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Content ArticleIn 2009, the World Health Organization (WHO) published the WHO Surgical Safety Checklist, and 3 years later, the Swiss Patient Safety Foundation adapted it for Switzerland. Several meta-analyses and systematic reviews showed ambiguous results on the effectiveness of surgical checklists. Most of them assume that the study checklists are almost identical, but in fact they are quite heterogeneous due to adaptations to local settings. In this study, Fridrich et al. aims to investigate the extent to which the checklists currently used in Switzerland differ and to discuss the consequences of local adaptations.
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Content ArticlePatients are more likely to experience preventable harm during perioperative care than in any other type of healthcare encounter. For several decades, a hallmark of surgical quality and safety has been the use of checklists to prevent errors (eg, wrong site surgery) and assure that key tasks have been or will be performed. There are widely disseminated arguments recommending the use of checklists in healthcare but also recognised limitations. In this editorial, Matthew B. Weinger discusses the use of the checklist and its limitations.
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News Article
Trust warned by regulator after cluster of never events
Patient Safety Learning posted a news article in News
The Care Quality Commission has ordered immediate improvements to a trust after it reported six never events inside eight months. The watchdog has issued a warning notice to Royal Cornwall Hospitals Trust after it carried out an announced inspection which focused on the trust’s surgical care group – where six never events had occurred between February and October last year. In November, HSJ reported that a total of eight never events had been recorded in 2020, with trust chief executive Kate Shields saying it had raised fears the trust had not fully embedded safety improvements initiated as part of the special measures regime. The inspectors visited three of the trust’s sites where the never events had happened. These were: Royal Cornwall Hospital in Truro, St Michael’s Hospital in Hayle and West Cornwall Hospital in Penzance. The inspectors reported that governance processes were “not effective enough” to ensure that changes were made across the trust, and that lessons from incidents and near misses were “not shared with the whole team and wider service to ensure patient safety”. Their report also stated the trust’s safety checklist for surgical procedures had improved but was not fully compliant with the World Health Organisation’s standards. However, the CQC found staff apologised and provided patients with information when things had gone wrong, and that there was an open culture in which staff felt able to raise concerns. Read full story (paywalled) Source: HSJ, 17 February 2021 -
Content ArticleThe Patient Safety Database (PSD), previously called Anesthesia Safety Network, is committed in the delivery of better perioperative care. Its primary goal is to make visible the lack of reliability of healthcare and the absolute necessity to build a new system for improving patient safety. They have begun by developing an open and anonymous incident reporting system focused on non-technical skills. Each quarter they summarise in their newsletter cases reported on the platform. Read the latest newsletter.
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Content Article
WHO: Anaesthesia safety checklist
Patient Safety Learning posted an article in Surgery
Anaesthesia safety checklist from the World Health Organization (WHO) covering: before induction of anaesthesia operating room operative procedure list postoperative care. -
Content ArticleDr Gordon Caldwell shares his hospital ward round sheet attached which follows a standard process, including quality and safety checking. Feel free to adapt.
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Community Post
Ward-patient eQMS with error recovery protocols saves many thousands of lives globally
Derek Malyon posted a topic in Improving patient safety
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Overview Human error (HE) in global medicine kills 2.6 million annually placing patient safety on the G20 Summit (1). Solutions available (a) more staff training dominated by a HE-rate of about one error in 200 tasks and (b) a simple computer system used by high reliability organisations such as Banking with zero HE. With 70% of adverse events occurring on wards, patients should electronically acknowledge each intervention with their wristband-data. Missed interventions now detectable are compellingly alarmed reducing the consequences of HE 10,000 fold. Problem: The Healthcare sector have no “HE Recovery Protocols” on their wards (2a) This massive management error is punishable with fines and imprisonment across every other sector including Nuclear Rail Shipping etc. by the CPS here in the U.K. HE recovery protocol for ward-patient safety The patient is placed in a computerised quality-loop enabling them to acknowledge received MDT interventions by tagging their personal wristband-data back to the computer care plan. Missed interventions easily detected by the software-checklist now compellingly alarmed on-screen in front of health worker and patient. Nigh impossible to ignore, missed interventions are corrected, reducing the consequences of HE by more than a factor of ten thousand (104) (2b). Example: Opioid overdose prevention Software analyses patient's analgesic ladder. Their previously tagged opioid consumption displayed with opioid headroom warning. The patient tags acknowledging and updating the new opioid volume correctly administered. The system would have saved 450 Gosport patients 30-years ago, and currently under live investigation by Police (Operation Magenta). Conclusion Placing the ward patient in a computer driven tagged quality loop significantly reduces HE-consequences improving compliance lowering death rates adverse events bed-days and litigation. The tag system has a long-standing pedigree too. U.K. Bank customers have electronically tagged 30 million times a day, keeping accounts healthy and error free for decades. Please could colleagues on the hub help the NHS/CQC understand this established Industrial H&S concept with a view to trialling it. (Sums: 2.6m/10,000=2600 saving 2,597,400 annually?) References: [1] The cost of patient safety inaction: Why doing more of the … A .M. Alhawsawi. Patient Safety Hub 2020. [2a] The Blame Machine. R B Whittingham. ISBN 0-7506-5510-0. Industrial H&S. https://books.google.co.uk/then type “5.3 error recovery ” (page 74-75). [2b] https://books.google.co.uk/ then type “1. compelling feedback ” (page 78-79). Compelling feedback reduces HE by a factor of 10,000. Foot note: Sometimes whole industries become unwilling to look too closely at system faults and the blame machine swings into action. Pity the individual health worker not protected by management HE recovery protocols. https://books.google.co.uk/ type “The blame machine preface xii” last two paragraphs and xiii. Derek Malyon. 