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Found 110 results
  1. Event
    Understanding human factors will allow surgical teams to enhance performance, culture and organisation of operating theatres. This one day masterclass will concentrate on human factors within the operating room. This is aimed at all theatre staff. It will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This Masterclass will focus on systems to improve patient safety as well as looking at never events and how to learn from them using a human factors approach. Key learning objectives: Safety culture Human factors Leadership Never events This masterclass is aimed at all theatre staff. Register hub members receive 20% discount using code hcuk20kh.
  2. Content Article
    In this BMJ opinion piece, Scarlett McNally discusses the revised National Safety Standards for Invasive Procedures (NatSSIP2). The original NatSSIPs were designed to prevent “never events”—yet more than 300 occurrences of wrong site surgery, retained objects after procedure, or wrong implant insertion still occur yearly in the UK.  NatSSIP2 brings in safety science and human factors, with expectations for organisations including standardisation, harmonisation, training, and audit. "The biggest danger is if the new standards sit on the shelf. With their benefits for patient safety and teamworking, we must accept the repetitive elements and consistently apply these new standards, every time, in every department", writes Scarlett.
  3. Content Article
    The original National Safety Standards for Invasive Procedures (NatSSIPs) were published in 2015. Understanding of how to deliver safe care in a complex and pressurised system is evolving. These revised standards (NatSSIPs2) are intended to share the learning and best practice to support multidisciplinary teams and organisations to deliver safer care. The Centre for Perioperative Care shares their slideset on the revised standards.
  4. Content Article
    The original National Safety Standards for Invasive Procedures (NatSSIPs) were published in 2015. Understanding of how to deliver safe care in a complex and pressurised system is evolving. These revised standards (NatSSIPs2) are intended to share the learning and best practice to support multidisciplinary teams and organisations to deliver safer care.
  5. Content Article
    This report considers the number of safety incidents in surgery occurring in the NHS since 2015 and calls for action to improve surgical safety. It also highlights the perceptions of patients from a survey of people who have had surgery in the last five years. It is authored by surgical care platform Proximie, with support from experts in the surgical space.
  6. News Article
    A record number of "foreign objects" have been left inside patients' bodies after surgery, new data reveals. Incidents analysed by the PA news agency showed it happened a total of 291 times in 2021/22. Swabs and gauzes used during surgery or a procedure are one of the most common items left inside a patient, but surgical tools such as scalpels and drill bits have been found in some rare cases. A woman from east London described how she "lost hope" after part of a surgical blade was left inside her following an operation to remove her ovaries in 2016. The 49-year-old, who spoke to PA on condition of anonymity, said: "When I woke up, I felt something in my belly. "The knife they used to cut me broke, and they left a part in my belly." She added: "I was weak, I lost so much blood, I was in pain, all I could do was cry." The object was left inside her for five days, leading to an additional two-week hospital stay. Commenting on the analysis, Rachel Power, chief executive of the Patients Association, said: "Never events are called that because they are serious incidents that are entirely preventable because the hospital or clinic has systems in place to prevent them happening. "When they occur, the serious physical and psychological effects they cause can stay with a patient for the rest of their lives, and that should never happen to anyone who seeks treatment from the NHS. "While we fully appreciate the crisis facing the NHS, never events simply should not occur if the preventative measures are implemented." Read full story Source: Sky News, 4 January 2022
  7. News Article
    A hospital is investigating how a pair of metal surgical forceps were left inside a patient after they had been stitched up after abdominal surgery. Worcestershire Acute Hospitals NHS trust has apologised unreservedly and said the incident at Redditch’s Alexandra hospital was “exceptionally rare”. The medical blunder only became apparent after a seven-hour abdominal procedure last month, according to BBC Midlands, when the forceps were reported to be missing. The worst fears of medics were confirmed when the missing 15cm arterial clamp was found by an X-ray while the patient was still under anaesthetic. The surgical instrument could not be immediately removed and the patient was moved to intensive care overnight before another operation was performed the next day to retrieve the clamp. It is understood the trust’s investigation will look at whether the required double-checking of all instruments was conducted before the patient was stitched up after surgery. It will also examine the end of operation signing-out process, which is supposed to ensure such errors do not happen. Read full story Source: The Guardian, 23 December 2022
  8. Event
    Never events are defined as “serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.” They are designed to act as a red flag for improvement by NHS organisations. This one day masterclass will focus on safety culture around Never Events within healthcare organisations. There were 364 never events in 2020/21 and 349 between April 2021 and Jan 2022. The masterclass will look at how Never Events have been investigated and at Human Factors approaches to improving learning and the systems to reduce harm. It will compare our experiences with learning from serious incidents from other countries. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/learning-from-never-events or email kate@hc-uk.org.uk. hub members receive a 20% discount, Email info@pslhub.org for discount code.
