Search the hub
Showing results for tags 'Risk assessment'.
Found 206 results
-
Content ArticleRisk assessment during the maternity pathway relies on healthcare professionals recognising a change in a pregnant woman/person’s circumstances that may increase the level of risk. Risk assessments are undertaken during the numerous contacts pregnant women/people have with a team of healthcare professionals throughout the maternity pathway. This thematic review draws on findings from the Healthcare Safety Investigation Branch's (HSIB's) maternity investigation programme to identify key issues associated with assessing risk during pregnancy, labour and birth (known as the ‘maternity pathway’). It examined all reports undertaken by the HSIB maternity investigation programme from April 2019 to January 2022, with the aim of identifying key learnings about risk assessment. A total of 208 reports that had made findings and recommendations to NHS trusts about risk assessment during the maternity pathway were included. The review identified an overarching theme around the need to facilitate and support individualised risk assessments for pregnant women/people to improve maternity safety. Within this, seven specific ‘risk assessment themes’ within the maternity care pathway were identified as commonly appearing in HSIB reports. These seven themes require a focus from the healthcare system to help mitigate risks and enable NHS trusts and clinicians to deliver safe and effective maternity care to pregnant women/people.
-
Content ArticleSlides from the recent Patient Safety Incident Response Framework (PSIRF) governance workshop giving an update and overview from the national team. Presentations were given from the early adopters: Jacquetta Hardacre, Assistant Director Safety and Risk, East Lancashire Hospitals NHS Trust and Kerry Crowther, Patient Safety Specialist, Cornwall Partnership NHS Foundation Trust. The workshop concluded with a Q&A panel with the presenters and Gillian Lewis Head of Patient Safety Strategy Delivery, NHS England.
-
Content ArticleECRI’s Top 10 Health Technology Hazards for 2023 list identifies the potential sources of danger they believe warrant the greatest attention for the coming year and offers practical recommendations for reducing risks. Since its creation in 2008, this list has supported hospitals, health systems, ambulatory surgery centres, and manufacturers in addressing risks that can impact patients and staff. Their executive now includes specific calls to action for industry.
-
Content Article
Fatigue: are you at risk? (Association of Anaesthetists)
Patient-Safety-Learning posted an article in Staff safety
This article by the Association of Anaesthetists (AoA) defines fatigue, looks at its causes and highlights how healthcare worker fatigue can impact on patient safety. It includes a 'High-risk checklist' outlining factors that could contribute to healthcare worker fatigue including recent illness, use of alcohol and medications and stress. -
News Article
Nasal decongestants safety review due to rare brain risk
Patient Safety Learning posted a news article in News
Experts are assessing a very rare but potentially serious brain side effect of nasal decongestants bought on the High Street. Ones containing pseudoephedrine are being reviewed because they may cause vessels supplying the brain to contract or spasm, reducing blood flow. The concern is this could lead to seizures and even a stroke. However, drug regulators stress the likelihood of this happening is extremely low. The UK-wide review for pseudoephedrine was initiated after regulators in France alerted European drugs regulator the EMA, which is also conducting a review, about some recent, rare cases. Experts say anyone with concerns about medication should speak to a doctor or pharmacist. Read full story Source: BBC News, 23 February 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. The Centre for Perioperative Care shares their slideset on the revised standards.
-
Content ArticleOn 4 March 2020 an investigation into the death of Yvonne Eaves was opened. The inquest came to a narrative conclusion that "The Deceased suffered from a chronic mental disorder and serious self-neglect. After compulsory admission to hospital under the Mental Health Act there was a gross failure to provide her with basic medical care which contributed to her death and it was possible that if she had received that care and VTE prophylaxis treatment she would not have developed a pulmonary thromboembolism and died."
