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Showing results for tags 'Risk assessment'.
Found 206 results
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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.
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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 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 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.
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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).
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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 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.
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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.
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EventuntilThe Flight Safety Foundation goal with this Seminar is to promote further globally the practical implementation of the concepts of system safety thinking, resilience and Safety II. There will be two sessions, one for each day, that will consist of briefings and a Q&A panel afterwards. The following themes are suggested for briefings and discussions for the Seminar 1.The limits of only learning from unwanted events. 2. Individuals’ natural versus organisations’ consciously pursued resilience. 3. How the ancient evolutionary individual instincts for psychological safety affect individual and team learning and how these can be positively managed? 4. The slow- and fast-moving sands of operations and environment change over time and their significance for safety. 5. How to pay as much attention to why work usually goes well as to why it occasionally goes wrong? 6. Understanding performance adjustments of individuals to get the job done. 7. The blessings and perils of performance variability. 8. Learning from data versus learning from observing. 9. Learning from differences in operations versus learning from monitoring for excrescences. 10. Can risk- and resilience-based concepts work together? 11. Does just culture matter for learning from success? 12. How to document explicitly, maintain current and use the information about success factors and safety barriers and shall this be a part of organisational SMS? Further information
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Content Article
Pressure Ulcer Path: prevent and treat step by step
Patient Safety Learning posted an article in Pressure ulcers
Research has shown that frontline staff understand the dangers of pressure sores but experience significant challenges in their attempts to prevent them. The research, undertaken by NHS Midlands and East and downloadable below, showed that staff feel they do not have the time to treat patients and need improved communication between the patients, their carers and the homes from which they might have come. In response to this, NHS Midlands and East has created the Pressure Ulcer Path, a tool to support staff in preventing pressure ulcers and treating them, alongside a number of useful resources. -
Content ArticleRoot Cause Analysis (RCA) is a generic method used in quality improvement and patient safety projects. In patient safety, it should help teams to ‘get to the bottom’ of the circumstances that led or could lead to an incident and take appropriate and effective action to prevent the recurrence of the incident or minimise the probability of recurrence. Find out more about RCA in this Healthcare Quality Quest booklet.
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Content Article
Prostate Cancer UK: risk checker
Patient Safety Learning posted an article in Men's health
Prostate cancer is the most common cancer in men, but most men with early prostate cancer don’t have symptoms. So what should you do? Click the link below and and answer three quick questions to find out. -
Content ArticleIn this Anaesthesia editorial, Simoes and Bhangu, on behalf of the CovidSurg Collaborative, outline why and how elective surgery must restart. "COVID‐19‐free pathways will be crucial for patient safety during the COVID‐19 pandemic, as they seem to lead to low rates of SARS‐CoV‐2 infection rates and complications. Further preventive measures and patient level risk assessment will allow surgery to safely restart and continue during this, and future, crises." This editorial accompanies an article by Kane et al. Anaesthesia 2020; 75: 1596–1604.
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Content ArticleOur understanding of race and human genetics has advanced considerably, yet these insights have not led to clear guidelines on the use of race in medicine. The result is ongoing conflict between the latest insights from population genetics and the clinical implementation of race. For example, despite mounting evidence that race is not a reliable proxy for genetic difference, the belief that it is has become embedded, sometimes insidiously, within medical practice. One subtle insertion of race into medicine involves diagnostic algorithms and practice guidelines that adjust or “correct” their outputs on the basis of a patient’s race or ethnicity. Physicians use these algorithms to individualise risk assessment and guide clinical decisions. By embedding race into the basic data and decisions of health care, these algorithms propagate race-based medicine. Many of these race-adjusted algorithms guide decisions in ways that may direct more attention or resources to white patients than to members of racial and ethnic minorities. To illustrate the potential dangers of such practices, Vyas et al. have compiled a partial list of race-adjusted algorithms.
