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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 -
Content ArticleThis toolkit created by The National Academies of Sciences, Engineering and Medicine contains information and resources to help patients learn about and engage in the diagnostic process. There are many barriers to patients fully engaging in their diagnosis, and this toolkit aims to help patients take control of their role in the process, as well as equipping healthcare providers to create an atmosphere that allows patients to contribute meaningfully.
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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 ArticleThis Joint Committee International handbook offers checklists for healthcare staff to keep themselves safe from chemical and physical hazards, infectious agents, workplace violence, ergonomic problems, work-related stress, and more. The book also includes managers’ checklists to ensure that the right administrative controls and processes are in place to safeguard health care staff. All checklists are based on authoritative, evidence-based sources that have proven valuable. All the checklists are straightforward and easy to use and understand and cover the key areas of risk for health care workers. Each section of checklists is introduced by compelling statistics that show how dangerous working in the healthcare environment can be, without proper precautions. The checklists provide the procedures or must-do activities to ensure that health care workers are as safe as can be.
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Content ArticleThe prevalence of facility-based childbirth in low-resource settings has increased dramatically during the past two decades, yet gaps in the quality of care persist and mortality remains high. The World Health Organization (WHO) Safe Childbirth Checklist, a quality-improvement tool, promotes systematic adherence to practices that have been associated with improved childbirth outcomes. This study, published in The New England Journal of Medicine, found that birth attendants’ adherence to essential birth practices was higher in facilities that used the coaching-based WHO Safe Childbirth Checklist program than in those that did not, but maternal and perinatal mortality and maternal morbidity did not differ significantly between the two groups.
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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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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 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 ArticleHaugen et al. studied the impact of the Norwegian National Patient Safety Campaign and Program on Surgical Safety Checklist (SSC) implementation and on safety culture. They found that the National Patient Safety Program, fostering engagement from trust boards, hospital managers and frontline operating theatre personnel enabled effective implementation of the SSC. As part of a wider strategic safety initiative, implementation of SSC coincided with an improved safety culture.
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Content Article
When a patient can’t breathe by themselves, healthcare staff may decide to intubate them to make it easier to get air into and out of the lungs. A tube goes down the throat and into the windpipe, and a machine called a ventilator pumps in air with extra oxygen. It can be life-saving, but life-threatening complications can also occur during a significant number of these procedures. Sam Goodhand is a registrar in the Sussex region, specialising in anaesthetics and intensive care medicine. In this interview for Patient Safety Learning he tells us how and why he developed an accessible checklist for staff involved in intubation processes. -
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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Content Article
Dr Gordon Caldwell believes that patient safety should be an active process of checking for avoidable errors. In this blog for the hub, he describes how he developed a checklist for his ward rounds and how this became incorporated into the daily clinical review notes to ensure that all the important aspects of care on a team’s routine ward rounds are actively addressed. -
Content ArticleThe Health Protection Agency has suggested that one in ten hospital patients experiences an incident that puts their safety at risk, around half of which could be prevented, and the RCN has identified the need to reduce nurses’ paperwork considerably. This article reports a successful project that set out to tackle these two issues by developing a risk-based nursing assessment system that is simple to use, reduces unnecessary paperwork and reduces the risk of harm to patients. It outlines how the initiative was introduced, as well as obstacles encountered during the process. The risk-assessment tool received positive feedback from nursing staff as it reduces paperwork while providing a risk-based assessment of care needs.
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Content ArticleThe Chartered Institute of Ergonomics and Human Factors (CIEHF) has launched an oxygen safety campaign aimed at people working at patient bedsides within hospitals. They have consulted with clinicians, fire safety experts and a wide range of allied professional bodies to design the campaign, which has been launched in response to the anticipated national surge in hospital patients as a result of the Omicron variant. Inevitably, the use of oxygen will be very high and issues such as oxygen leakage can cause major fire risks.
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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 ArticleMost healthcare organisations (HCOs) find diagnostic errors hard to address. Singh et al. developed a checklist (the Safer Dx Checklist) of 10 high-priority safety practices HCOs can use to conduct a proactive risk assessment to address diagnostic error.
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Content ArticleThis investigation aims to improve patient safety by supporting healthcare staff in a surgical setting to select and insert the appropriate type of implant (vascular graft) for haemodialysis treatment. The Healthcare and Safety Investigation Branch (HSIB) explored the factors that affect the ability of staff to safely select and insert vascular grafts for haemodialysis treatment. The national investigation focused on: The identification of factors within the healthcare system as a whole that influence patient safety risks associated with the selection and insertion of vascular grafts in an operating theatre environment. Exploration, using a systems approach, of the design of labelling and packaging used for the different types of vascular grafts for patients on haemodialysis treatment. Exploration of the impact on operating theatre teams of staff redeployment and repurposing of working environments in response to the COVID-19 pandemic.