-
News Article
‘Risk averse’ NHS 111 algorithm sends too many patients to A&E
Patient Safety Learning posted a news article in News
NHS 111 sends too many people to accident and emergency departments because its computer algorithm is “too risk averse”, the country’s top emergency doctor has warned. Dr Adrian Boyle, president of the Royal College of Emergency Medicine (RCEM), said that December was the “worst ever” in A&E with 9 in 10 emergency care leaders reporting to the RCEM that patients were waiting more than 24 hours in their departments. Asked what measures could help improve pressures in emergency care, Dr Boyle said more clinical input was needed in NHS 111 calls. “In terms of how we manage people who could be looked after elsewhere, the key thing to do is to improve NHS 111,” Dr Boyle told MPs. “There is a lack of clinical validation and a lack of clinical access within NHS 111 - 50 per cent of calls have some form of clinical input, there’s an awful lot which are just people following an algorithm.” Dr Boyle added where clinical input is lacking “it necessarily becomes risk averse and sends too many people to their GP, ambulance or emergency department”. Read full story (paywalled) Source: The Telegraph, 24 January 2023 -
EventuntilThis virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register
-
EventuntilThis virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register
-
EventuntilThis virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register
-
Content ArticleEven before the Covid-19 pandemic, rural and remote health services in England faced long-standing workforce, financial and capacity issues. This report by the Nuffield Trust explores the impact the pandemic has had on the delivery of rural and remote health services, highlighting the underlying challenges faced by these services. It outlines how the challenges faced are different for rural areas when compared to more urban areas. The authors also discuss how performance could be monitored to signal the risk of any significant service pressures over the coming months.
-
Content ArticleIn this article for The Guardian, an anonymous hospital consultant describes the situation in many NHS emergency departments in January 2023—patients ready for medical admission waiting in ambulances in the hospital car park, patients receiving IV antibiotics in chairs in the corridor and staff completely overwhelmed by the workload. The author highlights that accident and emergency departments are now being used for a purpose for which they were not designed—looking after patients who need to be admitted to hospital wards. They describe the implications of this on patient safety and staff wellbeing and argue that the NHS and Government need to call the situation what it is—a crisis—or we will come to accept poor quality care and low patient safety standards as the norm.
-
Content ArticleThis report from Simon Milburn, Area Coroner for the area of Cambridgeshire and Peterborough, looks at the death of Jonathan Kingsman, who died of pulmonary thromboembolism and deep vein thrombosis on 1 February 2021. Mr Kingsman had been admitted to Fulbourn Hospital, Cambridge under section 2 of the Mental Health Act 1983 on 26 January. It was noted that on admission, Mr Kingsman had not consumed any fluids for several hours. The doctor on call carried out an initial risk assessment for venous thromboembolism (VTE), but as Mr Kingsman's mobility was deemed to 'not have significantly reduced ability', the assessor was directed by the guidance to stop the assessment. It was agreed at the Inquest that Mr Kingsman fell into this category and likewise agreed that throughout his time in hospital that there were no changes to his mobility which would have prompted a renewed risk assessment. However, Mr Kingsman did have other risk factors for VTE, and the coroner raised matters of concern about the risk assessment process as follows: That the risk assessment requires no consideration of risk factors other than mobility unless ‘Step 1’ is passed regardless of the number of other risk factors which may be present and their severity – Mr Kingsman was not obviously at risk of ‘significantly increased immobility compared to his normal state’ but died as a result of a DVT/VTE nonetheless. It is reasonable to expect that others may be in the same position in the future. The risk assessment form contains no guidance on its completion and no definition of certain terms. A copy of the report was sent to The Secretary of State for the Department of Health.
-
EventThis masterclass will focus on developing your role as a SIRO (Senior Information Risk Owner) in health and social care. Key learning objectives Understanding the role of the Senior Information Risk Owner. Identifying information risks across the organisation. Working with others to mitigate the risk to patients, staff and organisation. Confidence that all reasonable technical and organisation measure are in place. Giving assurance to the Board that risks have been considered, mitigated or owned. Understand the requirements of external confidence that policies, procedures are in place to deal with Data Breaches, For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/masterclass-developing-your-role-as-a-senior-information-risk-owner-siro or email kate@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code.
-
Content ArticleThis article, published in The international journal for quality in healthcare, looks at the Hierarchy of Risk Controls approach to explore its usefulness and effectiveness in healthcare. To investigate this issue, a team of social scientists examined the risk controls introduced by four hospital teams in England and Scotland after they had identified hazards in their systems.
