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Showing results for tags 'Risk assessment'.
Found 206 results
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EventThe COVID-19 pandemic has profoundly impacted nearly all countries’ health systems and diminished their capability to provide safe health care, specifically due to errors, harm and delays in diagnosis, treatment and care management. “Implications of the COVID-19 pandemic for patient safety: a rapid review” emphasises the high risk of avoidable harm to patients, health workers, and the general public, and exposes a range of safety gaps across all core components of health systems at all levels. The disruptive and transformative impacts of the pandemic have confirmed patient safety as a critical health system issue and a global public health concern. The objectives of the WHO event are : provide an overview of implications of the COVID-19 pandemic for patients, health workers, and the general public highlight importance of managing risks and addressing avoidable harm in a pandemic situation discuss implications of the pandemic for patient safety within broader context of preparedness, response and recovery lay the foundation for follow-up work around generating more robust evidence and supporting countries in their efforts to build resilient and safer health care systems. Register
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Content ArticlePrevious research has shown that visitors can decrease the risk of patient harm; however, the potential to increase the risk of patient harm has been understudied. Sanchez et al. queried the Pennsylvania Patient Safety Reporting System database to identify event reports that described visitor behaviours contributing to either a decreased or increased risk of patient harm. The study provides insight into which visitor behaviours are contributing to a decreased risk of patient harm and adds to the literature by identifying behaviours that can increase the risk of patient harm, across multiple event types.
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Content ArticleThis mixed methods study in the BMJ Open aimed to investigate possible barriers and facilitators for venous thromboembolism (VTE) risk assessment in medical patients and evaluate the impact of local and national initiatives. The authors identified the following barriers to risk assessment: involvement of multiple staff in individual admissions interruptions lack of policy awareness time pressure complexity of tools They concluded that national financial sanctions appear effective in implementing guidance, where other local measures have failed.
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Content Article
Extravasation: a patient safety priority
Patient Safety Learning posted an article in Extravasation
Extravasation injuries occur when some intravenous drugs leak outside the vein into the surrounding tissue causing trauma. This leaflet describes the risks posed by extravasation to patients, the extent of the problem in the NHS and what is currently being done to reduce the risk of avoidable harm. The leaflet sets out the action to prevent, recognise, treat and report extravasation which is urgently needed. It emphasises the importance of all suspected extravasation injuries being reported and investigated, with reviews undertaken to learn and take action to prevent harm to future patients. -
Content ArticleThe Quality Network for Inpatient Working Age Mental Health Services (QNWA) based within the Royal College of Psychiatrists' Centre for Quality Improvement are pleased to announce the publication of their 8th edition standards. Since the publication of the first edition standards in 2006, the Network has grown to include over 140 members from the NHS and private sector. This new edition of standards aims to reflect the changes in working practices and legislation over the last two years in addition to placing greater emphasis on equality, diversity and inclusion as well as sustainability in inpatient mental health services. The eighth edition standards have been drawn from key documents and expert consensus and have been subject to extensive consultation with professional groups involved in the provision of inpatient mental health services, and with people and carers who have used services in the past.
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Content ArticleThis tool is easy to use and will help you better understand your own risks and benefits of having hip or knee joint replacement surgery. It has been designed using the National Joint Registry (NJR) information from people just like you who have chosen to have their procedure outcome details recorded on the registry. You may wish to take a printout of your results to use in your medical consultation.
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Content ArticleEarly in the pandemic, neither the NHS’s clinical or ancillary staff nor social care workers were adequately protected from the risks of catching covid-19 in the course of their work. In the UK alone, hundreds of infected workers have died, thousands have been admitted to hospital, and tens of thousands have experienced long term effects, How do we improve staff protection next time? Here’s David Oliver's manifesto.