24.11.2020. Ward-Patient eQMS with Error Recovery Protocols.3 pdf.pdf- Posted
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Content Article
Prostate Cancer UK: risk checker
Patient Safety Learning posted an article in Men's health
Prostate cancer is the most common cancer in men, but most men with early prostate cancer don’t have symptoms. So what should you do? Click the link below and and answer three quick questions to find out. -
Content ArticleEvidence suggests that full implementation of the WHO surgical safety checklist across NHS operating theatres is still proving a challenge for many surgical teams. The aim of the current study from Charles Vincent and colleagues was to assess patients’ views of the checklist, which have yet to be considered and could inform its appropriate use, and influence clinical buy-in.
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Content ArticleThis checklist is the first step in identifying and prioritizing areas of action for improving the protection of health and safety of health workers in line with WHO–ILO Global Framework for National Occupational Health Programmes for Health Workers. It is designed to be filled out in discussion with management, responsible officers for occupational health, environmental health, infection prevention and control, human resources and representatives of workers in the health facility. This participatory approach will provide a variety of perspectives and a more comprehensive basis for identifying the existing preventive measures, possible problems and solutions for continuous improvement. Using this checklist to begin this process will give you an overview of areas where you can propose to take action and help you determine what to prioritize. These priorities guide you in planning for improvements.
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Content ArticleWhen you are receiving treatment, it is important to feel that you are in safe hands. The Private Healthcare Information Network (PHIN) website publishes information on a range of patient safety measures, including about serious safety incidents. One category of these are known as Never Events. Here we explain what Never Events are, why they are measured, and how you can use them when considering which hospital is right for you.explain what Never Events are, why they are measured, and how you can use them when considering which hospital is right for you.
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Content ArticleDr Abdulelah Alhawsawi, Abdominal Organs Transplant and Hepato-biliary Surgeon, and Director General of the Saudi Patient Safety Center, discusses why hospitals are falling short of safe care levels. He believes healthcare continues to be structurally weak when it comes to the safety conditions and suggests that there is an urgent need for a paradigm shift in the way we think about patient safety and how we implement it while providing healthcare. In his essay, Dr Alhawsawi proposes four practical solutions.
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Content ArticleThis video looks at design and implementation of emergency checklists for rapid sequence induction (RSI) in the emergency department and intensive care unit: Where we've gone wrong, why the evidence shows no benefit, and how we can improve. It is presented by Michael Lauria who was a Pararescueman (PJ) in the US Air Force and Critical Care/Flight Paramedic for the Dartmouth-Hitchcock Advanced Response Team (DHART) . Currently he is an Emergency Medicine resident at the University of New Mexico Health Sciences Center.
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Content ArticleDouble checking medication administration in hospitals is often standard practice, particularly for high-risk drugs, yet its effectiveness in reducing medication administration errors (MAEs) and improving patient outcomes remains unclear. This systematic review of studies, published in BMJ Quality & Safety, evaluates evidence of the effectiveness of double checking to reduce MAEs.
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Content ArticleThis info-graphic by the Faculty of Pain Medicine is a safety checklist for Interventional Pain Procedures under local anaesthesia or sedation. This has been adapted from the World Health Organization surgical checklist.
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Content ArticleThis checklist from the Health and Safety Executive provides typical elements to score culture, particularly applicable for larger organisations.
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Content ArticleIn April 2009 a 'considerative checklist' was developed to ensure that all important aspects of care on a team's routine and post-take general internal medicine ward rounds had been addressed and in order to answer the question: How long should a ward round take, when conducted to high standards of quality and safety at the point of care? The checklist has been used on 120 ward rounds: 90 routine ward rounds and 30 post-take ward rounds. Overall, the average time per patient was 12 minutes (10 minutes on routine rounds and 14 minutes on post-take rounds). The considerative checklist has encouraged and enabled documented evidence of high quality and safe medical care, and anecdotally improved team working, communication with patients, and team and patient satisfaction.