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Content ArticleOperating theatre fires remain an uncommon but real safety risk for patients undergoing nearly all types of procedures, and despite ongoing safety initiatives, occur more commonly than wrong-site surgeries. One of the most compelling cases for safety improvement in the surgical setting is within this area. Combining the simple steps of operating theatre team education; improving lines of communication between surgeons, anaesthetists, and operating theatre nurses or practitioners; and the deliberate separation of the elements of the fire triangle can almost completely eliminate the incidence of surgical fires. In this brief review, Cowles Jr and Culp Jr hope that readers will be able to reduce the risk of surgical fires effectively by the application of the safety principles described.
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Content Article
Tim Stephens is a researcher at Queen Mary University of London and Barts Health NHS Trust and a qualified intensive care nurse. He is currently working with a large team of clinicians, patients and scientists to investigate how older people make decisions about having major surgery. In this blog, Tim talks about shared decision-making, individual impact and the need for better data to help clinicians quantify risk.- Posted
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Content ArticleClift et al. have developed a new risk prediction tool that estimates a person’s chance of hospitalisation and death from COVID-19. The algorithm, which was constructed using data from more than eight million people across England, uses key factors such as age, ethnicity and body mass index to help identify individuals in the UK at risk of developing severe illness.
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Content ArticleOn 24 June, NHS E&I mandated that all trusts perform occupational risk assessments of vulnerable NHS workers. Public Health England has also called for “accelerated development of culturally competent occupational risk assessment tools”. Rainbird Technologies has developed a tool with a SEQOHS-accredited NHS occupational health service. It is approved by a clinical safety review panel and being used by multiple NHS trusts. Follow the link below if you would like to request access to the tool for your trust.
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Content ArticleThe aim of this study from Jardine et al. was to determine the rate of complicated birth at term in women classified at low risk according to the National Institute for Health and Care Excellence guideline for intrapartum care (no pre-existing medical conditions, important obstetric history, or complications during pregnancy) and to assess if the risk classification can be improved by considering parity and the number of risk factors. The authors found nulliparous women without risk factors have substantially higher rates of complicated birth than multiparous women without a previous caesarean section even if the latter have multiple risk factors. Grouping women first according to parity and previous mode of birth, and then within these groups according to presence of specific risk factors would provide greater and more informed choice to women, better targeting of interventions, and fewer transfers during labour than according to the presence of risk factors alone.
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Content ArticleAlthough airway safety is known to be one of the key components in safe care, thousands of patients lose their lives each year to poor airway management and unplanned extubations. In this Patient Safety Movement webinar, the team discusses starting an unplanned extubation project without buy-in from others, multi-institutional collaboration, pushback from leaders, colleagues, or other organisations, the future of interventions, clinicians who have experience with unplanned extubations as key advocates, and cross-checking pediatric and adult safety efforts. The panel ends with Drew Hughes’ story and the team emphasises taking a moment to ground yourself in your practice and the importance of speaking up when you think the patient is at risk.
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Content ArticleScienceDirect uses heuristic and machine-learning approaches to extract relevant information from their extensive collection of content. They compile this information on a topic-by-topic basis providing the reader both depth and breadth on a specific area of interest. This collection of research and data focuses on safety risk management.
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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.
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Content ArticleFollowing the publication of Donna Ockenden’s first report: Emerging Findings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospitals NHS Trust on 11 December 2020, the NHS has issued this latest update. Read previous letter update
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Content ArticleThe Health Index is a new tool to measure a broad variety of health outcomes and risk factors over time, and for different geographic areas. This methodology article explains how the Health Index has been constructed.
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Content Article
Surgical Outcome Risk Tool v2 (SORT)
Patient Safety Learning posted an article in Surgery
Some patients die after major surgery. Risk prediction tools can help shared decision making with the patient, aiding decisions on whether to operate, how to prepare and use of critical care. An international multi-centre prospective observational cohort study in 274 sites with 22,631 patients compared risk prediction with 30-day mortality. In 88.7% of cases clinicians exclusively used subjective assessment. The best predictions were from the SORT tool combined with clinical assessment. P-POSSUM Surgical Risk Scale, SRS and SORT all over-predicted risk, with SORT performing best. This 10-question SORT model has been updated including clinician assessment and provides an accurate means of predicting perioperative risk.
