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Showing results for tags 'Operating theatre / recovery'.
Found 150 results
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News Article
‘Fifth of UK hospitals cancelled operations’ during three days of 2022 heatwave
Patient Safety Learning posted a news article in News
A fifth of UK hospitals were forced to cancel operations during the three days in July last year when temperatures soared, research suggests. The findings, published in a letter to the British Journal of Surgery, are based on surveys from surgeons, anaesthetists and critical care doctors working during the heatwave from July 16-19 2022, when temperatures reached as high as 40C in some parts of the country. The researchers received 271 responses from 140 UK hospitals – with one in five (18.5%) reporting elective surgeries being cancelled due to the heatwave. The respondents also said surgical services were poorly prepared for heatwaves, with 41% of operating theatres having no means to control ambient temperature, while more than a third (35.4%) reported making changes to maintain routine surgical activity during the period. These include delayed discharge of high-risk patients, changes to surgical teams, selecting lower-risk patients to have surgery, and restricting surgical activity to day cases. Other measures included longer staff breaks, extra fluids to patients, and surgeries earlier in the morning when temperatures were lower. Read full story Source: The Independent, 23 March 2023 -
Content ArticleThe 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.
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Content ArticleThis 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
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News Article
London surgeons complete record week’s worth of operations in one day
Patient Safety Learning posted a news article in News
Surgeons in a London hospital have performed a week’s worth of operations in a single day, pioneering a technique that could be used to help reduce the NHS backlog. The team at Guy’s and St Thomas’ hospital performed eight robot assisted radical prostatectomy operations in under ten hours, the highest number performed in a single day in the UK in one hospital. High Intensity Theatre lists (HIT) focus on one procedure at a time and seek to minimise the turnaround time between operations. Using two theatres, the surgeon can go between cases without having to wait for a patient to come in. This helps to cut the significant amount of time it takes for medics to anaesthetise a patient, set up equipment in the theatre and help them to recover – a process which sometimes takes longer than the operation itself. The team at Guy’s assembled a large team for the HIT list, which took place on 8 October. Each theatre had a team of around 1.5 times its usual size and staff were given very specific roles. By the time the list had reached the third patient, the turnaround time between operations had dropped as low as 32 seconds. Behind the scenes, staff in the control room used Proximie software to monitor activity in the theatre in real time. Dr Ben Challacombe, a consultant urological surgeon who performed the operations with his surgical consultant colleagues Paul Cathcart, Christian Brown, and Prokar Dasgupta, told the Standard that the success of the HIT list had given staff a “huge” morale boost. “Everyone pulled together to do the job, it really helped to energise the team. Morale has been hit by Covid and other issues, but people feel galvanised by doing something different.” Read full story Source: Evening Standard, 29 October 2022 -
News Article
NHS doing fewer operations as theatres go unused
Patient Safety Learning posted a news article in News
The push to tackle the hospital backlog is being undermined by the struggle to get services back to full strength. A BBC analysis shows the expected surge in new patients has not yet happened. Instead, the waiting list in England is growing because the NHS is carrying out fewer operations and treatments than it was before Covid, despite a government push to boost capacity. Surgeons said it was really frustrating as operating theatres were not being used due to a lack of beds and staff. They say it is not unusual to find surgery cancelled at the last minute as staff are unavailable or intensive care and ward beds are full with other patients. "It's tough on patients and tough on staff who want to get on and treat patients," said Tim Mitchell, vice-president of the Royal College of Surgeons of England. "Without treatment, the health of patients can deteriorate. Not only do we need to get back to where we were before the pandemic, we need to do more if we are going to tackle the backlog." Read full story Source: BBC News, 13 October 2022 -
News ArticleSurgical 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
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Content ArticleStandard operating procedures (SOPs) should improve safety in the operating theatre, but controlled studies evaluating the effect of staff-led implementation are needed. Morgan et al. evaluated three team process measures (compliance with WHO surgical safety checklist, non-technical skills and technical performance) and three clinical outcome measures (length of hospital stay, complications and readmissions) before and after a 3-month staff-led development of SOPs. They found that SOPs when developed and introduced by frontline staff do not necessarily improve operative processes or outcomes. The inherent tension in improvement work between giving staff ownership of improvement and maintaining control of direction needs to be managed, to ensure staff are engaged but invest energy in appropriate change.
