Journal Source: CINAHL

DETERIORATING PATIENT Title: Vital signs monitoring and nurse-patient interaction: A qualitative observational study of hospital practice. Citation: International journal of nursing studies, Apr 2016, vol. 56, p. 9-16, 1873-491X (April 2016) Author(s): Cardona-Morrell, M, Prgomet, M, Lake, R, Nicholson, M, Harrison, R, Long, J, Westbrook, J, Braithwaite, J, Hillman, K Abstract: High profile safety failures have demonstrated that recognising early warning signs of clinical and physiological deterioration can prevent or reduce harm resulting from serious adverse events. Early warning scoring systems are now routinely used in many places to detect and escalate deteriorating patients. Timely and accurate vital signs monitoring are critical for ensuring patient safety through providing data for early warning scoring systems, but little is known about current monitoring practices. To establish a profile of nurses' vital signs monitoring practices, related dialogue, and adherence to health service protocol in New South Wales, Australia. Direct observations of nurses' working practices were conducted in two wards. The observations focused on times of the day when vital signs were generally measured. Patient interactions were recorded if occurring any time during the observation periods. Participants (n=42) included nursing staff on one chronic disease medical and one acute surgical ward in a large urban teaching hospital in New South Wales. We observed 441 patient interactions. Measurement of vital signs occurred in 52% of interactions. The minimum five vital signs measures required by New South Wales Health policy were taken in only 6-21% of instances of vital signs monitoring. Vital signs were documented immediately on 93% of vitals-taking occasions and documented according to the policy in the patient's chart on 89% of these occasions. Nurse-patient interactions were initiated for the purpose of taking vital signs in 49% of interactions, with nurse-patient discourse observed during 88% of all interactions. Nursepatient dialogue led to additional care being provided to patients in 12% of interactions. The selection of appropriate vital signs measured and responses to these appears to rely on nurses' clinical

judgement or time availability rather than on policy-mandated frequency. The prevalence of incomplete sets of vital signs may limit identification of deteriorating patients. The findings from this study present an important baseline profile against which to evaluate the impact of introducing continuous monitoring approaches on current hospital practice. Copyright ÂŠ 2015 Elsevier Ltd. All rights reserved. Source: Medline

Title: Deteriorating patient a focus of adverse events report. Citation: Dissector, 2016, vol./is. 43/4(7-8), 11747579 Language: English Publication Type: Academic Journal Source: CINAHL

Title: Recognizing and managing a deteriorating patient: a randomized controlled trial investigating the effectiveness of clinical simulation in improving clinical performance in undergraduate nursing students. Citation: Journal of Advanced Nursing, 2015, vol. /is. 71/11(2563-2574), 03092402 Author(s): Stayt, Louise Caroline, Merriman, Clair, Ricketts, Barry, Morton, Sean, Simpson, Trevor Language: English Publication Type: Academic Journal Source: CINAHL Full Text: Available from EBSCOhost in Journal of Advanced Nursing

RESTRICTIVE PRACTICE Title: An integrative review exploring decision-making factors influencing mental health nurses in the use of restraint Citation: Journal of Psychiatric and Mental Health Nursing, Mar 2016, vol. 23, no. 2, p. 116-128, 1351-0126 (March 2016) Author(s): Riahi, S., Thomson, G., Duxbury, J. Abstract: Introduction: While mechanical and manual restraint as an institutional method of control within mental health settings may be perceived to seem necessary at times, there is emergent literature highlighting the potential counter-therapeutic impact of this practice for patients as well as staff. Nurses are the professional group who are most likely to use mechanical and manual restraint methods within mental health settings. In-depth insights to understand what factors influence nurses' decision-making related to restraint use are therefore warranted. Aim: To explore what influences mental health nurses' decision-making in the use of restraint. Method: An integrative review using Cooper's framework was undertaken. Results: Eight emerging themes were identified: 'safety for all', 'restraint as a necessary intervention', 'restraint as a last resort', 'role conflict', 'maintaining control', 'staff composition', 'knowledge and perception of patient behaviours', and 'psychological impact'.