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News Article
Inadequate Reading surgery had 'backlogs of test results', CQC says
Patient Safety Learning posted a news article in News
A GP surgery that provides treatment to about 5,600 patients has been placed in special measures by a regulator. London Street Surgery, in Reading, Berkshire, was found to have "significant backlogs of test results and care-related tasks". The Care Quality Commission (CQC) found there was "poor identification of risks to patients" during an inspection in April. The surgery has been approached for comment. The regulator rated the surgery's safety and leadership as inadequate, and said it had insufficient processes to ensure services' safety and effectiveness. Repeat prescriptions and medicines were "not managed safely", which could have posed risks to patients, and there were "risks associated" with the storage of blank prescriptions, it found. Staff training was "not monitored appropriately" and inspectors found patients with learning disabilities were not provided with health checks to make sure their wellbeing was properly monitored. Read full story Source: BBC News, 7 June 2022 -
Content ArticleThe purpose of the Learn from patient safety events (LFPSE) service (previously known during development as the Patient Safety Incident Management System - PSIMS) is to enable learning from patient safety events – incidents, risks, outcomes of concern and also things that went well. Our ability to protect future patients from harm depends on promoting a culture that welcomes and encourages the recording of events. It is essential to abide by these principles to ensure that we continue to successfully learn from patient safety events and reduce harm. This document sets out the circumstances in which LFPSE data are the appropriate data source to be used and describes their appropriate use. These principles emphasise the purpose and characteristics of LFPSE data, and promote consistency across data users. It is essential that users of LFPSE data understand and represent it appropriately, as inappropriate presentations of LFPSE data could discourage recording.
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Content Article
Safety Chats: Part 2 – Safety as measured
Gina Winter-Bates posted an article in Good practice
In a series of blogs, Gina Winter-Bates, Associate Nurse Director Quality and Safety at Solent NHS Trust, shares her experience of implementing Safety Chats. In her first blog, Gina explained what motivated her to introduce Safety Chats into her Trust. In part 2, Gina reflects on how we know we are safe and the safety measures her Trust has put in place. -
Content ArticleExtreme preterm birth, defined as birth before 28 weeks’ gestational age affects about two to five in every 1000 pregnancies, and varies slightly by country and by definitions used. Severe maternal morbidity, including sepsis and peripartum haemorrhage, affects around a quarter of mothers delivering at these gestations. For the babies, survival and morbidity rates vary, particularly by gestational age at delivery but also according to other risk factors (birth weight and sex, for example) and by country. In this BMJ clinical update, Morgan et al. focuses on high income countries and provide a broad overview of extreme preterm birth epidemiology, recent changes, and best practices in obstetric and neonatal management, including new treatments such as antenatal magnesium sulphate or changes in delivery management such as delayed cord clamping and placental transfusion. The authors cover short and long term medical, psychological, and experiential consequences for individuals born extremely preterm, their mothers and families, as well as preventive measures that may reduce the incidence of extreme preterm birth.
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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. Facilitated by: Barry Moult IG Consultant BJM IG Privacy Ltd Former NHS Trust Head of Information Governance, and Andrew Harvey IG Consultant BJM IG Privacy Ltd 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 20% discount. Email info@pslhub.org for discount code.
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Content Article"The inestimable, magnificent, Will Powell speaking on Radio Ombudsman about the long struggle to discover the truth about his son's death and the subsequent failure of accountability mechanisms" - Rob Behrens, Parliamentary and Health Service Ombudsman UK, Vice-President IOI Europe, Visiting Professor UCL. MCFC.
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Content ArticleAn investigation started on 9 October 2020 into the death of Matthew Alexander Caseby. Following his admission and subsequent absconsion from the Priory Hospital in Edgbaston, Matthew stepped in front of a train on the 8 September 2020 and was fatally injured. At the time, Matthew was suffering from disorder thinking and did not have the capacity to form any intention to end his life. Matthew absconded from Beech ward over a fence in the courtyard area and at the time of his absconsion Matthew was unattended. It was inappropriate for Matthew to be left unattended in the courtyard. There were concerns regarding Matthew absconding but the recording processes on Beech ward were inadequate which resulted in the communication to staff involved in Matthew's care being lacking. As a result of risks not being fully recorded, Matthew's risk assessment was not adequate as it was not based on all of the available information. Overall, the inadequate risk assessment for Matthew, the inadequate documentation records, the lack of a risk assessment for the courtyard area and the absence of a policy regarding observations levels in the courtyard means that the courtyard was not safe for Matthew to use unattended. His death was contributed to by neglect on the part of the treating hospital.