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Content Article
PIT stop (prosthesis/implant timeout) checklist
Nigel Roberts posted an article in Surgery
The PIT stop (prosthesis/implant timeout) checklist is Birmingham Women's and Children's NHS Trust's visual and aid memoir. It was launched to limit 'human error' and thus preventing never events (wrong implant/prosthesis). The four steps cover the intra-operative stages when implants are required. It works by recording what is requested on a small, hand held white board, and works in harness with the NatSSIPs 8, specifically step 5 of the infographic that has been previously developed. -
Content ArticleThis paper from Roberts et al. examines the application of the Surgical Safety Checklist (SSC) within NHS hospital operating theatres England. The aim of the study, through a combination of open-ended questions, was to solicit specific information including views and opinions from operating theatre experts to establish from how the World Health Organisations (WHO) SSC is being applied, and therefore and why intraoperative ‘Never Events’ continue to occur more than a decade after the SSC was introduced. Participants were from the seven regions identified by NHS England. The intention of this paper is not to establish definitively whether the quantitatively identified themes; including a lack of training and engagement with human factors explains the increased presence of intraoperative ‘Never Events’. However, these themes, when subjected to methodological triangulation with the current literature, do appear consistent, and therefore provide an exploratory approach to inform research intended to improve safety in the operating theatre by informing policy and its application to safe practice ultimately towards quality improvements.
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News Article
Patients must be warned of breast implant risks, FDA says
Patient Safety Learning posted a news article in News
A decade after scientists identified a link between certain implants and cancer, the US Food and Drug Administration has ordered “black box” warnings and a new checklist of risks for patients to review. Federal regulators have placed so-called black box warnings on breast implant packaging and told manufacturers to sell the devices only to health providers who review the potential risks with patients before surgery. Both the warnings and a new checklist that advises patients of the risks and side effects state that breast implants have been linked to a cancer of the immune system and to a host of other chronic medical conditions, including autoimmune diseases, joint pain, mental confusion, muscle aches and chronic fatigue. Startlingly, the checklist identifies particular types of patients who are at higher risk for illness after breast implant surgery. The group includes breast cancer patients who have had, or plan to have, chemotherapy or radiation treatments. That represents a large percentage of women who until now were encouraged to have breast reconstruction with implants following their treatment. Reactions to the new requirements were mixed. While some doctors welcomed the new warning system, others worried that the potential risks and side effects would not be conveyed adequately by plastic surgeons who were eager to reassure patients the procedure is safe and that the new checklist would be handled in a dismissive manner. But Dr. Mark Clemens, a professor at M.D. Anderson Cancer Center in Houston who serves a liaison to the F.D.A. for the American Society of Plastic Surgeons Society, said the black box warning and checklist represented “a huge step forward for patient safety and implants.” Read full story Source: The New York Times, 27 October 2021 -
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 -
News Article
Annual checks can lengthen life
Patient Safety Learning posted a news article in News
A group set-up following the Winterbourne View scandal is urging more people with learning disabilities to attend their annual health check-up. Healthwatch South Gloucestershire said regular health checks could prevent people from dying unnecessarily. It formed after BBC Panorama exposed abuse of patients at Winterbourne View hospital 10 years ago. Only about 36% of people with learning difficulties are believed to have an annual GP health check-up. The Local Democracy Reporting Service (LDRS). said the lack of regular, medical observations contributed to them having a life expectancy of 20 years lower than in the wider population. Healthwatch South Gloucestershire, a regional, independent health and social care champion, has created a checklist to encourage more people to attend appointments to help them improve their life expectancy. Vicky Marriott from the group said: "It is our unrelenting mission to listen and share people's lived experience so that the information informs how health and social care services improve. "We recently listened to people with learning disabilities and their families and developed with them an accessible info-sheet packed full of easy-to-read explanations about the lifesaving benefits of annual health checks." Read full story Source: BBC News, 1 June 2021 -
Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Annie talks to us about her work training teams in safety behaviours, why productivity and safety must go hand-in-hand, and how working on patient safety is like running a marathon. -
Content ArticleEvery day we use tools and resources to manage our lives, both personally and professionally. As a healthcare professional, you are committed to providing safe quality healthcare to all individuals. The checklists in this book are designed to help you succeed in that effort. You may be a first-time reader who has not had the opportunity to put these tools to the test, or you could be a returning reader interested in what new checklists you can use. In either instance, if you’re reading this book, then you are searching for tools to help your healthcare organisation navigate the increasing complexities of providing quality health care and maintaining the physical environment where healthcare is delivered.
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Content Article
Human factors - Safer surgery checklist (June 2022)
Patient-Safety-Learning posted an article in Surgery
This literature review in The Operating Theatre Journal looks at 'How industry has helped healthcare better understand human factors'. The author, Nigel Roberts, Theatre Lead at the University Hospitals of Derby and Burton, looks at this question in relation to teamwork, leadership, situational awareness, communication and culture.