These themes highlight how mental health nurses' decision-making is influenced by ethical and safety responsibilities, as well as, interpersonal and staff-related factors. Conclusion: Research to further understand the experience and actualization of 'last resort' in the use of restraint and to provide strategies to prevent restraint use in mental health settings are needed. References Source: BNI

Title: Physical restraint: experiences, attitudes and opinions of adult intensive care unit nurses Citation: Nursing in Critical Care, Mar 2016, vol. 21, no. 2, p. 78-87, 1362-1017 (March 2016) Author(s): Freeman, Samantha, Hallett, Christine, McHugh, Gretl Abstract: Aim: To determine the experiences, attitudes and opinions of adult intensive care nurses in relation to the application of physical restraint. Design: Questionnaire survey. Methods: A postal questionnaire was distributed to all nurses (n = 192) within two purposefully selected large adult intensive care units in the UK. Results: Data were collected between November 2012 and February 2013. The questionnaire was completed by 38Âˇ9% (n = 75) of the nurses contacted. All believed that physical restraint had a place, with the majority of the view that the reason for its application was to maintain patient safety. Some expressed discomfort about the use of physical restraint. Nurses were happy to discuss the use of restraint with families. There was a perceived need for training and support for nursing staff as well as the need for medical staff to support the decision-making process. Conclusion: Nurses require more support and evidence to base their decision-making upon. They require guidance from professional bodies as well as support from medical colleagues. The findings have limited generalizability as they can only be applied to the units accessed and the response rate was poor. Relevance to clinical practice: Alternative approaches such as pain management, sleep promotion and the involvement of relatives need to be explored before physical restraint policy can be written. Further research is required into the safety of physical restraint, alternative methods of managing the risk of agitation and identifying predisposing factors to accidental device removal. References Source: BNI

Title: A nationwide study of why and how acute adolescent psychiatric units use restraint. Citation: Psychiatry research, Mar 2016, vol. 237, p. 60-66, 1872-7123 (March 30, 2016) Author(s): Furre, Astrid, Sandvik, Leiv, Friis, Svein, Knutzen, Maria, Hanssen-Bauer, Ketil Abstract: The purpose of this study was to examine the type, reason, and duration of restraint episodes in acute adolescent psychiatric units. In a retrospective design we included data from paperbased protocols on all episodes of restraint and data from electronic patient records during 2008-2010 in all acute adolescent psychiatric in-patient units in Norway (N=16). The episodes of restraint included mechanical and pharmacological restraint, seclusion and physical holding that was not part of the implementation of forced feeding. Six-and-a-half per cent of all 4099 adolescents admitted to the acute units experienced restraint. Of the 2277 episodes, 13.4% were mechanical restraint, 1.6% were pharmacological restraint, 5.9% were seclusion and 78.7% were physical holding. The median number of restraint episodes per patient was two, the range was 1-171 and 47 patients (18%) experienced â&#x2030;Ľ10 episodes. The most common reason for using restraint was harming others. The median duration of the mechanical restraint episodes was 3.5h. The median duration of seclusion was 30min and the median duration of physical holding was 10min. Copyright ÂŠ 2016 Elsevier Ireland Ltd. All rights reserved. Source: Medline

PATIENT SAFETY Title: Understanding situation awareness and its importance in patient safety Citation: Nursing Standard 2016 30 (34) p50-60 Author(s): Heather Gluyas et al

Title: Safe staffing guidance halt sparks safety fears. Citation: Nursing Times, 112(17) p. 2-3 Author(s): Merrifield, N

Title: Interprofessional Collaborative Practice. Citation: Journal of continuing education in nursing, Apr 2016, vol. 47, no. 4, p. 156-157, 0022-0124 (April 1, 2016) Author(s): Sexton, Martha, Baessler, Matthew Abstract: The need for change in the delivery of health care could not be more imminent due to the multiple breaches in patient safety occurring in virtually all health care settings across the United States and internationally. The concept of health care teams working together is not new; however, implementing a culture of change, where concepts such as patient safety, mutual respect, shared decision making, and patient-centered care is the norm, remains a novel and often fleeting idea in most health care facilities. J Contin Educ Nurs. 2016; 47(4):156-157. Copyright 2016, SLACK Incorporated. Source: Medline Full Text: Available from ProQuest in Journal of Continuing Education in Nursing, The Title: Measurement, Standards, and Peer Benchmarking: One Hospital's Journey. Citation: Pediatric clinics of North America, Apr 2016, vol. 63, no. 2, p. 239-249, 1557-8240 (April 2016) Author(s): Martin, Brian S Abstract: Peer-to-peer benchmarking is an important component of rapid-cycle performance improvement in patient safety and quality-improvement efforts. Institutions should carefully examine critical success factors before engagement in peer-to-peer benchmarking in order to maximize growth and change opportunities. Solutions for Patient Safety has proven to be a high-yield engagement for Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, with measureable improvement in both organizational process and culture. Copyright ÂŠ 2016 Elsevier Inc. All rights reserved. Source: Medline

