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Showing results for tags 'Health and safety'.
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Content ArticlePatient safety groups consider surgical fires “never events,” incidents that can be avoided entirely with organisational checks and balances. Yet, the Canadian Medical Protective Association (CMPA) has handled dozens of lawsuits and regulatory complaints involving surgical burns in recent years. According to a review of 54 cases of perioperative burns between 2012 and 2016, almost a third involved surgical fires, while the rest involved burns from surgical equipment and chemicals used in surgery. Many patients were left scarred, disfigured and psychologically traumatised. Fifteen percent were severely harmed, with airway damage or full-thickness burns destroying the sensory nerves and all layers of the skin.
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News ArticleHealth products powered by artificial intelligence, or AI, are streaming into our lives, from virtual doctor apps to wearable sensors and drugstore chatbots. IBM boasted that its AI could “outthink cancer.” Others say computer systems that read X-rays will make radiologists obsolete. Yet many health industry experts fear AI-based products won’t be able to match the hype. Many doctors and consumer advocates fear that the tech industry, which lives by the mantra “fail fast and fix it later,” is putting patients at risk and that regulators aren’t doing enough to keep consumers safe. Early experiments in AI provide reason for caution, said Mildred Cho, a professor of pediatrics at Stanford’s Center for Biomedical Ethics. Systems developed in one hospital often flop when deployed in a different facility, Cho said. Software used in the care of millions of Americans has been shown to discriminate against minorities. And AI systems sometimes learn to make predictions based on factors that have less to do with disease than the brand of MRI machine used, the time a blood test is taken or whether a patient was visited by a chaplain. In one case, AI software incorrectly concluded that people with pneumonia were less likely to die if they had asthma an error that could have led doctors to deprive asthma patients of the extra care they need. “It’s only a matter of time before something like this leads to a serious health problem,” said Steven Nissen, chairman of cardiology at the Cleveland Clinic. Read full story Source: Scientific American, 24 December 2019
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Content ArticleSuperabsorbent polymer gel granules are used to reduce spillage onto bedding and clothing when patients use urine bottles or vomit bowls, or when staff move fluid-filled containers (eg washbowls or bedpans). If the gel granules are put in the mouth, they expand on contact with saliva risking airway obstruction. This National Patient Safety Alert requires any organisation still using these products to protect patients by introducing strict restrictions on their use.
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Content Article
Medical negligence: Diathermy burns
Patient Safety Learning posted an article in Legal matters
If you have suffered a diathermy burn during surgery, you will probably have a number of questions that need to be answered. For example, why did you wake up from surgery with a burn on your skin? Is this the fault of your surgeon? And is there any action you can take?- Posted
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Content ArticleFor over three decades, patients, consultants and perioperative staff have been exposed to diathermy tissue smoke in all operating hospital theatres. This smoke is called plaque and, when inhaled, is the same as smoking cigarettes. Research shows that inhalation of smoke from one gram of cauterised tissue is equal to smoking six cigarettes. This smoke is also cancerous and can mutate to other organs of the body just like cigarettes. Read my personal view of the harmful effects of diathermy smoke published in the Journal of Perioperative Practice, and also watch the short video kindly made for me by Knowlex UK.
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- Operating theatre / recovery
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A dropped instrument, washed in theatre and immediately reused: a story from a theatre nurse
Anonymous posted an article in By health and care staff
What happens if a surgeon accidentally drops an instrument on the floor, picks it up and reuses, without it going through a steriliser? Should this be allowed to happen? Well it did!- Posted
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Electrosurgery. Managing the risk (September 2004)
Patient Safety Learning posted an article in Surgery
This poster from the National Association of Theatre Nurses (ATN) aims to give an overview of electrosurgery in the perioperative setting. It identifies and defines some of the common forms of electrosurgery used in perioperative practice and identifies some of the hazards that can be associated with these products.- Posted
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Content ArticleEAST for Health & Safety: Applying behavioural insights to make workplaces safer is a report from the Behavioural Insights Team. The EAST framework focuses on four simple principles to encourage a behaviour: make it Easy, Attractive, Social and Timely (EAST).
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Content ArticleFollowing a reported death, the National Patient Safety Agency (NPSA) commissioned the Health and Safety Executive to undertake fire hazard testing with white soft paraffin on a variety of bandages, dressings and clothing. The results showed the ability to reproduce the fire hazard in a controlled environment. This risk was not previously well recognised.
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Content ArticleA workbook published by Health and Safety Executive (HSE), for employers, unions, safety representatives and safety professionals.
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Content ArticleIn January 2017, I read an article in Outpatient Surgery involving an elderly patient in the US who suffered multiple burns following the use of chlorohexidine bottled alcoholic prep. The Oregon woman filed a million-dollar lawsuit against the Oregon Outpatient Surgery Center in Tigard, Ore., saying she suffered severe burns when her face caught on fire during an electrocautery procedure. Having read this tragic story and escalated it to my theatre manager and colleagues, I decided to design and evaluate a FRAS (Fire Risk Assessment Score) and use it as part of the WHO Surgical Checklist at "time out" to raise awareness of fires in operating theatres.
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Content ArticleThis guidance is issued by the Health and Safety Executive, the Institution of Engineering Technology and the British Computer Society. Following the guidance is not compulsory but if you do follow the guidance you will normally be doing enough to comply with the law in Great Britain where this is regulated by the Health and Safety Executive (HSE). HSE inspectors seek to secure compliance with the law and may refer to this guidance as illustrating good practice.