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Content ArticleTraditional approaches to patient safety and handoffs need redesigning to acknowledge the different constraints, goals, and requirements necessary for each individual patient. There is no “one size fits all” approach to patient safety, handoffs or a perfect checklist. Despite the inherit complexity present in healthcare systems, we tend to reduce our thinking about handoffs into simple solutions of checklists and cognitive aids. In studies of these tools, their association with patient outcomes is unclear with mixed results in large studies. Incorporating general resilience engineering principles of visibility, understanding, anticipation, and learning provides new opportunities for increased patient safety. This involves situating the handoff in the context of the system - understanding the process of summarising pre-handoff and of developing understanding post-handoff, tracing flows of information and patients, and considering the role of feedback and control loops in the system. Direct observations, analysis of multiple outcomes, focus on patient evolving specific exceptions, reducing the number of handoffs, taking time for two-way discussions, and user-centred design and redesign may promote acceptability and sustainability of a new view of handoffs for improved patient safety.
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Content ArticleMaria Koijck's goal for this film was to create a movement within the pharmaceutical industry considering the waste it produces. In this film you see Maria lay in the middle of an incredible amount of waste from just one surgery, her surgery. In August 2019 Maria was diagnosed with breast cancer. Surgeons had to remove her entire left breast. After a successful recovery, she went to to have a deep lap surgery where they gave her an entire new breast of her own bodily materials. During this process she discovered that 60% of the surgery materials used for this operation is disposable. For example: the stainless steal scissors that are flown in from Japan, are used for one cut before they end up in the bin. Maria asked the doctors to collect all of the surgery materials used for her operation, to get a clear idea of how much it really was. She was shocked to see six bags full of plastic waste.
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Content Article
The IPP (Innovation, People and Practice) magazine
Patient Safety Learning posted an article in Surgery
Published 10 times a year by the Association for Perioperative Practice, the IPP covers a variety of topics relevant for perioperative practitioners. Ranging from news and information, special focus pieces, industry interviews and profiles of company leaders in an easy-to-read format. -
Content ArticleIn this blog, the Healthcare Safety Investigation Branch (HSIB) reflects on the recent publication of the new National Safety Standards for Invasive Procedures (NatSSIPs 2) by the Centre for Perioperative Care. It outlines how these standards can help NHS organisations provide safer care and reduce the number of patient safety incidents, including a comment on this from Deinniol Owens, Associate Director of National Investigations at HSIB.
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Content ArticleThe 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.
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Content ArticleThe Centre for Perioperative Care (CPOC) has published new safety standards (NatSSIPs2) to enable all hospitals in the UK to improve patient safety by applying a consistent and proportionate set of safety checks for all invasive procedures. Listen to the podcast from the Royal College of Anaesthetists on the new standards.
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News ArticleThousands of hospital surgeries are likely to be cancelled as NHS leaders prepare for unprecedented strike action, The Independent has been told. Most operations apart from cancer care are likely to be called off when nurses take to the picket line, with NHS trusts planning for staffing levels to be similar to bank holidays. Multiple sources say they are almost certain that the upcoming Royal College of Nursing ballot will result in strike action. Results are expected to be finalised on Wednesday. “Trusts are looking at the totality of it. It’s the waiting list that is going to be hit, massive questions over waiting lists, and we’re going to lose days of activity in terms of addressing that growing pressure. “The more we see strike action the harder it is, the risk is [that] the rate of recovery [of waiting list] slows.” They added: “The unions normally provide bank holiday cover and maintain emergency service basically.” Read full story Source: The Independent, 7 November 2022
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News Article
Hospital chiefs keen to restart operations as covid peak passes
Patient Safety Learning posted a news article in News
Several acute trust chief executives have told HSJ they are keen to resume more planned operations, as the peak of new coronavirus cases has passed and many hospital beds remain empty. Some trust leaders said they believed routine elective surgery could be restarted as early as next week. There is also tension between NHS hospitals — some of which are keen to resume their own planned care, especially the more urgent operations — and a desire to use private hospitals, which have been booked out by NHS England. The government said yesterday the number of people in hospitals with COVID-19 has fallen by 10% over the last week. Around 42% of acute beds are now unoccupied, according to figures seen by HSJ. The peak of new infection cases in hospitals was at about 3,000 on 1 April — the number is now about half that figure. However, there will be fears nationally about the NHS seeking to return to normal and being caught out by ongoing COVID-19 pressures, or by a second peak of infections. Read full story Source: HSJ, 24 April 2020 -
News Article
NHS trusts suspend life-saving organ transplants
Patient Safety Learning posted a news article in News
Major transplant centres have stopped performing many of their procedures due to the coronavirus pandemic, while the national coordinating body says a complete cessation “may only be days away”. Read full story (paywalled) Source: HSJ, 2 April 2020 -