Title: Pediatric Quality and Safety: A Nursing Perspective. Citation: Pediatric clinics of North America, Apr 2016, vol. 63, no. 2, p. 329-339, 1557-8240 (April 2016) Author(s): Butler, Gabriella A, Hupp, Diane S Abstract: Patient safety and quality are 2 of many competing priorities facing health care providers. As safety and quality rise on the agenda of executives, payers, and consumers, competing priorities, such as financial sustainability, patient engagement, regulatory standards, and governmental demands, remain organizational priorities. Nursing represents the largest health care profession in the United States and has the ability to influence the culture of patient safety and quality. It is essential for hospital leadership to provide a culture whereby nurses and staff are actively engaged and feel comfortable speaking up. Transparency is critical in the strategy and implementation of improving quality and safety. Copyright © 2016 Elsevier Inc. All rights reserved. Source: Medline

Title: Promoting Patient Safety: Results of a TeamSTEPPS® Initiative. Citation: The Journal of nursing administration, Apr 2016, vol. 46, no. 4, p. 201-207, 1539-0721 (April 2016) Author(s): Gaston, Teresa, Short, Nancy, Ralyea, Christina, Casterline, Gayle Abstract: Teamwork is an essential component of communication in a safety-oriented culture. The Joint Commission has identified poor communication as one of the leading causes of patient sentinel events. The aim of this quality improvement project was to design, implement, and evaluate a customized TeamSTEPPS® training program. After implementation, staff perception of teamwork and communication improved. The data support that TeamSTEPPS is a practical, effective, and low-cost patient safety endeavor. Source: Medline

Title: Measuring and improving patient safety culture: still a long way to go. Citation: BMJ Quality & Safety, 2016, vol./is. 25/3(209-211), 20445415 Author(s): Trbovich, P. L., Griffin, M. Language: English Publication Type: Academic Journal Source: CINAHL Full Text: Available from Highwire Press in BMJ Quality and Safety

HUMAN FACTORS Title: A Human Factors Engineering Study of the Medication Delivery Process during an Anesthetic: Self-filled Syringes versus Prefilled Syringes.

Citation: Anesthesiology, Apr 2016, vol. 124, no. 4, p. 795-803, 1528-1175 (April 2016) Author(s): Yang, Yushi, Rivera, Antonia Joy, Fortier, Christopher R, Abernathy, James H Abstract: Prefilled syringes (PFS) have been recommended by the Anesthesia Patient Safety Foundation. However, aspects in PFS systems compared with self-filled syringes (SFS) systems have never been explored. The aim of this study is to compare system vulnerabilities (SVs) in the two systems and understand the impact of PFS on medication safety and efficiency in the context of anesthesiology medication delivery in operating rooms. This study is primarily qualitative research, with a quantitative portion. A work system analysis was conducted to analyze the complicated anesthesia work system using human factors principles and identify SVs. Anesthesia providers were shadowed: (1) during general surgery cases (n = 8) exclusively using SFS and (2) during general surgery cases (n = 9) using all commercially available PFS. A proactive risk assessment focus group was followed to understand the risk of each identified SV. PFS are superior to SFS in terms of the simplified work processes and the reduced number and associated risk of SVs. Eight SVs were found in the PFS system versus 21 in the SFS system. An SV example with high risk in the SFS system was a medication might need to be "drawn-up during surgery while completing other requests simultaneously." This SV added cognitive complexity during anesthesiology medication delivery. However, it did not exist in the PFS system. The inclusion of PFS into anesthesiology medication delivery has the potential to improve system safety and work efficiency. However, there were still opportunities for further improvement by addressing the remaining SVs and newly introduced complexity. Source: Medline Full Text: Available from Ovid online collection in Anesthesiology Available from Ovid fulltext collection in Anesthesiology Title: Why you need to include human factors in clinical and empirical studies of in vitro point of care devices? Review and future perspectives. Citation: Expert review of medical devices, Apr 2016, vol. 13, no. 4, p. 405-416, 1745-2422 (April 2016) Author(s): Borsci, Simone, Buckle, Peter, Hanna, George B Abstract: Use of in-vitro point of care devices - intended as tests performed out of laboratories and near patient - is increasing in clinical environments. International standards indicate that interaction assessment should not end after the product release, yet human factors methods are frequently not included in clinical and empirical studies of these devices. Whilst the literature confirms some advantages of bed-side tests compared to those in laboratories there is a lack of knowledge of the risks associated with their use. This article provides a review of approaches applied by clinical researchers to model the use of in-vitro testing. Results suggest that only a few studies have explored human factor approaches. Furthermore, when researchers investigated people-device interaction these were predominantly limited to qualitative and not standardised approaches. The methodological failings and limitations of these studies, identified by us, demonstrate the growing need to integrate human factors methods in the medical field. Source: Medline