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Content Article
Swab safe management to prevent retained swabs
Kathy Nabbie posted an article in Improving systems of care
Implementation of the Swabsafe™ management system at the The Princess Grace Hospital following a never event.- Posted
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Content ArticleCIRAS (Confidential Reporting for Safety) is a safety charity for the transport industry. They look at a range of concerns affecting the health, wellbeing and safety of staff, passengers or the public. The concerns raised through their hotline often have common themes – non-compliance, equipment issues, fatigue, security and working conditions – and they share this learning and good practice across the CIRAS community. Some of this learning and good practice can be applied to other industries and organisations, including healthcare. Each month, CIRAS publish a newsletter: Frontline Matters, with articles on health and safety.
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Content ArticleThis report from Saaiq and colleagues, published in the Annals of Burns and Fire Disasters, highlights three cases of iatrogenic electrocautery burns with review of the relevant published literature. The aim is to prompt awareness among surgeons and theatre staff regarding this avoidable hazard associated with the equipment frequently used for the purpose of electrocautery. This may serve as a reminder to professionals to be cautious about the pitfalls that lead to such preventable injuries.
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- Operating theatre / recovery
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Content ArticlePublished in the BMJ journal Quality & Safety, the authors draw out high-level learning about culture and behaviour in NHS organisations; what influences culture and behaviour; and what needs to change to give effect to the vision of a safe, compassionate service in which patients and their families could have trust and confidence.
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- Quality improvement
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Content ArticleISO 45001 is an international standard for health and safety at work developed by national and international standards committees independent of government. Introduced in March 2018, it replaces the current standard (BS OHSAS 18001) which will be withdrawn. Businesses have a three-year period to move from the old standard to the new one. You're not required by law to implement ISO 45001 or other similar management standards, but they can help provide a structured framework for ensuring a safe and healthy workplace.
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Content ArticleSmoking or a naked flame could cause patients’ dressings or clothing to catch fire when being treated with paraffin-based emollient that is in contact with the dressing or clothing. The Medicines and Healthcare products Regulatory Agency (MHRA) provided this update for healthcare professionals.
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Content Article"It’s time to halt, take a break, and redraw the relationship between patient care and self-care. Self-care isn’t an optional luxury. It must sit at the heart of what we do, to ensure our teams can continue to rise to the challenges of working in the 21st century NHS, to give our patients the best of both ourselves, and the organisation so many of us are proud to be a part of."
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Content ArticleFrimley Health NHS Foundation Trust have devised a patient leaflet to help patients play a role in their safety while at the hospital.
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- Patient
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Content Article
Delirium - What NOT to do
Claire Cox posted an article in Care settings
This infographic designed by Dr Dan Thomas and Dr Lynda Dykes gives advice on what NOT to do if your patient has delirium.- Posted
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Content ArticlePatients with delirium have changes in their thinking and are often confused and cannot pay attention. About half of patients in an intensive care unit (ICU) have delirium during their stay. Research has shown that patients with delirium are more likely to die or to have long-term brain problems, including posttraumatic stress disorder, depression and other mental health issues, than those without delirium. Although nurses and doctors have tools to measure delirium in the ICU, it can be hard to identify and, in some cases, may be missed. Family members may be the first to notice that their loved ones have changes in their thinking or cannot pay attention. There are tools called the Family Confusion Assessment Method (FAM-CAM) and Sour Seven questionnaire that can be used by family members to detect delirium. However, neither of these tools has been used in an ICU. This study from Krewulak et al., published in CmajOPEN, shows that these tools can be used by family members to measure delirium in the ICU. The results from this study could lead to a change in policy that would involve partnering with family members to improve the diagnosis of delirium in the ICU. In turn, this would improve patient and family care and outcomes in the ICU.
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Content ArticleThis guideline from the National Institute for Health and Care Excellence (NICE) covers preventing and controlling healthcare-associated infections in children, young people and adults in primary and community care settings. It provides a blueprint for the infection prevention and control precautions that should be applied by everyone involved in delivering NHS care and treatment.
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News Article
Man dies after being sucked into an MRI machine
Patient Safety Learning posted a news article in News
An unfortunate series of events involving a magnetic resonance imaging (MRI) machine led to the death of a man at a hospital in India. Rajesh Maruti Maru, a 32-year-old, was thrust into the MRI machine while he was visiting an elderly relative at the BYL Nair Charitable Hospital in Mumbai, India. As the Hindustan Times reports, the man was apparently told by a junior member of staff to carry a metal cylinder of liquid oxygen into a room containing an MRI machine. Unbeknownst to everyone, the MRI machine was turned on. This caused Maru to be suddenly jolted pulled towards the machine, causing the oxygen tank to rupture and leak. The man later died after inhaling large amounts of oxygen. His body also bled heavily as a result of the accident. "When we [the hospital staff] told him that metallic things aren't allowed inside an MRI room, he said 'sab chalta hai, hamara roz ka kaam hai' [it's fine, we do it every day]. He also said that the machine was switched off. The doctor, as well as the technician, didn't say anything,” Harish Solanki, Maru's relative, told NDTV. "It's because of their carelessness that Rajesh died," Solanki added. Police are currently examining the CCTV footage of the incident and have arrested at least two members of hospital staff for the negligence. The local government has also awarded the man's family 500,000 rupees ($7,855) in compensation. Read full story Source: IFL Science, 29 January 2018- Posted
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