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Showing results for tags 'Risk management'.
Found 339 results
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Content ArticleRisk scores are widely used in healthcare, but their development and implementation do not usually involve input from practitioners and service users and carers (SU/C). This study from Dyson et al., published in BMJ Open contributes to the development of The Computer-Aided Risk Score (CARS) by eliciting views of staff and who provided important, often complex, insights to support the development and implementation of CARS to ensure successful implementation in routine clinical practice.
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Content ArticleOver the last two decades, safety improvements have flat-lined (as measured in fatalities and serious injury rates, for instance) despite a vast expansion of compliance and bureaucracy. The cost of compliance and bureaucracy can be mind-boggling – up to 10% of GDP, with every person working some 8 weeks per year just to cover the cost of compliance, paperwork and bureaucratic accountability demands. This is non-productive time. It has also stopped progressing safety.
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Content ArticleThe act of open disclosure of an adverse event alone may not be enough for patients or their families. Patients and patient advocates are asking for increased transparency and a greater role in the process of change. When properly handled, involving patients in post‐event analysis allows risk management professionals to further improve their organisation's systems analysis process while empowering patients to be part of the solution. First published by the US-based Journal of Health Care Risk Management, this article examines the legal and psychological considerations surrounding the involvement of patients in system failure analysis and provides tools for selecting patients who are able to benefit from this process and for adequately preparing patients and caregivers for what lies ahead.
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Content Article"Among many other opportunities created by the launch of the World Alliance for Patient Safety is the hope that one day the learning from the inadvertent death of a patient in a hospital in one country could save the lives of many others around the world." In his paper, Sir Liam Donaldson (Chair of the WHO World Alliance for Patient Safety at the time) talks about the importance of global collaboration for patient safety.
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Content ArticleEffective teamwork is critical to successful outcomes in pediatric cardiac surgery. Unfortunately, lapses in professional performance and conduct by those who treat paediatric cardiac patients pose threats to quality and safety. One hallmark of a profession is self regulation. Therefore, healthcare leaders need specific means for identifying and addressing those lapses and indicators of unsafe systems or individuals. This article from Pichert et al. describes an initial “near miss” event involving a paediatric cardiac surgeon. While fictional, the case represents a composite of events involving several paediatric cardiac surgeons who practice at different medical centers throughout the US.
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Content ArticlePractice staff should use the GP e-form to report all patient safety incidents and near misses whether they result in harm or not. These reports are used by to spot any emerging patterns of similar incidents or anything of particular concern. This will help protect patients by raising awareness of the risks through shared learning with general practices and other health providers across the country.
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Content ArticleAbout one in ten patients are harmed during health care. Published on the OECD Library website, this paper estimates the health, financial and economic costs of this harm. Results indicate that patient harm exerts a considerable global health burden. The financial cost on health systems is also considerable and if the flow-on economic consequences such as lost productivity and income are included the costs of harm run into trillions of dollars annually. Because many of the incidents that cause harm can be prevented, these failures represent a considerable waste of healthcare resources, and the cost of failure dwarfs the investment required to implement effective prevention.
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Content ArticleIn his article for KevinMD.com, Ashish Jha looks at the metrics associated with hospital acquired conditions (HACs) in the US. He discusses the imperfections of HAC scored and argues that we need better measures in order to make further progress in the field of patient safety.
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Content ArticleEighteen years after the advent of the National Patient Safety Agency (NPSA) why is investigating in such a parlous state? Ed Marsden, Managing Director of independent investigative consultants Verita, discusses why making improvements to patient safety comes second place to sorting out problems with the investigative process.
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Content ArticlePublished by wbur, an American news station, this account from a doctor tells the story of his father's admission to hospital. Dr. Ashish Jha lists a catalogue of errors that took place over those few days, notes how common these mistakes are and argues we should be less tolerant of poor patient safety in healthcare.
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Content Article
Letter from America: A Grand Adventure
lzipperer posted an article in Letter from America
‘Letter from America’ is a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. The series will cover successes large and small. I share them here to generate conversations through the hub, over a coffee and in staff rooms to transfer these innovations to the frontline of UK care delivery.- Posted
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Community PostHi everybody This is Jaione from Spain (we are in the North, Basque Region) and i am a nurse working in collaboration with the Patient Safety Team in our local NHS (Basque Health Service). First of all, I would like to congratulate the team for this hub which i think is a wonderful idea. Secondly, i would like to apologize for the language, since, although i lived in England many years ago, that is not the case anymore and I'm afraid i don't speak as well as I used to. I would like to comment a problem that we encounter very often in our organization which is related to patient's regular medications when they are admitted to hospital. We do have online prescriptions for both acute and community settings but the programs don't really speak to each other so, for example, if I take a blood pressure pill everyday and i get admitted into hospital, chances are that my blood pressure tablet won't get prescribed during my in-hospital stay. The logical thing to do would be to change both online systems so they communicate to each other, but that's not possible at the moment. I wanted to ask whether other systems have the same problem and, if so, if there is any strategy implemented to alleviate this issue. I hope i have expressed myself as clearly as possible. Thanks very much once more for this hub! Kind regards Jaione
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Content Article
Clinical Risk Management Training
HannahMcCann posted an article in Specialist patient safety training
A large part of our role is delivering training in Clinical Risk Management. -
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NHS Digital’s Clinical Safety team – Our day to day work
HannahMcCann posted an article in NHS Digital
On a day to day basis, the NHS Digital Clinical Safety team are involved in several wide-ranging and very different projects. As you know, clinical safety should be part of everything the NHS do. Every project, every programme, every deployment. Clinical safety should be considered, understood and implemented to the highest calibre. So as you can imagine, we are a busy team. For those manufacturers with systems in use, we deal with live incidents, upgrades, further geographical or functionality deployments. For those creating new systems we are supporting them in their clinical risk management process, running hazard workshops, creating hazard logs and writing the supporting documentation. We are constantly reviewing and peer reviewing, assessing compliance and marking against the standard requirements. We assist suppliers and health organisations to self-audit their compliance against the standards so they may improve their clinical safety position. We are assessing new and emerging apps and mobile health solutions to ensure they are going through the same standard of assessment as the traditional computer-based systems and we are providing representation across the NHS to ensure clinical safety remains paramount to the work being done. One of the biggest branches of our role is training delivery. We know first-hand the importance of having a team that are educated and confident in clinical risk management. -
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MHRA: The Yellow Card Scheme
Claire Cox posted an article in Adverse interactions
The Yellow Card Scheme helps the Medicines and Healthcare products Regulatory Agency (MHRA) monitor the safety of all healthcare products in the UK to ensure they are acceptably safe for patients and those who use them. On the Yellow Card Scheme website you can report a suspected incident or problem. -
Content ArticleThe Institute for Safe Medication Practices (ISMP) is the only US nonprofit organisation devoted entirely to preventing medication errors. In this short video, produced by ISMP in partnership with the Temple University School of Pharmacy, experts discuss current medication safety concerns and offer practical error prevention recommendations.