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News ArticleEarly warning scores are used in the NHS to identify patients in acute care whose health is deteriorating, but medics say it could actually be putting people in danger. The rollout of an early warning system used in hospitals to identify patients at the greatest risk of dying is based on flawed evidence, according to a study published in the BMJ which suggests that much of the research supporting the rollout of NEWS was biased and overly reliant on scores that could put patients at greater risk.. Medical researchers said problems with NHS England's National Early Warning Scores (NEWS) system had emerged "frequently" in reports on avoidable deaths. The system sees each patient given an overall score based on a number of vital signs such as heart rate, oxygen levels, blood pressure and level of consciousness. Doctors and nurses can then prioritise patients with the most urgent NEWS scores. But some professionals have argued that the system has reduced nursing duties to a checklist of tasks rather than a process of providing overall clinical assessment. Professor Alison Leary, a fellow of the Royal College of Nursing and chair of healthcare and workforce modelling at London South Bank University, told The Independent: “In our analysis of prevention of future death reports from coroners, early warning scores and misunderstanding around their use feature frequently". “It's clear that some organisations use scoring systems and a more tick box approach to care as they lack the right amount of appropriately skilled staff, mostly registered nurses.” “Early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care,” the authors of the research conclude. “Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice.” Read full story Source: The Independent, 21 May 2020
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Content ArticlePrevious research suggests that surgical safety checklists (SSCs) are associated with reductions in postoperative morbidity and mortality as well as improvement in teamwork and communication. These findings stem from evaluations of individual or small groups of hospitals. Studies with more hospitals have assessed the relationship of checklists with teamwork at a single point in time. The objective of this study from Molina et al. was to evaluate the impact of a large-scale implementation of SSCs on staff perceptions of perioperative safety in the operating room. They concluded that a large-scale initiative to implement SSCs is associated with improved staff perceptions of mutual respect, clinical leadership, assertiveness on behalf of safety, team coordination and communication, safe practice, and perceived checklist outcomes.
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Content ArticleThe purpose of this document, from the Chartered Institute of Ergonomics and Human Factors, is to provide health and social care teams with advice and guidance on the human-centred design of work procedures such as written instructions, checklists or flow charts during this period of 'crisis management' in response to COVID-19 and to support the design and re-design of care services and new ways of working. Implementation of the guidance will contribute to safer and easier to use procedures, which better support how people work and reduce risks to themselves, patients, carers and others.
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Content ArticleIn a crisis, normal processes must often be modified to ensure that the best possible care is provided while ensuring the safety of patients and personnel despite limited resources. ECRI has collated resources that include preparation checklists, patient handling checklists, equipment lists, lists of alternative suppliers, recommendations for patient care equipment such as ventilators, and recommendations for infection control.
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Content ArticleThe OneTogether Quality Improvement Resources are intended to provide practical information for implementing best practice for each of the elements of care across the surgical pathway. These resources can be used as stand‑alone documents, but are recommended to be used in conjunction with the OneTogether Assessment Toolkit. The OneTogether Assessment Toolkit is designed to measure adherence to best practice to prevent surgical site infection (SSI). Following completion of the OneTogether Assessment, healthcare professionals will be able to identify areas of low compliance and develop a prioritised action plan for improvement. The Quality Improvement Resources summarise the evidence underpinning recommended practice and provide a competency assessment checklist. The information they contain is drawn from evidence-based guidelines or expert recommendations from professional bodies
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Content Article
'Storm in a Checklist'
Kathy Nabbie posted an article in Surgery
Kathy Nabbie reflects on the recent flights caught up in Storm Dennis and how 'routine' quickly became 'out of the ordinary'. As with aviation, in surgery we must always do the safety checks for each patient to ensure that every journey for the patient is a safe one. -
Content ArticleThis checklist, recommended by the Association of Anaesthetists, with accompanying guidance is written to ensure the correct functioning of draw-over anaesthetic equipment and is important to patient safety.
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News Article
‘Dr. Checklist’ Peter Pronovost gets chance to transform University Hospitals
Patient Safety Learning posted a news article in News
The ghosts of medical errors haunt Dr. Peter Pronovost. Two deaths, both caused by mistakes. First, his father’s, who died as the result of a cancer misdiagnosis. Then a little girl, a burn victim who succumbed to infection and diagnostic missteps at the hospital where Pronovost worked early in his career. Those deaths led Pronovost to pursue a medical career dedicated to patient safety, and to create the medical checklist he has become known for worldwide. Now, he’s implementing his second act, at University Hospitals in the USA, as its Chief Transformation Officer, a job he has held since late 2018. His goal: To transform a $4 billion health care system by reducing shortcomings in medical care and increasing the quality of treatment. The challenge fits Pronovost, says one of his former Johns Hopkins University professors, Dr. Albert Wu. “He’s one of the few people for whom the title might be appropriate, because his work has led to significant changes and innovations in how we deliver health care in the United States. “He’s a once-in-a-generation guy.” Read full story Source: Cleveland.com, 9 February 2020