  9. Content Article
    This paper asked healthcare workers who are considered to be theatre safety experts—theatre managers, matrons and clinical educators—to take part in the second round of a Delphi study. These individuals work at the coalface in operating theatres and deliver the surgical safety checklist daily. It addresses information raised as part of a Delphi study of NHS hospital operating theatres in England. The aim of the second Delphi study round was to establish the views of theatre users on the theatre checklist and local safety standards for invasive procedures. Likert scale responses and a combination of closed and open-ended questions solicited specific information about current practice and researched literature that generated ideas and allowed participants freedom in their responses of how the World Health Organisation’s (WHO's) Surgical Safety Checklist (SSC) is currently being used in the peri-operative setting as part of a strategy to reduce surgical ‘never events’. The paper is part of a literature review undertaken by the author towards a Doctor of Philosophy (PhD). Read the findings of round one of the Delphi study
  10. Content Article
    This paper addresses information raised as part of a Delphi study of NHS hospital operating theatres in England. The aim of the first Delphi study round was to establish how the World Health Organisation’s Surgical Safety Checklist (SSC) is currently being used in the peri-operative setting as part of a strategy to reduce surgical ‘never events’. It used a combination of closed and open-ended questions that solicited specific information about current practice and research literature, that generated ideas and allowed participants freedom in their responses. The study asked theatre managers, matrons and clinical educators that work in operating theatres and deliver the surgical safety checklist daily, and who are therefore considered to be theatre safety experts. Participants were from the seven regions identified by NHS England. The study revealed that the majority of trusts don’t receive formal training on how to deliver the SSC, checklist champions are not always identified, feedback following a ‘never event’ is not usually given and that the debrief is the most common step missed. While the intention of the study was not to establish whether the lack of training, cyclical learning and missing steps has led to the increased presence of never events, it has facilitated a broader engagement in the literature, as well highlighting some possible reasons why compliance has not yet been universally achieved. Furthermore, the Delphi study is intended to be an exploratory approach that will inform a more in-depth doctoral research study aimed at improving patient safety in the operating theatre and informing policy making and quality improvement.
  11. News Article
    A consultant urologist left a 6.5cm swab in a patient after surgery and failed to identify it in a scan three months later, an inquiry has heard. The public inquiry concerns the work of Aidan O'Brien at the Southern Trust between January 2019 and June 2020. It heard Mr O'Brien endangered or potentially endangered lives by failing to review medical scans. He previously claimed the trust provided an "unsafe" service and was trying to shift blame on to its medics. On Tuesday, the inquiry into Mr O'Brien's clinical practice heard almost 600 patients received "suboptimal care". Counsel for the inquiry Martin Wolfe KC said the 6.5cm swab was left inside a patient by Mr O'Brien during a bladder tumour operation in July 2009. The error was described as a "never event'. At a CT scan appointment three months later in October 2009, a mass inside the patient's body was discovered by the reporting consultant radiologist. While he did not say it was a swab, he did "highlight the abnormality", said Mr Wolfe. A report was sent to Mr O'Brien but, the Inquiry heard, he did not read it and no one took steps to check out the abnormality. Read full story Source: BBC News, 9 November 2022
  12. News Article
    A teenager died after a breathing tube was possibly squashed by a wheel of her hospital trolley during emergency surgery, an inquest has heard. Jasmine Hill, 19, had a cardiac arrest shortly after undergoing a procedure on her neck at Gloucestershire royal hospital in Gloucester. The inquest heard that a report commissioned by lawyers acting for Hill’s family referred to the tube being “squashed by the wheel of a trolley”. Hill, from Cirencester, had been readmitted to the hospital after her neck became swollen five days after a thyroidectomy – the removal of all or part of the thyroid gland – in September 2020. Doctors thought the site of the surgery in Hill’s neck, which was red and swollen, may have become infected and it was decided the wound should be cleaned under general anaesthetic. The procedure took less than an hour and the teenager went into cardiac arrest shortly after she was moved by staff from the operating table to a bed. Gloucestershire coroner’s court heard an endotracheal tube, which supports breathing, was positioned behind Hill’s head and away from her neck, fixed to a holder and connected to the ventilator. The assistant Gloucestershire coroner Roland Wooderson asked Dr Hiro Ishii, who carried out the procedure, whether he was aware that the anaesthetist had checked the position of the endotracheal tube. Ishii replied: “I didn’t make a formal inquiry at that stage.” Read full story Source: The Guardian, 7 November 2022
  13. 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. Kathy tells us about the importance of breaking down barriers to share patient safety tools, and talks about changes she has implemented to make surgery safer.