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News Article
Autistic girl, 14, unlawfully detained in hospital, high court judge finds
Patient Safety Learning posted a news article in News
A 14-year-old autistic girl was unlawfully detained in hospital and restrained in front of scared young patients, a high court judge has found. On one occasion last month the teenager managed to break into a treatment room where a dying infant was receiving palliative care. She was restrained there by three security guards, Mr Justice MacDonald said in a judgment in the family court that ordered Manchester city council (MCC) to find the girl a suitable community care placement instead of what he described as the “brutal and abusive” and “manifestly unsuitable” hospital environment. Nurses witnessed the girl screaming “very loudly” and sounding “very scared” when repeatedly held down on her hospital bed so that she could not move her legs, arms or head, before being tranquillised. Other children on the ward were frightened to witness the frequent battles between the girl and security guards, the judge said. The judge noted that the teenager made “regular and determined” efforts to run away, sometimes using screwdrivers to try to unlock doors and windows, and running away from her family on walks. He described the teenager as having an autistic spectrum disorder and a learning disability. She demonstrated “complex and extreme behaviour” that could not be controlled even within a school environment involving six adults to one child supervision, he added. Despite this, the council and NHS trust decided to have the girl be detained in hospital on a general paediatric ward “solely as a place of safety”, without applying for the necessary court order to do so, the judge found. She did not require any medical treatment, the judge said. Read full story Source: The Guardian, 5 April 2022 -
News Article
Patient care and safety put at risk in A&E at brand new £350m hospital
Patient Safety Learning posted a news article in News
Patients visiting Wales' newest emergency department were likely to have been put at risk of harm due to the lack of processes and systems in place, inspectors found. Healthcare Inspectorate Wales (HIW) carried out an unannounced inspection of The Grange University Hospital in Cwmbran between 1 and 3 November last year and published its findings on 29 March. On the day of their arrival inspectors said The Grange was at full capacity with no empty beds in A&E or in the hospital in general. Despite the best efforts of staff who were "working hard under pressure" the report stated the emergency department had several issues which could have compromised the privacy and dignity of patients. This included problems with the physical environment of the waiting room, which was described as a "major cause of anxiety" for visitors, as well as with the flow of patients through the hospital in general. It found that patients were not triaged and medically managed in A&E in a timely fashion with many being placed on uncomfortable chairs or in corridors for hours on end. Between 1 April 2021 and 1 November 2021, the average waiting time in the department was six hours and seven minutes. The report said some issues required immediate action including the fact patients in the waiting area were often left to "deteriorate without being overseen". There were also infection control failures which could have led to the cross-contamination of Covid-19. "We were not assured that all the processes and systems in place were sufficient to ensure that patients consistently received an acceptable standard of safe and effective care," the report stated. Read full story Source: Wales Online, 1 April 2022 -
News Article
Private hospital rated ‘inadequate’ again amid safety concerns
Patient Safety Learning posted a news article in News
A privately run mental health hospital put in special measures last year has been rated “inadequate” again following a fresh Care Quality Commission inspection. Inspectors raised serious concerns about unsafe ward environments and staff not managing patient risks at the Priory Hospital Arnold, which has beds commissioned by Nottinghamshire Healthcare Foundation Trust. Inspectors said that while the leadership team was experienced, the registered manager had been in post since April last year and the improvements they had made “had not been fully embedded”. The registered manager had changed after the service was placed in special measures. Ligature risks were found in patients’ bathrooms despite the provider making “some progress” and undertaking “substantial work” to remove them, the CQC