As many as 33.75% of patients with proximal upper limb deficiency rejected their prostheses and many who continue to wear them do not find them useful in ADL and employment, etc. It is vital that rehabilitation programmes should focus on both prosthetic and nonprosthetic training to achieve maximal independence.

The measurement and examination of adverse events (AEs) that occur in children during hospital admissions is essential if we are to prevent, reduce or ameliorate the harm experienced. The UK Paediatric Trigger Tool (UKPTT) is a method of retrospective case note review that measures harm in hospitalised children.ObjectivesTo examine the harm resulting from the processes of healthcare in hospitalised children from centres providing data to the National Health Service (NHS) Institute UKPTT data portal, to understand the positive predictive values of triggers and to make recommendations for the further development of the trigger tool.Setting25 hospitals across the UK, including secondary, tertiary and quaternary paediatric centres.ParticipantsRandomly selected children who were admitted to hospital for longer than 24 h.Outcome measuresThe primary outcome measure was the rate of harm (the percentage of children experiencing one or more AEs during a hospital admission). Secondary measures were the severity of harm and performance of triggers.ResultsData from 3992 patient admissions were reviewed across the hospitals and submitted to the trigger tool portal from February 2008 to November 2011. At least one AE was reported for 567 (14.2%) patients, with 211 (5.3%) experiencing more than one event. There were 1001 AEs identified. Where harm occurred, it was considered temporary for 923 (92.2%) AEs; however, 43 (4.3%) AEs resulted in the need for life-sustaining interventions, 18 (1.8%) AEs led to permanent harm and for 17 children (1.7% of AEs) the AE was believed to have contributed to death.ConclusionsThere is a significant, measurable level of harm experienced by children admitted to hospitals in the UK. While most of this harm is temporary, some of it is serious. The UKPTT offers organisations the means to measure and examine the AEs occurring in their hospital in order to reduce harm.

As an alternative to 'big bang' initiatives, plan-do-studyact (PDSA) cycles are an increasingly popular approach to conducting tests of change to support quality improvement in healthcare. Using PDSA cycles can help clinicians deliver improvements in patient care through a structured experimental approach to learning and tests of change. The PDSA approach facilitates individual, team and organisational learning, making it an essential tool for the future hospital. This paper provides an example of the benefi ts of using PDSA in practice to test and develop a change idea to ensure it is fi t for purpose. As with any new skill or competency, learning to use PDSA cycles takes time and practice and is necessary to ensure that the method is being used to its full effect. This paper explores some of the challenges encountered by clinicians in learning to use PDSA cycles well, and provides advice on how they can be overcome to help practitioners get more out of using the method.

ConclusionQuetiapine and rivastigmine seemed of no benefit in patients with dementia and agitation in institutional care, and quetiapine was associated with greater cognitive decline than placebo. Our results suggest that quetiapine should not be used in people with dementia and highlight concerns regarding the long term use of antipsychotics in these patients.We thank the Alzheimer's Research Trust for their support in our programme of work to evaluate the impact of antipsychotics on cognition; Alistair Burns for his helpful comments on the manuscript; and Andrea Burton for her helpful advice regarding the sensitivity analysis. Contributors: See bmj.com Funding: The study was funded largely from general donations to C Ballard's research programme and profits from previously completed commercially funded clinical trials, with additional support from the Alzheimer's Research Trust. Competing interests: C Ballard has received honorariums and research donations to support his general research programme from Astra Zeneca and Novartis. Ethical approval: The study was approved by a properly constituted local research ethics committee. One refusal (0.2%) was received. Consent rates were significantly better for children who were more severely ill on admission and for hospital stays of six days or more, and significantly poorer for children aged 10-14 years. Long hospital stays and children aged 10-14 years remained significant in a stepwise regression model of the factors that were significant in the univariate model. Conclusion Systematically obtaining individual signed consent for sharing patient identifiable information with an externally located clinical audit database is difficult. Obtaining such consent is unlikely to be successful unless additional resources are specifically allocated to training, staff time, and administrative support.

Stat medications are regularly prescribed on hospital wards as part of the ongoing care for patients. Because they are prescribed at variable times that do not coincide with regular nursing drug administration times, they rely on good communication and vigilance on staff to ensure they are administered in a timely manner. Delays in drug administration can lengthen patient recovery times, prolong admission, and can lead to avoidable patient harm and suffering.While working on a geriatrics ward I noticed that there were often significant delays in administration of stat medications which occurred on a regular basis. I therefore investigated this by collecting data over a two week period to assess the situation based on our current practice. After root cause analysis (figure 1), it became clear that communication between staff was a significant factor in delayed administration. A solution was implemented in the form of “ward bay wall charts” to aid documentation and communication of stat medication requirements between nursing and medical staff with the intention to reduce delays by improving communication.After gaining support of medical and nursing staff, a trial was undertaken and a further two weeks of data collected to see the effect of the intervention. The results showed that there was an increase in the median time delay (1 hour 34 minutes to 2 hours 26 minutes, a 55% increase in median time delay) after the implementation of the my intervention, suggesting that it actually made communication worse, creating more delays. Subsequent feedback and analysis showed that this was due to a number of factors that led to worsened communication between staff and therefore an increase in medication delays. Early recognition allowed the intervention to be promptly withdrawn and a re-assessment of the nature of the initial problem.This project highlights the importance of measurement in determining if an intervention actually works and is an improvement on current practice.