News ArticleNHS hospitals have been told to cancel operations in an effort to free up 30,000 beds to create space for an expected surge in coronavirus patients. In a letter to NHS bosses today, NHS England said hospitals should look to cancel all non-urgent surgeries for at least three months starting from 15 April. Hospitals were given discretion to begin winding down activity immediately to help train staff and begin work setting up makeshift intensive care wards. Any cancer operations and patients needing emergency treatment will not be affected. The letter from NHS England Chief Executive Simon Stevens said: “The operational aim is to expand critical care capacity to the maximum; free up 30,000 (or more) of the English NHS’s 100,000 general and acute beds." In the meantime hospitals were told to do as much elective surgery, such as hip operations and knee replacements, as possible and to use private sector hospitals which it said could free up 12 to 15,000 beds across England. Sir Simon also said patients who did not need to be in hospital should be discharged as quickly as possible adding: “Community health providers must take immediate full responsibility for urgent discharge of all eligible patients identified by acute providers on a discharge list. For those needing social care, emergency legislation before Parliament this week will ensure that eligibility assessments do not delay discharge. Read full story Source: The Independent, 17 March 2020
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News Article
NHS prepares to cancel elective ops in readiness for covid-19 surge
Patient Safety Learning posted a news article in News
System leaders are telling hospitals to prepare for a potential suspension of all non-emergency elective procedures which could last for months, as they get ready for a surge in coronavirus patients. Senior sources told HSJ NHS England had asked trusts to risk stratify elective patients in readiness for having to suspend non-emergency work to free up capacity. HSJ understands trusts have been told to firm up their plans for how they would incrementally reduce and potentially suspend non-emergency operations, while also protecting “life saving” procedures such as cancer treatment. An announcement is expected soon, with patients affected given at least 48 hours notice. It has not been decided how long it might last for, as the duration of any surge in cases and acute demand is unknown. But HSJ has been told it could stretch out for several months, with three or four months discussed, which would potentially mean tens of or even hundreds of thousands of cancelled operations. Read full story (paywalled) Source: HSJ, 12 March 2020 -
News Article
Call for action following latest 'Never Events' report
Patient Safety Learning posted a news article in News
The Association for Perioperative Practice (AfPP) is calling for action to be taken after a recent report suggests little progress has been made to prevent errors within the perioperative environment. The patient safety charity made the call following the release of NHS Improvement’s latest Never Event report; Provisional publication of Never Events reported as occurring between 1 April and 31 December 2019, which revealed an alarming 81% (284) of the never events recorded happened while a patient was on the operating table. Lindsay Keeley, patient safety and quality lead at AfPP said: “The survey highlighted that there’s a need to take action now if we are to support the healthcare profession in reducing the occurrence of never events. It has become clear that receptive team culture, a strong leadership team and better support for staff is what will help to reduce the risk of a never event occurring. It’s vital that those in leadership positions begin to understand the contributory factors in the recurrence of never events and the challenges faced by staff." She went on to highlight some of the recent initiative taking place: “What is promising is that there are practitioners who are developing new, practical and simple solutions every day that can support other team members and can be used within theatres across the country." "One example is Rob Tomlinson’s introduction of the 10,000 Feet initiative – a safety initiative designed to cut through noise and distraction within the theatre environment, particularly at critical points of the patient’s journey. If correctly implemented, initiatives like this can cut through the hierarchies that stop people feeling unable to speak up when they see something that shouldn’t be happening, thus reducing the occurrence of never events" “We of course need to be mindful that there will always be challenges within perioperative practice in the form of interruptions and distractions, but the key is how as practitioners we engage with this to recognise and reduce never events.” Read full story Source: Clinical Services Journal, 25 February 2020 -
News ArticleA baby with a serious heart condition has died after she received an infection from mould in a Seattle hospital's operating room, her mother says. Elizabeth Hutt was born with a heart condition that she battled for the entirety of her six-month-long life. The young child underwent three open heart surgeries, and after the third one is when it's believed she contracted an Aspergillus mould infection in the hospital's operating room. The mould in the hospital's operating rooms was first detected in November, around the same time as the child's third surgery. It was later determined the infection was contracted from the mould discovered in three of the 14 operating rooms at the hospital in November. The mould came from the hospital's air-handling units in the operating rooms, and 14 patients have developed infections from the mould since 2001, the hospital revealed. Seven of those 14 children have since died from their infections. Elizabeth's parents have joined a class action suit against Seattle Children's Hospital in January, which alleges facility managers knew about the mould since 2005 and failed to fix the problem. Read full story Source: The Independent, 14 February 2020
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News Article
India: When a ‘never event’ hits a patient
Patient Safety Learning posted a news article in News
