Orientações para o Cuidado e Controle da Tuberculose e Tuberculose Multirresistente - 3ª Edição - ICN

O Conselho Internacional de Enfermeiros (ICN) anunciou a publicação da 3ª edição de Orientações Actualizadas para os enfermeiros que trabalham nos Cuidadose Controle da Tuberculose e Tuberculose Multirresistente.

Estas orientações destinam-se a ajudar os enfermeiros no seu importante papel de detecção de casos de tuberculose (TB), na prestação de cuidados e gestão do tratamento da TB.

Este documento estabelece uma abordagem de enfermagem para o planeamento e prestação de assistência ao doente, visando melhorar o acesso e a qualidade dos cuidados durante todo o período de tratamento.

O documento está (infelizmente) em inglês, mas há semelhança de outros documentos, poderá em breve ser traduzido para o português.

Fica aqui a partilha.

CDC Video - Stop the Spread of Antibiotic Resistance

CDC have recently released a video that demonstrates how antibiotic-resistant germs spread between healthcare facilities, including those that practice infection control and antibiotic stewardship.

The, "CDC Vital Signs: Stop the Spread of Antibiotic Resistance," video also spotlights a coordinated approach to reduce germs and infections.

According to the CDC's latest mathematical modeling, the number of drug-resistant infections, including Clostridium difficile infections, is expectedto rise if no immediate, nationwide infection control and antibiotic prescription improvements are made. The research found that a coordinated response could reduce infections by 74 percent over five years.

Of course, all this can only be achieved if there is an honest and frank collaboration between the various institutions providing health and social support.

Questions to consider

• What are the measures implemented in my institution to ensure that the information on resistant microorganisms to antibiotics is transmitted to other institutions when the patient is transferred or discharged?
• When a patient is transferred to my institution, we received this information?

Checklists - Why are they failing?

In the beginning the initial trials involving the implementation of hospital checklists seemed to result in lower infection rates, lower mortality rates and fewer post-surgical complications, long-term analyses of the success of such checklists in many hospitals are getting uninspiring results, according to an article from Nature.

Incident – Orthopedic Implant “out-of-date” applied to the patient

Brief description of the incident:

On July 2015, Hospital X receives a box of implant material "counter-consumption", that is, the hospital only pay the material consumed.

The box with the material was delivered by a competent company, which has certified "quality".

During a surgical intervention the implant material was applied to the patient.

After surgery, implant data is sent to the provisioning service to be introduced into the system for later payment.

The supply system does not allow the introduction of the material data, stating that this material would be " out-of-date ".

Issues:

Presentation "The Checklist Paradox", by Lorelei Lingard

Today I want to recommend the viewing of a brilliant presentation, made by Lorelei Lingard, titled

"The Paradox Checklist".

In her presentation, Lorelei tells us about not one, but of three paradoxes on the use of checklists, and in particular of the "surgical checklist".

Who can claim to have no difficulty in ensuring the implementation of this tool? And even when getting high compliance levels of 95% or more, who does not have the knowledge that patients are really not safer because of it?

Do not be discouraged by the time (45 minutes presentation + 11 minutes of questions and answers). It´s really worth listening to, and perhaps it will help you to improve our practice.

(Click on the image to access the presentation)

Manual Prático de Avaliação do Risco / Practical Guide for Risk Assessment

Patient Safety / Segurança do Doente

After overcoming 40,000 views (and we are very grateful to you) we chose to make a change.

The change is in our name: Segurança do Doente / Patient Safety

We make this change consciously assuming the scope of a larger concept

According to WHO the simplest definition of patient safety “is the prevention of errors and adverse effects to patients associated with health care. While health care has become more effective it has also become more complex, with greater use of new technologies, medicines and treatments. Health services treat older and sicker patients who often present with significant co-morbidities requiring more and more difficult decisions as to health care priorities. Increasing economic pressure on health systems often leads to overloaded health care environments.

We also like the definition of LindaEmanuel (et. all), that says that “Patient safety is a discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Patient safety is also an attribute of health care systems; it minimizes the incidence and impact of, and maximizes recovery from, adverse events.”

We could share and discuss other definitions, but in essence all of them refer to “safety healthcare”.

It is the sharing of this knowledge and experience, and the path traveled, that we have done from day one, from the first "post" on February 4, 2011.

And that's what we will continue to do.

Once again thank you all for reading us and spread the "Patient Safety".

NGS publishes an updated list of Never Events 2015-2016

(Author of the text: NHS)

A revised Never Events Policy and Framework was published on 27 March 2015, this includes changes to the definition of what a Never Event is and adjustments to the types of incident that are included on the Never Events list, reducing the list from 25 to 14 incident types.

Never Events are serious incidents that are wholly preventable as guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.

Each Never Event type has the potential to cause serious patient harm or death. However, serious harm or death is not required to have happened as a result of a specific incident occurrence for that incident to be categorised as a Never Event.

 The never events list 2015/16

SURGICAL

1. Wrong site surgery

2. Wrong implant/prosthesis

3. Retained foreign object post-procedure

MEDICATION

4. Mis – selection of a strong potassium containing solution

5. Wrong route administration of medication

6. Overdose of Insulin due to abbreviations or incorrect device

7. Overdose of methotrexate for non-cancer treatment

8. Mis – selection of high strength midazolam during conscious sedation

MENTAL HEALTH

9. Failure to install functional collapsible shower or curtain rails

GENERAL

10. Falls from poorly restricted Windows

11. Chest or neck entrapment in bedrails

12. Transfusion or transplantation of ABO-incompatible blood components or organs

13. Misplaced naso- or oro-gastric tubes

14. Scalding of patients

The original information and additional information can be found here: http://www.england.nhs.uk/ourwork/patientsafety/never-events/

What Can We Learn From Stories of Self-Diagnosis?

O que podemos aprender com as histórias de Doentes que definem o seu próprio diagnóstico, quando os médicos não o conseguem fazer?

Isso é o que podemos descobrir nesta newsletter (em inglês) que contêm histórias bem interessantes e principalmente sobre a importância de uma COMUNICAÇÃO eficaz de parte-a-parte.