  14. News Article
    Hundreds of patients with metallic implants narrowly avoided death or serious injury after being wrongly referred for MRI scans, an investigation revealed yesterday. The powerful magnets used in the machines can displace and damage metallic items such as pacemakers, ear implants and aneurysm clips. Doctors should question patients and check medical records before requesting a scan because of the risk of injury. But hospitals in England recorded 315 near-misses from April 2020 to March 2022 involving patients sent for an MRI. An MRI scan at Mid Yorkshire Hospitals Trust was ditched after staff confirmed the skin over the patient’s pacemaker had begun heating up. Another patient – at Wrightington, Wigan and Leigh Trust – told staff about a metal plug implanted in their nose only after the scan had begun. Many of the incidents involved forms being filled out incorrectly on behalf of elderly and disoriented patients. At East Kent Hospitals University Trust, a patient described as ‘not compos mentis’ was given the all-clear by a care home nurse and again by a clinician for MRI – only for staff to realise at the last moment that metal clips were implanted in their chest. Information about the incidents was obtained using freedom of information requests. Helen Hughes of Patient Safety Learning, said: "It is vital that near-misses are regularly reported, their causes understood, and that this learning is acted on to prevent future avoidable harm." Read full story Source: MailOnline, 15 October 2022
  15. News Article
    Surgical blunders have soared 60% in five years – and extreme mistakes are now a daily occurrence in the NHS. Some 13,921 people were treated for damage caused by botched operations in the year to March 31 – up from 8,695 in England in 2016/17. Cases involved an “unintentional cut, puncture, perforation or haemorrhage”. Separately, a report from NHS England shows 134 patients fell victim to so-called Never Events from April 1 to July 31. Extreme errors included two women left infertile after their ovaries were wrongly removed. Injections and invasive tests were given to the wrong patients and in 39 cases foreign objects, such as drill bits and wires, were left inside bodies. There were 57 cases of surgery on the wrong body part and 12 instances of patients being given the wrong implant or prosthesis. The Royal College of Surgeons in England said: “If the system is overstretched, there is a risk that mistakes will happen.” Rachel Power, chief executive of the Patients Association, said: “When Never Events occur, the physical and psychological effects can stay with a patient for life.” Read full story Source: The Mirror, 1 October 2022
  16. Content Article
    In this blog, Nigel Roberts, who is a registered Allied Health Professional theatre lead at the University Hospitals of Derby and Burton (which has in excess of 50 operating theatres and performs over 50,000 procedures annually), considers the current challenges facing all operating theatre staff post pandemic. Nigel looks at how human factors may influence the delivery of the surgical safety checklist, and discusses whether Local Safety Standards for Invasive Procedures (LocSSIPs) are making a difference in terms of the number of intra-operative Never Events being reported.
  17. Content Article
    This literature review in The Operating Theatre Journal examines why the decision was made not to class surgical fires as a 'Never Event', even though research has identified them as a preventable hazard. The author also examines steps that could be taken to further reduce the risk of surgical fires in the NHS and other health systems. You will need to create a free online account to view this article.