A young woman was left with a retained foreign object, after surgery in an India hospital. A checklist could have avoided her death. The response from the health officials was: “We have issued a show-cause notice to the staff seeking an explanation. We will initiate departmental action based on their replies and finding of our inquiry.” In the fields of healthcare quality and patient safety, such punitive measures of “naming and shaming” have not worked. T.S. Ravikumar, President, AIIMS Mangalagiri, Andhra Pradesh, moved back to India eight years ago with the key motive to improve accountability and safety in healthcare delivery. He believes that we have a long way to go in reducing “preventable harm” in hospitals and the health system in general. "We need to move away from fixing blame, to creating a 'blame-free culture' in healthcare, yet, with accountability. This requires both systems design for safe care and human factors engineering for slips and violations". "Providing safe care without harm is a 'team sport', and we need to work as teams and not in silos, with mutual respect and ability to speak up where we observe any deviation or non-compliance with rules, says Ravikumar. Basic quality tools and root-cause analysis for adverse events must become routine. Weekly mortality/morbidity conferences are routine in many countries, but not a routine learning tool in India. He proposes acceleration of the recent initiative of the DGHS of the Government of India to implement a National Patient Safety Framework, and set up an analytical “never events” or sentinel events reporting structure. Read full story Source: The Hindu, 12 January 2020 -
News Article
Hywel Dda cancels operations after 'critical pressures'
Patient Safety Learning posted a news article in News
A health board has cancelled planned operations at four of its hospitals "in the interest of patient safety". Hywel Dda University Health Board made the decision after "an extraordinary weekend" of "critical pressures". On Monday, inpatient operations were cancelled at Bronglais, Glangwili, Prince Philip and Withybush hospitals in mid and west Wales. The health board said it had contacted the patients affected and outpatient appointments continued as normal. No decisions have been taken yet to cancel more non-emergency operations on Tuesday, it added. Dr Philip Kloer, the health board's medical director, said the weekend saw hospitals "at a level of escalation not seen before". "It is in the interest of patient safety that we have postponed planned operations today," he added. Plaid Cymru's shadow minister for health, Helen Mary Jones, said the decision to cancel operations was "deeply concerning". She said that patients in Wales "deserve so much better". Read full story Source: BBC News, 6 January 2020 -
News ArticleMore than 80% of patients who have signs of a deadly sepsis infection before high-risk surgery are not getting antibiotics fast enough, a major NHS report has warned. Sepsis kills an estimated 44,000 people in England every year and rapid access to antibiotics within the first hour after diagnosis is vital to halt the infection. However, a review of performance across 179 NHS hospitals has found a majority of patients undergoing emergency bowel surgery are not getting medication early enough. A leak of the bowel can cause sepsis and while antibiotics will help treat the infection, surgery is essential to repair any sepsis-causing leak. The Royal College of Anaesthetists, which carried out the study for the NHS, said although the number of patients getting surgery in time had improved over the last five years, the numbers receiving antibiotics within an hour had not. Read full story Source: The Independent, 4 January 2020
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News Article
Woman awarded £8m after doctors left sponge inside her during surgery
Patient Safety Learning posted a news article in News
A woman has been awarded $10.5 million (£8m) in damages after medical staff left a sponge inside her body. The sponge – which measured 18-by-18 inches and was left behind during surgery – was inside the woman's body for years before she realised. It had been left in her body after she underwent heart surgery at a Kentucky hospital in 2011. The bypass surgery is said to have gone wrong, leaving a mess – and as nurses rushed to deal with the problems, the sponge was left inside her body. It was not discovered for four years, until she had a CT scan in 2015. In the meantime, the sponge had moved around the woman's body, shifting around her intestines and causing pain as it did so. She had her leg amputated and was left with gastrointestinal issues after the sponge eroded into her intestine. The patient's lawyers said the case should be a reminder to hospitals to ensure that objects such as needles and other sharp objects, as well as sponges, are removed from patients after surgery. Read full story Source: The Independent, 1 January 2020 -
News Article
Woman dies after being set on fire during surgery in Romania
Patient Safety Learning posted a news article in News
A woman has died after being set on fire during surgery in Romania, the country’s health ministry has said, in a case that has cast a spotlight on the ailing Romanian health system. The patient, who had pancreatic cancer, died on Sunday after suffering burns to 40% of her body when surgeons used an electric scalpel despite her being treated with an alcohol-based disinfectant. Contact with the flammable disinfectant caused combustion and the patient “ignited like a torch”, Emanuel Ungureanu, a Romanian politician, said. A nurse threw a bucket of water on the 66-year-old woman to prevent the fire from spreading. The health ministry said it would investigate the “unfortunate incident”, which took place on 22 December. “The surgeons should have been aware that it is prohibited to use an alcohol-based disinfectant during surgical procedures performed with an electric scalpel,” the Deputy Minister, Horatiu Moldovan, said. Read full story Source: The Guardian, 30 December 2019 the hub has a number of posts on preventing surgical fires: Surgical fires: nightmarish “never events” persist MHRA. Paraffin-based skin emollients on dressings or clothing: fire risk (18 April 2016) National Patient Safety Agency: Fire hazard with paraffin-based skin products (Nov 2007) How I raised awareness of fires in the operating theatre