said. And in one instance, a patient had tried to harm themselves with a plastic bag which was a restricted item on the ward. CQC head of hospital inspection for mental health and community services Craig Howarth said staff “had not followed the patient’s risk assessment” and had not searched the patient on their return from a visit off the ward. He added: “It was also concerning that despite rotas showing enough staff were available across the hospital, staff gave examples of when a lack of staffing had impacted on patient care and safety. “Despite the measures in place, the risks to patients were not reduced and there was evidence of incidents of harm to patients.” Read full story (paywalled) Source: HSJ, 15 March 2022 -
Content ArticleA strong focus on systems thinking and an encouragement to apply insights and expertise from human factors and ergonomics is paramount in how we plan, design and deliver healthcare safely. It’s central to the WHO Global Patient Safety Action Plan, the NHS Patient Safety Strategy, new Patient Safety Incident Response Framework (PSIRF) guidance on how to investigate incidents of unsafe care and the National Patient Safety Syllabus.[1-3] It’s something Patient Safety Learning emphasise in our report A Blueprint for Action and is central to the organisational standards for patient safety that we’ve developed.[4] But how should we ‘do’ human factors? How do we apply the concepts, methodologies, tools and techniques in healthcare? What training do we need? How can patient safety managers embed human factors in all of their work, not just a reactive response to incidents of harm? These are some of the questions that patient safety managers have been asking and discussing in the recent Patient Safety Manager Network (PSMN) meetings. The PSMN is an informal voluntary network for patient safety managers in England. Created by and for patient safety managers it provides a weekly drop-in session with guests to talk through issues of importance, providing information, peer support and safe space for discussion. You can find out more about the network here.
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News Article
'Overworked staff' impacting patient safety at Torbay Hospital
Patient Safety Learning posted a news article in News
The Care Quality Commission (CQC) has raised concerns about Torbay Hospital being understaffed and the impact that has had on patient safety. It carried out an unannounced focused inspection of medical care services at Torbay Hospital in December, after receiving information of concern about the service. Cath Campbell, CQC’s head of hospital inspection, said: “When we inspected medical care services at Torbay Hospital, we were mindful of the pressures that the COVID-19 pandemic had had on the trust, and aware that staff were working extremely hard during this time. However, we were concerned to find some of the wards didn’t have enough staff to meet the needs of patients, especially those on a dedicated COVID-19 ward, and the trust wasn’t able to provide us with evidence that there were enough staff on the ward to monitor patients to keep them safe.! “In addition, staff didn’t always complete risk assessments for each patient to remove or minimise risks to people’s safety. Staff also did not always identify patients at risk of deterioration and act quickly to keep them safe." The Torbay and South Devon NHS Foundation Trust says it has taken the CQC’s findings very seriously and made immediate improvements, which the CQC have recognised. Read full story Source: Torbay Weekly, 4 March 2022 -
Content ArticleCancer Research UK’s latest analysis of NHS Digital cancer registration data uses the most complete recording to date of cancer rates by ethnicity in England, providing crucial data on how some cancer rates vary by ethnicity. The study found that although a small number of cancer sites have higher incidence rates in Asian, Black and Mixed/Multiple ethnic groups, for the majority of cancer sites these groups have a lower incidence than the White population. Differing prevalence of risk factors and access to/use of health services is likely to explain more of this variation than are genetic factors; if risk factor prevalence changes cancer rates may rise in minority ethnic groups, therefore action to address key risk factors and to improve the cancer experiences and outcomes of people in minority ethnic groups is vital. Improving the collection of ethnicity information in healthcare datasets will support a better understanding of differences in disease, as well as inequalities in cancer and where improvements in the health service can be made.
