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Showing results for tags 'Risk assessment'.
Found 206 results
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Content Article
ECRI's Risk Assessment
Patient Safety Learning posted an article in Improving systems of care
Keeping patients and staff safe is a top priority for every healthcare organisation. Leaders must be vigilant in continually monitoring, measuring, and improving risk, as well as identifying processes, environments, cultures and other factors affecting patient safety and organisational performance. ECRI’s Risk Assessments provide an efficient web-based solution for conducting such evaluations. These assessments collect multidisciplinary safety perspectives—from front-line workers to the executive suite—with reporting and analysis dashboards to help identify opportunities for improvement. -
Content ArticleAs an employer, you're required by law to protect your employees, and others, from harm. Under the Management of Health and Safety at Work Regulations 1999, the minimum you must do is: identify what could cause injury or illness in your business (hazards) decide how likely it is that someone could be harmed and how seriously (the risk) take action to eliminate the hazard, or if this isn't possible, control the risk Assessing risk is just one part of the overall process used to control risks in your workplace. The Health and Safety Executive (HSE) provide a risk assessment template and examples.
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Content ArticleThis toolkit published by the Royal College of Nursing (RCN) aims to support healthcare professionals to consider and manage risks associated with the transmission of respiratory infections, specifically Covid-19. It is designed to aid local decision making about the level of personal protective equipment (PPE) required to protect healthcare professionals while at work.
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News Article
The paramedics keeping patients out of hospital
Patient Safety Learning posted a news article in News
Chest pains for a 63-year-old man might typically mean a hospital trip to check it out. But after Clive Pietzka's 999 call, an advanced paramedic practitioner carried out tests and discharged him. The Welsh Ambulance Service Trust (WAST) job is one of those in a growing team who work to keep people out of hospital. Solutions like this are being sought following ambulance queues for hospital and worst ever performance figures. Mr Pietzka, from Barry, who has a heart problem, said initially he did not want to call an ambulance because of high demand. "They're very busy with Covid and everything else. But the GP practice said to call 999," he said. However, on this occasion a rapid response vehicle - a car with a single paramedic - came within 15-20 minutes and tests were performed, without a hospital trip. Advanced paramedic practitioner John McAllister who attended said he sees people more medical low acuity cases rather than emergency and trauma conditions. "I use assessment techniques and diagnostic tools to assess patients, formulate a diagnosis then put a plan in place," he said. "It's about trying to treat them at the right time and the right place, without having to take them to A&E." Adding to the pressure of the pandemic and winter demand, a shortage of social care workers to support patients' safe discharge means a large number of patients find themselves in hospital longer than medically necessary. The knock-on impact means it is becoming harder for new patients to be treated and admitted. Penny Durrant, the service manager for the clinical support desk at WAST regional headquarters in Cwmbran, said current challenges had led to growth in her team. She said it was a "recognition of needing to do something different". Read full story Source: BBC News, 21 December 2021 -
Content ArticleHealthcare can be risky. Adverse events carry a high cost – both human and financial – for health systems around the world. So in an effort to improve safety, many health systems have looked to learn from high-risk industries. The aviation and nuclear industries, for example, have excellent safety records despite operating in hazardous conditions. And increasingly, the tools and procedures these industries use to identify hazards are being adopted in healthcare. One prominent example involves the Hierarchy of Risk Controls (HoC) approach, which works by ranking the methods of controlling risks based on their expected effectiveness. According to HoC, the risks at the top are presumed to be more effective than those at the bottom. The ones at the top typically rely less on human behaviour: for example, a new piece of technology is considered to be a stronger risk control than training staff. This article looks more deeply at the (HoC) 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.
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Content ArticleHigh Reliability Organisations (HRO), including healthcare and aviation, have a common focus on risk management. The human element is a ‘weak link’ which may result in accidents or adverse events taking place. Surgeons and other healthcare professionals can learn from aviation's rigorous approach to the role of human factors (HF) in such events, and how we can minimise them. Air Accident Investigation Branch (AAIB) reports show that fatal accidents are frequently caused by pilots flying outside their own personal limits, those of the aircraft or environment. Similarly, patient morbidity or mortality may occur if surgeons work outside personal their capability, with poor procedure selection and patient optimisation, or with a team or theatre environment not suited to the procedure. The authors of this study introduce the personal limitations checklist – a tool adapted from aviation that allows surgeons to define their limits in advance of any decision to operate, and develop critical self-reflection. It also allows management of patient expectations, shared decision making, and flattening of team hierarchy. The minimum skills, patient characteristics, team and theatre resources for any given procedure to proceed are defined. If the surgeon is ‘out of limits’, redressing these factors, seeking additional assistance, or thorough patient consenting may be required for the safe conduct of the procedure. The authors explore external pressures that could cause a surgeon to exceed both personal and organisational limits.
