Trust-Level Risk Evaluation and Risk Control Guidance in the NHS East of England

In recent years, the healthcare sector has adopted the use of operational risk assessment tools to help understand the systems issues that lead to patient safety incidents. But although these problem-focused tools have improved the ability of healthcare organizations to identify hazards, they have not translated into measurable improvements in patient safety. One possible reason for this is a lack of support for the solution-focused process of risk control. This article describes a content analysis of the risk management strategies, policies, and procedures at all acute (i.e., hospital), mental health, and ambulance trusts (health service organizations) in the East of England area of the British National Health Service. The primary goal was to determine what organizational-level guidance exists to support risk control practice. A secondary goal was to examine the risk evaluation guidance provided by these trusts. With regard to risk control, we found an almost complete lack of useful guidance to promote good practice. With regard to risk evaluation, the trusts relied exclusively on risk matrices. A number of weaknesses were found in the use of this tool, especially related to the guidance for scoring an event's likelihood. We make a number of recommendations to address these concerns. The guidance assessed provides insufficient support for risk control and risk evaluation. This may present a significant barrier to the success of risk management approaches in improving patient safety. © 2013 Society for Risk Analysis.

Guidewire retention following central venous catheterisation: a human factors and safe design investigation.

BACKGROUND: Central Venous Catheterisation (CVC) has occasionally been associated with cases of retained guidewires in patients after surgery. In theory, this is a completely avoidable complication; however, as with any human procedure, operator error leading to guidewires being occasionally retained cannot be fully eliminated. OBJECTIVE: The work described here investigated the issue in an attempt to better understand it both from an operator and a systems perspective, and to ultimately recommend appropriate safe design solutions that reduce guidewire retention errors. METHODS: Nine distinct methods were used: observations of the procedure, a literature review, interviewing CVC end-users, task analysis construction, CVC procedural audits, two human reliability assessments, usability heuristics and a comprehensive solution survey with CVC end-users. RESULTS: The three solutions that operators rated most highly, in terms of both practicality and effectiveness, were: making trainees better aware of the potential guidewire complications and strongly emphasising guidewire removal in CVC training, actively checking that the guidewire is present in the waste tray for disposal, and standardising purchase of central line sets so that differences that may affect chances of guidewire loss is minimised. CONCLUSIONS: Further work to eliminate/engineer out the possibility of guidewires being retained is proposed.

Directly-modulated DS-DBR tunable laser for uncooled C-band WDM system

A tunable DS-DBR laser is demonstrated for uncooled WDM C-band channel generation with tight spacing (SOGHz) and low thermal drift (±2.5GHz) up to 70°C. 2.5Gb/s direct modulation with transmission over a 75km link is achieved. © 2000 Optical Society of America.

INFLUENCE OF MICROSTRUCTURE ON THE TOUGHNESS OF CARBON FIBRE/PLASTIC COMPOSITES.

A preliminary study is presented of the relationship between the microstructural aspects of failure and the fracture energy G//1//C for cracking parallel to the fibres in long-fibre/thermoplastic matrix composites. Fracture energies are measured by a new technique, and fracture surfaces generated by the test are examined by scanning electron microscopy.

INFLUENCE OF MICROSTRUCTURE ON THE TOUGHNESS OF CARBON FIBRE/PLASTIC COMPOSITES.

A preliminary study is presented of the relationship between the microstructural aspects of failure and the fracture energy G//l//C for cracking parallel to the fibres in long-fibre/thermoplastic matrix composites. Fracture energies are measured by a new technique, and fracture surfaces generated by the test are examined by scanning electron microscopy.