-
EventuntilThe free, one-day, virtual conference will explore the themes and issues arising from the report recently published by the Authority, Safer care for all – solutions from professional regulation and beyond. It will be an opportunity to hear a range of views, debates and discussions about some of the issues in the report with the aim of moving towards solutions to support safer care for all. Safer care for all – solutions from professional regulation and beyond is the Authority’s contribution to the debate on some of the key patient and service user safety challenges within health and social care, drawing on insights from our role overseeing the ten health and care professional regulators and the Accredited Registers programme. Topics that we focus on within the report include: tackling inequalities regulating for new risks facing up to the workforce crisis accountability, fear and public safety. Register
-
Content ArticleA themed review may be useful in understanding common links, themes or issues within a cluster of investigations or incidents. It will seek to understand key barriers or facilitators to safety using reference cases (e.g. individual datix incidents or previous investigations).
-
Content ArticleThis guidance from NHS England aims to support Integrated Care System (ICS) leaders as they develop their approach to quality management, providing clarity on how quality concerns and risks should be managed through systems. It provides an overarching approach to quality risk response and escalation, including guidance on routine, enhanced and intensive quality assurance and improvement activity.
-
Content ArticlePURPOSE-T (Pressure Ulcer Risk Primary or Secondary Evaluation Tool) is an evidence-based pressure ulcer risk assessment instrument that was developed by the University of Leeds using robust research methods. PURPOSE-T identifies adults at risk of developing a pressure ulcer and supports nurse decision‐making to reduce that risk (primary prevention), but also identifies those with existing and previous pressure ulcers requiring secondary prevention and treatment. It uses colour to indicate the most important risk factors and forms a three‐step assessment process. To register for the tool, visit the CTRU Leeds Research Portal at the link below.
-
News Article
NHS eating disorder services forced to ‘exclude’ patients and ‘ration care’
Patient Safety Learning posted a news article in News
Patients are being excluded from life-saving eating disorder treatment as services are severely underfunded, experts have warned. Adult eating disorder services are so severely underfunded and understaffed that they are having to employ rationing measures and turn away patients, leading psychiatrist Dr Agnes Ayton told The Independent. In their research, Dr Ayton and 22 other psychiatrists found that in 2019-20, just 31% of eating disorder services accepted all patients, regardless of the level of illness. The researchers warned that the situation had become more serious following the pandemic, which had driven a “worsening of the demand and capacity” crisis across the services. Experts have called for emergency funding to meet the needs of adult patients with eating disorders, and say that these services should be receiving at least £7m per million population each year to meet standards. Dr Ayton warned that patients who are “literally on death’s door” are not getting care when they need it. Read full story Source: The Independent, 25 September 2022 -
Content ArticleThe National Institute for Health and Care Excellence (NICE) is developing an update to the guideline on assessment and prevention of falls in older people and people 50 and over at higher risk. It has published the final scope for the update alongside consultation comments and responses, an equality impact assessment and the stakeholder list. The final guidance is expected to be published on 13 June 2024.
-
Content ArticleBob Hanscom, J.D., is retiring this week after a nearly 30-year career championing patient safety improvement. He has been Vice President of Risk Management and Analytics at Coverys since 2013 and earlier held similar positions at CRICO and CRICO Strategies. He was Vice President of Clinical Services at Lahey Clinic from 1993 to 1998 and prior to that practiced law.
-
Content ArticleOn the 21 July 2022 NHS Resolution’s Safety and Learning team, in partnership with the National Infusion and Vascular Access Society, hosted a virtual forum on extravasation injury claims. The intention of this event was to raise awareness of these injuries and help spread learning and process review across health providers.
-
Content ArticleSuccessful adoption of novel noncontact physiological measurement and physical monitoring requires analysis of how they support patient care. Lloyd-Jukes et al. review available technologies and present their vision-based patient monitoring and management system, supported by a framework enabling its integration within clinical workflows. The framework links tasks such as assessing patients to elements of the patient journey (eg, risk factors and early warning signs). The system enabled insights from patient activity reports and noncontact vital sign measurements. It supports staff in ensuring patients' health follows desired trajectories, avoiding adverse events, making observations without disrupting patients' rest, intervening proactively, and learning from incidents.