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Content ArticleThe Institute for Safe Medication Practices (ISMP) is the only nonprofit organisation in the US devoted entirely to preventing medication errors. In this video, produced by ISMP in partnership with the Temple University School of Pharmacy, experts discuss medication safety concerns and offer practical error prevention recommendations.
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Content ArticleThe Care Quality Commission (CQC) is the independent regulator of health and adult social care in England. We make sure that health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve. When CQC inspects health and care services they assess how well these services meet people’s needs. As part of this, they look at how people’s medicines are optimised. Medicines optimisation is the safe and effective use of medicines to enable the best possible outcomes for people. It also looks at the value that medicines deliver, making sure that they are both clinically and cost effective, and that people get the right choice of medicines, at the right time, with clinicians engaging them in the process.
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Content ArticleThe use of health technology has grown exponentially in the past few decades, and the proliferation and complexity of this technology has led to new risks to patient safety. The Institute of Medicine (IOM) discussed this issue in their report, Health IT and Patient Safety: Building Safer Systems for Better Care, and concluded that achieving better health care requires “a robust infrastructure that supports learning and improving the safety of health IT.”
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Content ArticleDoctors feel that they are increasingly expected to treat patients in an unsafe, unsupportive environment, contributing to a vicious cycle of low morale and poor rates of recruitment and retention. This can and must change. This British Medical Association (BMA) report draws on the experience and expertise of BMA members across all branches of medical practice in the UK. It outlines where change is needed to ensure we safeguard patient care, make the NHS a great place to work and transform services for the better. This report sets out specific recommendations aimed at government and NHS bodies.
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Content ArticleThe Medicines and Healthcare products Regulatory Agency (MHRA) regulates medicines, medical devices and blood components for transfusion in the UK. MHRA is an executive agency, sponsored by the Department of Health and Social Care. Recognised globally as an authority in its field, the agency plays a leading role in protecting and improving public health and supports innovation through scientific research and development. The agency has 3 centres: Clinical Practice Research Datalink (CPRD), a data research service that aims to improve public health by using anonymised NHS clinical data the National Institute for Biological Standards and Control (NIBSC), a global leader in the standardisation and control of biological medicines the Medicines and Healthcare products Regulatory Agency (MHRA), the UK’s regulator of medicines, medical devices and blood components for transfusion, responsible for ensuring their safety, quality and effectiveness.
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Content ArticleIdentification of hospitalised patients with suddenly unfavorable clinical course remains challenging. Models using objective data elements from the electronic health record may miss important sources of information available to nurses.
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Content ArticleA three-year programme launched in February 2017 to support improvement in the quality and safety of maternity and neonatal units across England - formerly known as the Maternal and Neonatal Health Safety Collaborative. NHS Improvement aim to: improve the safety and outcomes of maternal and neonatal care by reducing unwarranted variation and provide a high quality healthcare experience for all women, babies and families across maternity and neonatal care settings in England contribute to the national ambition, set out in Better Birthsopens in a new window of reducing the rates of maternal and neonatal deaths, stillbirths, and brain injuries that occur during or soon after birth by 20% by 2020.
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Content ArticleThe Academic Health Science Network’s (AHSN) plan 'Patient safety in partnership' has been developed to support the NHS Patient Safety Strategy and sets out how England’s 15 AHSNs, and the Patient Safety Collaboratives (PSCs) they host, will work more closely with their local health and care organisations to improve safety both in hospitals and community-based services such as care homes.
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Content ArticleInfants born preterm or with complex congenital conditions are surviving to discharge in growing numbers and often require significant monitoring and coordination of care in the ambulatory setting. This toolkit, produced in the US, includes resources for hospitals that wish to improve safety when newborns transition home from their neonatal intensive care unit (NICU) by creating a Health Coach Program, tools for coaches, and information for parents and families of newborns who have spent time in the NICU.