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Content Article
Patient Safety Syllabus training
Mark Hughes posted an article in Specialist patient safety training
The National patient safety syllabus outlines a new approach to patient safety, emphasising a proactive approach to identifying risks to safe care while also including systems thinking and human factors and applies to all NHS employees. This page provides access to learning materials (via the E-Learning for Health platform) for staff relating to Level one – Essentials for patient safety and Level two – Access to practice of the training associated with this. -
Content ArticleOn 11 June 2019 an investigation into the death of Brooke Martin aged 19 started. Brooke was a patient at Isla House, Chadwick Lodge, Milton Keynes and was detained under the Mental Health Act. She had been diagnosed with Emotionally Unstable Personality Disorder and Autism Spectrum Disorder. Brooke was found hanging in her room and was taken to Milton Keynes University Hospital where she died on 11 June 2019.
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Content Article
HSIB Maternity newsletter (May 2021)
Patient Safety Learning posted an article in HSSIB investigations
HSIB is pleased to present the first quarterly newsletter sharing learning from trusts across the whole of England. The purpose of this newsletter is to allow clinical teams and trusts to share the changes that have been made as a result of the findings and recommendations from maternity investigations undertaken by the Healthcare Safety Investigation Branch (HSIB). These initiatives were developed by the trusts and their maternity teams, we would like to thank them for sharing their work with others. This approach to collaborative learning supports trusts to share resources and improvement ideas that relate to similar concerns each trust experiences, as they strive to continually improve the care and safety of mothers and their babies. These examples of learning reflect what is being implemented in trusts with varying requirements to support their maternity services. This allows what is learnt in Newcastle to be known about in Penzance. -
Content ArticleThe risk of medication errors with infusion pumps is well established, yet a better under-standing is needed of the scenarios and factors associated with the errors. This study from the Patient Safety Authority explored the frequency of medication errors with infusion pumps, based on events reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) during calendar year 2018.
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Content ArticleOn 24 March 2021, an investigation into the death of Hazel Fleur Wiltshire was opened. The conclusion of the inquest was that Mrs Wiltshire died from pneumonia caused by a fall and by COVID-19 that she acquired in hospital. The fall was caused by her trying to relieve herself without assistance in the context of long delays in answering calls bells at the time.
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Content Article
CDC: Hierarchy of controls
Patient Safety Learning posted an article in Occupational health and safety
Controlling exposures to occupational hazards is the fundamental method of protecting workers. Traditionally, a hierarchy of controls has been used as a means of determining how to implement feasible and effective control solutions.This Centers for Disease Control and Prevention (CDC) summarises the hierarchy of controls. -
Content ArticleIn this article, Brian Edwards, MD, discusses pharmacovigilance, society's changing approach to benefit and risk, confusion between compliance and ethics within pharmacovigilance and how ethical business practice is the basis of good business practice.
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Content ArticleIn the UK over 1000 people with epilepsy die every year and it's estimated that more than half of these deaths could be avoided. This is a free evidence-based tool, supporting clinicians in discussing risk with people with epilepsy. It includes risk factors linked to epilepsy mortality, including (but not restricted to) Sudden Unexpected Death in Epilepsy (SUDEP). To watch the introductory video and register for access to checklist, follow the link below to the SUDEP Action website.
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Content ArticleThere is an overall dearth of information on implementation and compliance with patient safety standards in developing countries. In recognition of this, the World Bank Group’s Health in Africa Initiative, WHO and the PharmAccess Foundation came together with the ministries of health to conduct an assessment of patient safety at Kenyan health facilities. The study is the first nationwide assessment of patient safety levels based on documented processes and levels of risk, and is meant to serve as a baseline against which future interventions can be measured.
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Content ArticleHealth Education England (HEE) has published the first NHS-wide Patient Safety Syllabus which applies to all NHS employees and will result in all NHS employees receiving enhanced patient safety training. Written by the Academy of Medical Royal Colleges and commissioned by HEE the new National Patient Safety Syllabus outlines a new approach to patient safety emphasising a proactive approach to identifying risks to safe care while also including systems thinking and human factors. Level one and two learning materials will be available on the E Learning for Health platform for staff to access and complete from August and September 2021.
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EventSarah Miller, Director of Partnerships, Patient Safety Movement Foundation is joined by Ariana Longley, Chief Operating Officer of the PSMF to discuss how you and your loved ones can prepare before going into the hospital. Ariana highlights the importance of knowing possible risks and alternatives to proposed treatments, things you should bring to your hospital visit, and shares the free resources the Patient Safety Movement Foundation has to offer, both general and COVID-19 resources.