Title: Human factors and the death of a child in hospital: a case review. Citation: Nursing standard (Royal College of Nursing (Great Britain): 1987), Mar 2016, vol. 30, no. 31, p. 46-51, 2047-9018 (March 30, 2016) Author(s): Gluyas, Heather, Hookham, Emily Michelle

Abstract: Learning from adverse events and errors is important if systems and processes are to be improved and to minimise the likelihood of similar events in the future. This article uses the report from a coroner's inquest into the death of a seven-year-old child in hospital to examine errors that contributed to the child's death. These errors are reviewed from a human factors perspective. The article provides an overview of error causation concepts and offers strategies that healthcare organisations can implement to reduce the incidence of such errors. Source: Medline Full Text: Available from NURSING STANDARD in Library MPH Title: Human factors and ergonomics for primary care. Citation: Education for primary care : an official publication of the Association of Course Organisers, National Association of GP Tutors, World Organisation of Family Doctors, Mar 2016, vol. 27, no. 2, p. 86-93, 1473-9879 (March 2016) Author(s): Bowie, Paul, Jeffcott, Shelly Abstract: In the second paper of this series, we provide a brief overview of the scientific discipline of human factors and ergonomics (HFE). Traditionally the HFE focus in healthcare has been in acute hospital settings which are perceived to exhibit characteristics more similar to other high-risk industries already applying related principles and methods. This paper argues that primary care is an area which could benefit extensively from an HFE approach, specifically in improving the performance and well-being of people and organisations. To this end, we define the purpose of HFE, outline its three specialist sub-domains (physical, cognitive and organisational HFE) and provide examples of guiding HFE principles and practices. Additionally, we describe HFE issues of significance to primary care education, improvement and research and outline early plans for building capacity and capability in this setting. Source: Medline

Title: Night shifts, human factors, and errors in the ICU: a causal pathway? Citation: Intensive care medicine, Mar 2016, vol. 42, no. 3, p. 456-457, 1432-1238 (March 2016) Author(s): Rubulotta, F, Scales, D C, Halpern, S D Source: Medline

BOOKS BACK TO TOP If you are unable to find a book, or require a book that is not on this list, please ask library staff who will be able to locate the book for you using interlibrary loan. Patient safety and managing risk in nursing / Melanie Fisher, Margaret Scott (2013)

Patient safety is a predominant feature of quality healthcare and something that every patient has the right to expect.nbsp; As a nurse, you must consider the safety of the patient as paramount in every aspect of your role; and it is now an increasingly important topic in pre-registration nursing programmes. This book aims to provide you with a greater understanding of how to manage patient safety and risk in your practice. The book focuses on the essentials that you need to know, and therefore provides a clear pathway through what can sometimes seem an overwhelmingly complex mass of rules, procedures and possible options.

The patient experience : the importance of care, communication, and compassion in the hospital room / Brian Boyle (2015)

Brianâ&#x20AC;&#x2122;s story about catastrophe, survival, and transcending all odds has implemented new and innovative strategies for improving patient safety and quality of care on a national level, as well as serving as a learning experience for healthcare providers of all levels and backgrounds.

