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Showing results for tags 'Risk assessment'.
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Content ArticleIntrahospital transport is a common occurrence for many hospitalised patients. Critically ill children are an especially vulnerable population who experience preventable adverse events at least once a week, on average. Transporting these patients throughout the hospital introduces additional hazards and increases the risk of adverse events. The transport process can be decomposed into a series of steps, each incurring specific risk. These risks are numerous and few of these risks are specific to the transport process. There is a paucity of literature available on paediatric intrahospital transport and related adverse events. Elliot et al. recently reviewed the Wake Up Safe database, a paediatric anesthesia quality improvement initiative across member institutions to disseminate information on best practices, for paediatric perioperative adverse events associated with anaesthesia-directed transport. The authors present several examples of airway and respiratory events taken from the database and discuss the complexity of the transport process.
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- Patient safety incident
- Paediatrics
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Content ArticleThe tragic and preventable death of Ruth Perry, headteacher at a school downgraded by an Ofsted inspection, has sparked calls for a review of regulatory oversight. While safety and quality must be assured, it’s crucial to consider the impact of regulatory inspections on the well-being of passionate workforces facing complex and challenging environments. In this blog, healthcare entrepreneur Vanessa Webb makes the case that as a potential cause of harm to staff, regulatory inspections in public services including healthcare should be subject to Health and Safety Risk Assessments. There should be a systematic process to identify hazards, evaluate the likelihood and severity of harm, and determine appropriate controls to prevent or mitigate those risks.
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- Risk assessment
- Regulatory issue
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Content Article
Patient Safety Indicator Measures (AHRQ)
Patient_Safety_Learning posted an article in Improving patient safety
The Patient Safety Indicators (PSIs) provide information on potentially avoidable safety events that represent opportunities for improvement in the delivery of care. More specifically, they focus on potential in-hospital complications and adverse events following surgeries, procedures, and childbirth. You can find out more about PSIs and access related resources, on the Agency for Healthcare Research and Quality (AHRQ) website via the link below.- Posted
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- Risk management
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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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- Investigation
- Patient death
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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- Posted
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- Surgeon
- Anaesthetist
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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 -
News ArticleAlmost half of NHS Trusts in England have reported risks classified as “significant” or “extreme”, with issues facing funding, buildings and failing equipment, according to an analysis by Labour. Highlighting warnings of staff shortages and patient safety, the party demanded urgent action from the government to prepare the health service for the winter months as cases of COVID-19 accelerate across the country. Labour said its study of 114 NHS Trusts’ risks registers showed that over three quarters of trusts logged a workforce risk. The analysis also revealed that 66% reported a financial risk, 82% highlighted risks directly related to COVID-19 and 84% recorded a risk to patient safety. Almost half of Trusts (54), the party said, had outlined risks described as “significant” or “extreme”. One hospital trust reported it was “not financially stable” beyond the current financial year while another recorded a potential risk to patient safety due to “structural deficiencies” in roof structure. NHS hospitals are expected to consider risks to their operations and processes and when risks are identified, it is likely they will have been considered at board level and mitigations put in place. Describing the registers – compiled between March and August - as “worrying” in a normal winter, Jonathan Ashworth, the shadow health secretary, said: “In the coming winter, with the incompetent handling of the test and trace system leaving the NHS wide open and poorly supported, they take on a whole new meaning." "We urgently need a commitment from ministers to fix the problems with test and trace and a timetable by which these issues will finally be sorted. On top of this it is vital that ministers confirm that the NHS will get the additional support it needs to address these risks." Read full story Source: The Independent, 6 October 2020
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- Risk assessment
- Health and safety
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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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- Hospital ward
- Patient death
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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- Posted
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- Quality improvement
- Risk assessment
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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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- Healthcare
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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 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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- Patient / family involvement
- Behaviour
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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.- Posted
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- Adminstering medication
- Patient harmed
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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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- Mental health
- Mental health unit
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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 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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- Surgery - Trauma and orthopaedic
- Patient
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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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- Staff safety
- Pandemic
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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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- Pregnancy
- High risk groups
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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.- Posted
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- Organisational culture
- Staff support
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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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- Coroner
- Coroner reports
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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.
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- Negligence claim
- Risk assessment
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Content ArticleThis prospective study aimed to determine the surgical site infection (SSI) rate and associated risk factors was carried in a general surgical ward at Liaquat University Hospital Jamshoro. A total of 460 patients requiring elective general surgery from July 2005 to June 2006 were included in this study. All four surgical wound categories were included. Primary closure was employed in all cases. Patients were followed up to 30th day postoperatively. All cases were evaluated for postoperative fever, redness, swelling of wound margins and collection of pus. Cultures were taken from all the cases with any of the above finding. The overall rate of surgical site infection was 13·0%. The rate of wound infection was 5·3% in clean operations, 12·4% in clean‐contaminated, 36·3% in contaminated and 40% in dirt‐infected cases. Age, use of surgical drain, duration of operation and wound class were significant risk factors for increased surgical site infection.. Postoperative hospital stay was double in cases who had surgical site infection. Sex, haemoglobin level and diabetes were not statistically significant risk factors. In conclusion, surgical site infection causes considerable morbidity and economic burden. The routine reporting of SSI rates stratified by potential risk factors associated with increased risk of infection is highly recommended.
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- Surgery - General
- Healthcare associated infection
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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.
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- Adminstering medication
- Patient harmed
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