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Content Article
Queensland Health: Fatigue risk management systems
Patient Safety Learning posted an article in Good practice
This guideline has been developed to support all Australia's Queensland Health workplaces to identify and manage fatigue risks. It draws on lessons learnt from over a decade of implementing fatigue risk management systems (FRMSs) in Queensland Hospital and Health Services (HHSs) and from proven approaches to safety risk management. -
Content ArticleThis report was commissioned by the Royal College of Obstetricians and Gynaecologists, with research led by Leeds Beckett University in collaboration with the University of Sheffield and the University of Oxford. It aims to inform those involved in the care of pregnant women in the UK about the relationship between social determinants of health and the risk of maternal death.
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News ArticleA vulnerable woman judged to be at medium risk of self harm was on a mental-health ward that catered for low-risk patients, an inquest heard. Zoe Wilson, 22, died on the Larch Ward at Bristol's Callington Road Hospital in June 2019 after being found unconscious in her room at 01.30 BST. She had previously told staff that voices were telling her to kill herself, her inquest heard. Healthcare assistant Sarah Sharma found her and immediately called for help. Addressing a jury inquest at Avon Coroners' Court, she said that "patients admitted to Larch should have all been low risk". This meant they would "preferably" have hourly observations by staff and be able to take their medication without any issues. Many were ready to be discharged and they were there because something was holding them up, normally housing, she said. The experienced healthcare assistant said if the patient's risk increased they should be placed under "one to one" monitoring with a member of staff until they were moved to a more suitable unit. The inquest heard earlier that Ms Wilson had been judged to be medium risk and was placed on 30-minute observations on 18 June. Her risk level was re-assessed when she handed a belt to staff and informed them voices were telling her to kill herself. Ms Sharma told the court that she was on her first overnight shift in two and a half weeks that night, and was informed in a handover that Ms Wilson was at risk of self-harming. Having never met Ms Wilson - who had schizophrenia - she queried what kind of self-harm the patient was at risk of but said the nurse performing the handover told her he "didn't know". Ms Sharma told the inquest she was unaware of the belt incident or that Ms Wilson had not been sleeping well and had requested medication to calm her down. Read full story Source: BBC News, 24 January 2022
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News Article
Coroner concerned with Barts NHS trust after woman 'unlawfully killed'
Patient Safety Learning posted a news article in News
Barts Health NHS Trust has been told to take action to prevent future deaths after an elderly woman was unlawfully killed at one of its hospitals. East London acting senior coroner Graeme Irvine sent a report to the trust in which he raised concerns over the death of 78-year-old Surekha Shivalkar in 2018. The report follows an inquest into Mrs Shivalkar's death, which reached a narrative conclusion incorporating a finding of unlawful killing. A Barts spokesperson said the trust had made a number of changes after carrying out an investigation. Mrs Shivalkar underwent hip replacement revision surgery at Newham Hospital on September 28, 2018 in a procedure estimated to last between four and five hours, the coroner wrote. She had a number of serious conditions, including ischaemic heart disease, osteoporosis and chronic obstructive pulmonary disorder. But Mr Irvine said an inaccurate risk of death of less than 5% was given, as no formal risk assessment tool was used. The surgery took longer than seven and a half hours, during which time Mr Irvine said Mrs Shivalkar sustained a "prolonged and dangerous" period of hypotension, or low blood pressure. He said the anaesthetist failed to communicate this to the surgical team and agreed to prolong surgery at the six hour point. Mr Irvine said: "Poor communication between the orthopaedic surgical team and the anaesthetist during surgery led to a collective failure to identify a critically ill patient." Read full story Source: Newham Recorder, 17 January 2022 -
Content ArticleSurekha Shivalkar was a 78-year-old woman who was scheduled for elective total hip replacement revision surgery. Following surgery she suffered a cardiac arrest and subsequently died. The conclusion of the inquest was that died from multi-organ failure and complications arising during anaesthesia and hip revision surgery, which led to hypotension and hypoperfusion in a woman with ischaemic heart and chronic obstructive pulmonary disease. In his report, the Coroner raises concerns about the lack of a use of a formal risk assessment tool prior to her surgery, communication failures between the orthopaedic surgical team and the anaesthetist and the departure of the Senior Consultant surgeon prior to the surgeries conclusion.