We now have a subscription to EBL Electronic Books and would be interested to know if there are any titles you feel would be of benefit to be added to our collection. The catalogue can be browsed here; you will need your OpenAthens password to access it. You can request books either on the site itself or by emailing us on library@tst.nhs.uk

COCHRANE SYSTEMATIC REVIEWS BACK TO TOP

Antibiotics and antiseptics for pressure ulcers Gill Norman , Jo C Dumville , Zena EH Moore, Judith Tanner , Janice Christie and Saori Goto Online Publication Date: April 2016

Oral aspirin for treating venous leg ulcers Paulo Eduardo de Oliveira Carvalho, Natiara G Magolbo, Rebeca F De Aquino and Carolina D Weller Online Publication Date: February 2016

New review

UPTODATE and DYAMED PLUS BACK TO TOP

UpToDate Access is available to MPH staff only but topics from UpTodate can be supplied to Sompar staff on request. 

Falls in older persons: Risk factors and patient evaluation

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Falls: Prevention in nursing care facilities and the hospital setting

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Prevention of pressure ulcers

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Evaluation and management of severe sepsis and septic shock in adults

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Assessment and emergency management of the acutely agitated or violent adult

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Prevention of adverse drug events in hospitals

Please contact library staff for details on how to access this resource; you will need an Athens password if accessing from home.

Dynamed Plus Access is available to Sompar staff only but topics from UpTodate can be supplied to MPH staff on request

Falls in the elderly Pressure ulcer Sepsis in adults Sepsis treatment in adults Please contact library staff for details on how to access this resource; you will need an Athens password if accessing from home.

REPORTS, PUBLICATIONS AND RESOURCES

Falls risk assessment tool Walsall CCG, in partnership with Keele University, have developed an Emis web protocol and template to help identify patients at risk of falls and potentially at risk of unplanned hospital admissions. The Falls Risk Assessment Toolkit allows users to search for read codes consistent with predictors of falls risk as recommended by NICE and high risk psychotropic medicines which can contribute to falls. It can also identify patients over the age of 65 who may benefit from a medication review or falls assessment and prompt background alerts to systematically identify â&#x20AC;&#x2DC;at riskâ&#x20AC;&#x2122; patients.

UK Sepsis Trust Clinical toolkits available covering paediatrics, ambulance and acute services: See: http://sepsistrust.org/clinical-toolkit/

MPH Colleague App For Musgrove staff the SUTS current awareness is now available on the Colleague App. If you have not downloaded this App here are the instructions: To download, follow the short instructions below: For Apple / Android devices: 1. Copy or type the link below into your device browser: https://apps.appmachine.com/3591BD/download

2. Give permissions for the download when asked 3. Allow push notifications, to get regular updates/rewards info 4. Click on the app and start exploring. Please note: if you have upgraded your software to iOS 9 you will need to follow these steps once the app has been downloaded: o Click on ‘Settings’ o Click on ‘General’ o Click on ‘Profile’ o Tap on the colleague app o Tap on @Trust (Chapelcroft Limited).

In addition to the above the following QR Code is now appearing in the staff bulletin inviting staff to ‘download the free colleague app to your mobile device’

LITERATURE SEARCH SERVICE BACK TO TOP Looking for the latest evidence-based research but havenâ&#x20AC;&#x2122;t got time to trawl the databases? Do you need a literature search carried out? Do you need to find evidence to support an improvement? Do you want to know how something has been done elsewhere and whether it worked?

Library staff provide a literature search service for busy clinicians who are pressed for time.

To request a search please complete and return the attached form ,providing as much information as possible. Alternatively if you would like an assisted search training session, where we will sit down with you and go through the steps of a literature search, then please contact the library.

TRAINING AND ATHENS BACK TO TOP Most electronic resources are available via an Athens password. You can register for this via the Library intranet page, or from home at www.swice.nhs.uk and following the link for Athens selfregistration. Please note that registering from home will take longer as it will need to be verified that you are NHS staff/student on placement. The library offers training on how to access and use Athens resources, as well as an introductory course on critical appraisal. You can book a course through the Learning and Development intranet page, or by contacting the library directly.