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Create a Safer
Anticoagulation Process - Learning from Others |
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Syd Stewart,
Managing Director of 4s Dawn Clinical Software, reports:
"I recently attended a talk on creating safer processes in major
hazards installations. The interesting point that came out of
the presentation was that before several well known incidents,
management staff had known about the potential risk.
For example, in 1987 a fire on an escalator at Kings Cross
Station in London resulted in the death of 37 people. In the
years leading up to this event, 20 similar escalator fires per
year had been reported, but no action was taken to examine how
this could be avoided.
In 2000, the Concorde crashed in Paris, due to a tyre bursting
and throwing debri at the fuel tank, which then burst into
flames. Previous to this, 57 incidents of tyres bursting had
been recorded, 6 of which had burst the fuel tank.
BP suffered
from a major US refinery fire in Texas, USA, and had tracked the
metrics relevant to their process safety. However, BP did not
understand or accept what these indicated about the risk of a
major event for the company.
It is important to learn from other disciplines - do you measure
the overall performance of your safety systems? (See the last
story in this newsletter edition). Have you interpreted what
this really means in terms of risk?"
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Backing up Your Data - Are
you Backing Up Regularly? |
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As most of
you know, backing up your patient data is essential to
protect it in the event of a system crash, power cut, etc
where data can be lost. But do you know how often your data is
being backed up, if at all?
For Dawn
AC version 7 users, backups can be scheduled to run
automatically so that this is taken care of for you. However,
you should periodically check that scheduled backups are still
running and have not stopped if maintenance work or updates
have been performed on the server.
If you would like any advice on how to set this up, or need
any assistance with backing up data on any version of Dawn AC,
then please contact us at
support@4s-dawn.com or
call us on
015395 63091
and we will be more than happy to help you.
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Benchmarking Scheme in
Progress |
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 The 21st
run of the Benchmarking is currently taking place. The primary
focus of our Benchmarking Service is to provide a forum for
benchmarking of pertinent operational and clinical performance
or outcome measures indicators to support and enhance the
clinical practice of each member organisation.
It enables
your organization to identify areas for improvement and
provide a means of continuously monitoring progress in these
areas.
If you would like to know more about our benchmarking scheme
or are already involved and would like some assistance getting
the data to us, then please email us at
support@4s-dawn.com.
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Home INR Monitoring as
Effective as Clinic-Based Monitoring, but Risks of Events
the Same |
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Results of a Home INR study presented at the American Heart
Association 2008 Scientific Sessions recently revealed that
regular (weekly) home INR monitoring is safe, but does not
reduce the number of bleeds, strokes or death compared to
clinic-based monthly testing.
The study compared 2922 patients with atrial fibrillation or
mechanical valves, with one group attending monthly clinic
visits to have their INR taken, and another group taking their
own INRs weekly and using an interactive voice-response system
and web-based local monitoring.
Dr. Alan K Jacobson, study cochair, commented,"..while there was
no evidence of patient harm with patients self-testing, we could
not identify a benefit as large as the hypothesized 1.75%
absolute reduction in total major events, even though the total
number of events exceeded what was hypothesized".
Dr David B Matchar, another cochair, concluded, "We suggest that
these results support that home INR testing is an acceptable
alternative to high-quality anticoagulation management, such as
in an anticoagulation clinic, and it may be preferable when
patient access is difficult, such as might occur with patients
with disabilities or [patients who live at a] geographic
distance".
To read more of this article, please follow the link below:
http://www.theheart.org/viewArticle.do?primaryKey=921079
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Drug Dose Mistakes Lead to Woman's Death
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The Health and Disability Commision in New Zealand found
that errors made by rest home care staff had resulted in
the death of a woman, who suffered from a major stroke.
The woman, 89, was discharged from hospital in 2007
after having suffered from, among other things, an
irregular heartbeat and pneumonia. Whilst in hospital
the woman had been prescribed warfarin after developing
a blood clot.
A catalogue of errors then occured:
- The new manager of the care home failed to pass on the
prescription onto the pharmacy and GP, so some drugs
were missed.
- The nurse looking after the woman mistakenly gave her
1mg of warfarin instead of the recommended 3 or 4mg,
after mis-reading the dose instruction.
- The next day, another duty nurse decided to stop the
warfarin altogether until the woman's next appointment
with her doctor, as she found the GP's dose instructions
too confusing.
Five days after the woman was discharged, she was
finally given the correct dose, but sadly suffered from
a major stroke on day 6 and died a few weeks later.
Jan Featherston, an expert nursing advisor, commented,
"a series of errors starting at the admission procedure
caused the multiple drug errors".
To read more of this article, please follow the link
below:
http://www.stuff.co.nz/stuff/4768984a20475.html
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Natural Supplements Best
Avoided for Children Taking Warfarin |
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The Canadian Cardiovascular Congress announced recently that the
risk of bleeding and clots may be raised in children taking
warfarin when they are also given vitamins, natural products or
herbs.
Dr. Patti Massicotte, director of the pediatric thrombosis
program at the Stollery Children's Hospital in Edmorton,
commented that little research has been carried out on the
possible drug interactions between warfarin and these products,
and said, "The problem is that the anticoagulant action of
warfarin is unpredictable on its own, so adding dietary
supplements to that can be a challenge. Sometimes that product
is the straw that breaks the camel's back and could push
children into high-risk situations."
To read more of the article, please follow the link below:
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New Method For Detecting the Cause of Strokes is
Explored
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A study carried out by researchers at the Allegheny General
Hospital (AGH) in Pittsburgh recently examined the use of
mobile cardiac telemetry over a 2 - 3 week period in
patients who have suffered an unexplained stroke or
transient ischemic attack.
Although atrial fibrillation is believed to be the main
factor in patients suffering a stroke, nearly a third of all
stroke sufferers had not had any obvious problems previous
to the episode which could have caused the event.
56 patients were monitored during the study, and it was
found using mobile cardiac telemetry that 23% of these
patients had either prolonged or brief episodes of atrial
fibrillation. Currently patients are only monitored for AF
for a few days whilst in hospital, which makes discovering
the disease more difficult.
Dr Tayal, the medical director of AGH's Comprehensive Stroke
Center, commented, "If we can indeed identify AF more
promptly in these cases, our ability to treat patients and
perhaps prevent a second, more catastrophic injury would be
significantly enhanced".
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Start Analyzing your Data Like
Never Before |
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Tableau is a robust software
solution that can help users measure the quality of care,
patient safety, financial
performance and productivity. The software not only allows
users to mine their data warehouse and analyse clinical
incidents, but it also makes it easier to create statistical
reports, reduce clinical audit times, monitor bed utilisation
and meet government targets.
You can use Tableau to:
-
marshall
and interpret your data
- view trends & other patterns
- provide statistics and summaries
- answer questions & provide insights into your data
- identify outliers & variation
We are proud
to announce we have teamed up with Tableau Software (awarded
"Product of the Year" by both PC Magazine & SQL Server Magazine)
and are delighted to be able to offer a trial of this innovative
and user-friendly software up until the middle of December.
If you think
that you or any of your colleagues may have a need to analyse
some data that is currently residing in a spreadsheet or an
Access database etc, why not ''have a go'' and click on the
following link below to begin:
http://www.4s-dawn.com/Tableau
You can watch a 5 minute demonstration video on this site and
download a free trial of the software. If you have any
difficulty downloading the software or have any queries, please
call us on 015395 63091 (internationally
4415395 63091) or email us at
support@4s-dawn.com.
Also, if you know any managers or clinicians keen on analyzing
data, please tell them about Tableau!
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