  18. Content Article
    Research undertaken by digital health platform, CAREFUL shows that handover in hospitals is the cause of frequent and severe harm to patients.
  19. Content Article
    Never Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers are following national guidance and safety recommendations. In this blog John Tingle, a lecturer at Birmingham Law School, raises concerns about the number of Never Events that continue to take place within health services, the lack of public awareness about Never Events and the need to develop a safety culture that allows learning from Never Events to actually take place.
  20. News Article
    A fifth patient has been given the wrong blood at a major teaching hospital’s haematology department where patient safety concerns were raised by clinicians last year. The incident, at University Hospitals Birmingham Foundation Trust, is the fifth never event involving patients being transfused with the wrong blood at the trust since April 2020. Only 15 such never events have been recorded in England in the last two financial years, which means UHB accounted for a third of the total in 2020-21 and 2021-22. HSJ revealed last year that several clinicians had raised safety concerns at the trust’s haematology specialty after most of its services at Heartlands Hospital were moved to Queen Elizabeth Hospital as part of the trust’s pandemic response. The latest never event, which occurred in March, saw a patient being given an “unintentional transfusion of ABO-incompatible blood components” – according to papers provided to the trust’s council of governors. Read full story (paywalled) Source: HSJ, 14 June 2022
  21. Content Article
    According to new data released by the NHS, a total of 379 medical malpractices called ‘Never Events’ were recorded between 1 April 2021 and 28 February 2022. The term is defined by the service as “serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.” See below Statista's chart representing the data.
  22. News Article
    A woman who had her ovaries removed by mistake was one victim of the hundreds of “never events” that occurred in the NHS over the past year. Between April 2021 and March 2022 more than 400 patients in England’s hospitals suffered errors so serious that they should never have happened according to data released by NHS England. They include the wrong hips, legs, eyes and knees being operated on, and diabetic patients being given too much insulin. Foreign objects were left inside 98 patients after operations, including gauzes, swabs, drill guides, scalpel blades and needles. Vaginal swabs were left in patients 32 times and surgical swabs were left 21 times. Other objects left inside patients included part of a pair of wire cutters, part of a scalpel blade, and the bolt from surgical forceps. On three separate occasions part of a drill bit was left in a patient. “Wrong-site surgery” was carried out on 171 patients and six patients had injections to the wrong eye. The wrong hip implant was put in 12 times, a wrong knee implant was performed 11 times, and patients were connected to air instead of oxygen 13 times. Seven patients were given the wrong type of blood during a transfusion. Some patients were given doses of drugs that were far too high, including the immunosuppressant methotrexate, which is used for severe arthritis, psoriasis and leukaemia. There were 11 overdoses of insulin. Read full story (paywalled) Source: The Times, 19 May 2022
  23. Content Article
    Never Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations. This document details Never Events that were reported by NHS trusts in England between 1 April 2021 and 31 March 2022. Never Events are categorised by type of incident and by trust.
  24. Content Article
    Van Thai Tuyen was admitted to the Royal London Hospital on 1 August 2021 for treatment of a stroke. A nasogastric tube was inserted to administer medication and food, due to Mr Tuyen being assessed as having an unsafe swallow. Despite an x-ray showing that the nasogastric tube had been misplaced into his right lung the tube was used to administer approximately 300ml of liquid feed. This caused the cavitating necrotising pneumonia from which he died.
  25. Content Article
    AHRQ PSNet is looking for interesting, provocative cases that illustrate key issues in patient safety such as medication errors, diagnostic errors, and adverse events that either had the potential for or resulted in patient harm. Cases from outpatient, ambulatory surgery, home health, long-term care, and rehabilitation settings are of particular interest. When a case is selected, the editorial team invites an expert author to write a commentary based on the case. Please note that case submitters do not receive any “authorship” because case submissions are anonymous. However, submitters of selected cases will receive a $300 honorarium. The AHRQ Patient Safety Network (PSNet) is a national web-based resource featuring the latest news and essential resources on patient safety. 
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