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Showing results for tags 'Risk management'.
Found 338 results
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Content ArticleA framework for NHS Trusts and NHS Foundation Trusts on identifying, reporting, investigating and learning from deaths in care set out by the National Quality Board in 2017.
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Content ArticleNHS England helps illustrate the benefits of business continuity planning and how the planning is implemented during a response. Case studies have been put together from various incident debrief reports from organisations to provide examples of approaches to incident reports and also allow identification of learning across organisations
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Content ArticleThis pack is for acute, specialist, mental health and community trust boards and specifically trust non-executive directors (NEDs) and non-clinical executive directors. It explains what boards are expected to do in relation to the Learning from Deaths framework.
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WHO surgical safety checklist (1st edition, 2009)
Patient Safety Learning posted an article in WHO
The World Health Organization's surgical safety checklist to be used in all hospitals in the UK. -
Content ArticleHealthcare Safety Investigation Branch (HSIB) report on the inadvertent administration of an oral liquid medicine into a vein. This report indicated the importance of using human factors in the investigation process. The investigation reviewed the effectiveness of the current processes for the storage of medicines, equipment design, and the prescribing, preparation, checking and administration of medication. It also considered the contextual, environmental and human factors that influenced the inadvertent administration of an oral solution into a vein. The effectiveness of current processes for implementation of local safety standards for invasive procedures was also considered. A human factors expert was involved in the investigation and a dedicated report was written based on the evidence reviewed, a reconstruction of the event and a simulation of what should have happened.
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Content ArticleA presentation by Shelia Yates on root cause analysis and Just Culture. Shelia is trained and educated in the performance of behaviour health services through interpersonal communications and analysis.
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Content ArticleThe Just Culture Guide from NHS Improvement supports a conversation between managers about whether a staff member involved in a patient safety incident requires specific individual support or intervention to work safely. It asks a series of questions that help clarify whether there truly is something specific about an individual that needs support or management versus whether the issue is wider, in which case singling out the individual is often unfair and counter-productive. It helps reduce the role of unconscious bias when making decisions and will help ensure all individuals are consistently treated equally and fairly no matter what their staff group, profession or background.
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WHO Safe Childbirth Checklist (December 2015)
Patient Safety Learning posted an article in WHO
Of the more than 130 million births occurring each year, an estimated 303 000 result in the mother’s death, 2.6 million in stillbirth, and another 2.7 million in a newborn death within the first 28 days of birth. The majority of these deaths occur in low-resource settings and most could be prevented. The World Health Organization (WHO) has produced a safe birth checklist. -
Content ArticleThe Healthcare Safety Investigation Branch (HSIB) launched an investigation following the referral of a case from an acute trust involving failure of oxygen delivery during a resuscitation. The case highlighted several issues related to the safe delivery of oxygen from portable systems.
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Content ArticleEvery year, avoidable unsafe care harms and kills thousands of people in the UK, with the NHS estimating that there are 11,000 deaths annually due to patient safety incidents. This causes not only untold physical and emotional damage but it also creates a huge financial burden, with the annual cost to the NHS of unsafe care and litigation standing at close to £5 billion. It is important that when organisations are considering the workplace as a whole system, safety should be at the core of its design. This blog discusses the impact of COVID-19 and workforce pressures on patient safety and outlines key considerations for Boards as we return to 'normal'.
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Content ArticleIn the past 10 years, rates of Obstetric Anal Sphincter Injury (OASI) have increased in England. Experiences in some maternity units have shown that some of the underlying problems related to this rise in OASI include:Inconsistencies in approaches to preventing OASIsInconsistencies in training and skillsLack of awareness of risk factors and long-term impact of OASIsVariation in practice between health professionalsIn light of this, the OASI care bundle team have developed and piloted an intervention package, including a care bundle and guide, a multidisciplinary skills development module for health care professionals, and campaign materials (such as leaflets and newsletters designed to raise awareness).This scaling up programme is a collaboration between the Royal College of Obstetricians and Gynaecologists (RCOG), Croydon Health Services NHS Trust, the Royal College of Midwives (RCM) and the London School of Hygiene and Tropical Medicine (LSHTM), with funding provided by The Health Foundation.
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Content ArticleIn response to the pandemic earlier this year, the priority became freeing up as much bed and staffing capacity as possible within hospitals in anticipation of the incoming tide of COVID-19 patients. One way of doing this was postponing all non-urgent elective operations for a period of at least three months. It was estimated that this would free up 12,000-15,000 hospital beds in England alone. This approach was successful in the short-term, helping the NHS to meet the immediate demand created by the pandemic. However, it has produced a longer-term challenge as we transition back to ‘normal’ with a large backlog of cases. Decisions about how these are prioritised will have significant implications for the health and wellbeing of patients. In this blog, Patient Safety Learning look at the patient safety implications and highlight where we need to focus on to avoid patient harm. Read the full blog on the Patient Safety Learning website.