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EventSince the emergence of the disease, severe Covid infections have been associated with a risk of severe and dangerous coagulopathy. And in recent weeks two vaccines have been linked to a rare increased risk of clotting, in particular cerebral sinus venous thrombosis (CSVT) which requires urgent and specific treatment. This Royal Society of Medicine webinar will tell the story of our understanding of these coagulation disorders, looking at the causes, risks, diagnosis, and treatments. Register
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Content Article
In his latest blog, Ehi Iden, hub topic lead for Occupational Health and Safety, OSHAfrica, discusses the importance of documenting and learning from patient safety incidences. Using a fictional story to draw parallels from, Ehi highlights how accountability, leadership and reporting incidences will help us keep staff and patients safe. -
Content ArticleA group of royal colleges has produced guidance for doctors seeing patients who have concerns about symptoms after receiving the Oxford AstraZeneca COVID-19 vaccine. The Royal College of Emergency Medicine, the Society for Acute Medicine, and the Royal College of Physicians say that anyone who presents with symptoms suggestive of COVID-19 vaccine induced thrombosis and thrombocytopenia (VITT)1 should have a full blood count to check their platelet level. Symptoms of concern include persistent or severe headaches, seizures, or focal neurology; shortness of breath, persistent chest, or abdominal pain; and swelling, redness, pallor, or cold lower limbs.
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News Article
The crisis at England's NHS child gender clinic
Patient Safety Learning posted a news article in News
In January, England's only NHS gender clinic for children and young people was rated "inadequate" by the country's health watchdog - the lowest rating, meaning it is performing badly. The findings make for sobering reading with inspectors raising "significant concerns" about the way the Gender Identity Development Service (GIDS) works. Nearly 5,000 children are waiting - sometimes for up to two years - for an appointment, and the management team has been disbanded following the inspection. Now BBC News has had exclusive sight of an external report written in 2015 which recommended GIDS take drastic action. It argued the service was "facing a crisis of capacity" to deal with an ever-increasing demand and strikingly it should "take the courageous and realistic action of capping the numbers of referrals immediately". With Care Quality Commission inspectors recently confirming many of the risks highlighted still remain, some have expressed concern about why neither GIDS, nor NHS England, which has ultimate responsibility for the service, have done more to help the children and young people it cares for. Read full story Source: BBC News, 30 March 2021 -
News ArticleWards at a trust facing an inquiry over the deaths of vulnerable patients have been downgraded to ‘inadequate’ over fresh patient safety concerns. The Care Quality Commission said five adult and intensive wards across three hospitals run by Tees, Esk and Wear Valleys (TEWV) Foundation Trust “did not manage patient safety incidents well”. It also criticised the trust’s leaders for failing to make sure staff knew how to assess patient risk. The watchdog rated the trust’s acute wards for adults of working age and psychiatric intensive care units as “inadequate” overall as well as for safety and leadership. The trust was also served a warning notice threatening more enforcement action if the patient safety issues are not urgently addressed. At the previous inspection in March 2020, the service was rated “good”. TEWV said it has taken “immediate action” to address the issues, including a rapid improvement event for staff and daily safety briefings, and will also spend £3.6m to recruit 80 more staff. The trust’s overall rating of “requires improvement” remains unchanged after this inspection. Brian Cranna, CQC’s head of hospital inspection for the North (mental health and community health services), said: “We found these five wards were providing a service where risks were not assessed effectively or managed well enough to keep people safe from harm." “Staff did not fully understand the complex risk assessment process and what was expected of them. The lack of robust documentation put people at direct risk of harm, as staff did not have access to the information they needed to provide safe care." Read full story (paywall) Source: HSJ, 26 March 2021
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Content Article
Manchester Triage System (updated 24 February 2021)
Patient Safety Learning posted an article in Emergency medicine
The Royal College of Emergency Medicine has raised a concern to NHS England and Improvement Patient Safety, following several reported incidents noting that organisations may not be using the latest version of The Manchester Triage System clinical risk management triage tool. Old versions of the system have outdated treatment/priority parameters for adult and paediatric sepsis that could affect patient outcome. The updated Manchester Triage System can be accessed from the link below. -
News Article
CQC to expand inspection programme from April
Patient Safety Learning posted a news article in News
More Care Quality Commission (CQC) inspections will take place from next month as pressures from COVID-19 continue to ease. Board papers published ahead of a meeting on Wednesday have revealed the CQC will return to inspecting and rating NHS trusts and independent healthcare services which are rated “inadequate” or “requires improvement”, alongside those where new risks have come to light. From April, the CQC also plans to carry out well-led inspections of NHS and private mental healthcare providers, and programmes of focused inspections on the safety of maternity departments and providers’ infection prevention processes. Focused inspections into emergency departments, which the CQC began in February, will continue. Inspections into GP services rated “requires improvement” and “inadequate” will also resume in April, focusing on safety, effectiveness and leadership. Finally, the papers said the watchdog would prioritise inspections of “high-risk” independent healthcare services, such as ambulances, cosmetic surgery or where closed cultures may exist. Read full story (paywalled) Source: HSJ, 24 March 2021 -
Content ArticleIn this paper, published by the Tony Blair Institute, authors combine data from the Covid Symptom Study with emerging evidence from the broader scientific community to understand what we do and don’t know about those suffering with long-term symptoms of COVID-19. Properly understanding the scope and scale of the issue of Long COVID is critical in both communicating and balancing the overall risk of the virus.
