The phrase expresses one of the principal precepts all medical students are taught in medical school and is a fundamental principle for the emergency medical services. It reminds the physician and other health care providers that she or he must consider the possible harm that any intervention might do.
The Severn Foundation School would like to work with all of its trainers and trainees to reduce medical errors. We are going to have an opportunity via the website to share good practices in this area. We are planning to appoint a person who will have responsibility for reviewing reported errors. The deanery will then try and develop practices to minimize the chances of these errors recurring by examining the factors that led to the errors.
PMETB has found that trainees in their first two years of practice are most likely to make errors and this is why we would like to take this opportunity to work with trainers and trainees in the Foundation School. The hyperlink below is to the summary report of the PMETB trainee survey 2007.
Summary report of the PMETB trainee survey 2007
Over a thousand staff were trained and assessed against new competencies, and training of new staff and refresher training is ongoing. Wall mounted computers alongside blood fridges control access to the blood via magnetic door locks. A porter collecting blood is required to scan his or her barcoded staff ID card before using the system, and barcodes on the patient paperwork and blood packs are scanned to ensure the right blood is being collected for the right patient. At the patient bedside those administering blood must scan their own ID card, the barcoded patient wristband, and the blood itself, to back up prescribed visual checks. The handheld scanners and linked computers provide visual and audible alarms when blood may be about to be transported or put up that is for the wrong patient, has exceeded time out of prescribed temperature controls, or has expired.
Blood Transfusion processes have not only been made safer with the new system - additional benefits are now being realised in a reduction in costly blood wastage.
More information on the implementation can be found via the following link Full Blood Tracking Project
The background to the implementation of the Electronic Discharge Summary System was to improve the patient discharge process ensuring a smooth transition of care for patients when they leave hospital after an inpatient admission. An electronic solution was developed and tested and a 6 week pilot commenced in May 2007, followed by Trust-wide roll-out over the next 6 months. The new system now delivers benefits in terms of:
After an audit found that very few young women with lower abdominal pain were being tested for chlamydia to rule out PID, this protocol was developed and implemented through the hospital to reduce medical errors. There has been a recent legal case where a woman presented to hospital with lower abdo pain and was not tested for chlamydia, and as a result became infertile. It is hoped that this protocol will help prevent similar cases in the future.
Chlamydia Poster The authors of the poster are Kimberly Bruce (F2), Karla Blee (F2), Mr Peter Greenhouse (Consultant in Sexual Health).
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