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Content ArticleA 14 minute TEDx talk by Niall Downey, a doctor and pilot, exploring how healthcare could modify aviation's approach to error for use in managing and reducing adverse events to improve patient safety.
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Content ArticleThe National Falls Prevention Coordination Group has identified resources to address Covid-19 related falls and fracture issues including advice for patients on keeping active following hospital discharge. The advice leaflet has been designed for patients who are discharged home with no community rehabilitation and can be download via the Chartered Society of Physiotherapy link below. It explains why muscle wasting occurs with prolonged bed rest or inactivity and why it is important to be active when discharged home from hospital.
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NHS trade unions’ blueprint for return (May 2020)
PatientSafetyLearning Team posted an article in Exit strategies
As we enter what could be the start of a gradual easing of lockdown restrictions, discussion has turned to how the NHS restarts those services that were stepped down during the peak of the COVID-19 pandemic. In this document, 16 NHS trade unions That is why 16 NHS trade unions are asking UK governments and employers to work with them to deliver their Blueprint for Return, in which they set out 9 key recommendations. -
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Infection control tips for dental patients
Claire Cox posted an article in Infection control
This video is to help dental patients make sure they are getting safe care from their dental practitioners. Developed by the Dental Board of Australia, it aims to: help patients know what infection prevention and control protocols to expect when visiting their dental practitioner encourage patients to ask their treating dental practitioner questions about infection prevention and control and how their treating dental practitioner can ensure that they meet their infection control obligations to inform patients on what to do if they have a concern about their dental practitioner’s infection control practices. -
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COVID-19: guidance for health professionals (Coronavirus)
Claire Cox posted an article in Guidance
Information on COVID-19, including guidance on the assessment and management of suspected UK cases. -
Content ArticlePresentation from WHO's 'A Decade of Patient Safety 2020-2030: Formulating Global Patient Safety Action Plan' patient safety meeting in Geneva.
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Content ArticleMedicines optimisation and shared decision making are frequently used buzzwords, but what do these terms mean in practice? Steve Turner shares some patient stories to reflect on.
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Content ArticleDr Hein Le Roux is Primary Care Patient Safety GP Lead at the West of England Academic Health Science Network. Here Hein interviews Dr Emma Redfern on their programme to encourage the use of the National Early Warning Score (NEWS), followed by a conversation with Dr Sheena Yerburgh on a standardised admission sheet they have helped to develop, which is being used by GPs in the Gloucestershire area when referring patients to emergency departments.
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Content ArticleIn this powerful blog, the author draws upon personal experience and insight to explain why she campaigns for carers and patients to have access to their own health records, and the difference this would make to patient safety. "Despite continued promises of access to all our health information by successive politicians and the talk of new gateways to our health information linking primary, secondary and social care, to people like us it seems as far away as ever. We hear about the Empowering the Person initiative, projects to improve data flows, data standards and all those new Apps but citizens like us are still as helpless as ever standing next to that stretcher in A/E without the very basic information to save our loved one’s life in a crisis."
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Content ArticleThe novel coronavirus began circulating in China in December 2019. The number of confirmed cases and deaths from this pneumonia-like condition are rising. This page is where all BMJ coverage of the coronavirus outbreak can be found. All articles and resources are freely available.
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Content ArticleIn this PharmaTimes article, Anna Smith discusses a survey, published by Medicspot, that has revealed that pharmacists are “worried” about the supply of medicines to the UK, after we officially left the European Union (EU) on 31 January 2020.
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Content ArticleThe objective of this study, published in the Journal of Clinical Nursing, was to determine the predictive value of individual and combined dutch-early-nurse-worry-indicator-score indicators at various Early Warning Score levels, differentiating between Early Warning Scores reaching the trigger threshold to call a rapid response team and Early Warning Score levels not reaching this point.
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Content ArticleIn 1991, the Institute of Medicine released a landmark report revealing that as many as 98,000 patients a year were dying due to avoidable medical error. But even more recent research indicates that estimate was, if anything, a drastic understatement of the patient-safety crisis in the US healthcare system. In Malpractice, neurosurgeon and attorney Dr. Larry Schlachter demonstrates how most patients enter the system without any idea of the risks they face due to a medical culture that avoids transparency, perpetuates an atmosphere of blind deference to doctors, and protects dangerous doctors from any accountability. Drawing on twenty-three years of experience, Dr. Schlachter recounts unbelievable stories that illustrate the host of risks patients face whenever they seek diagnostic evaluation or go under the knife. This book brings readers inside the healthcare citadel, exposing the flawed culture that can fuel egos and outlining the steps every patent should take to protect himself or herself in “a bitter pill for an industry that for many years has avoided the hardest conversations about patient safety.”—Dr. Michael Dogali, MDCM, FACS, president of Pacific Neurosurgery
