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Showing results for tags 'Risk management'.
Found 338 results
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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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Content Article
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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Content Article
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 ArticleThis Healthcare Safety Investigation Branch (HSIB) report looks at the transfer of critically ill adults. It has previously been referred to as 'Cardiac and vascular pathways', but the original investigation was split. This is part one of the investigation and part two, with a focus on the clinical diagnosis of aortic dissection, is due to be published in Spring 2019.
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Content ArticleRisk management has a number of accident causation models that have been used for a number of years. Dr Nancy Leveson has developed a new model of accidents using a systems approach. The new model is called Systems Theoretic Accident Modeling and Processes (STAMP). It incorporates three basic components: constraints, hierarchical levels of control, and process loops. In this model, accidents are examined in terms of why the controls that were in place did not prevent or detect the hazard(s) and why these controls were not adequate to enforcing the system safety constraints. Altabbakh et al. present STAMP accident analysis and its usefulness in evaluating system safety is compared to more traditional risk models. STAMP is applied to a case study in the oil and gas industry to demonstrate both practicality and validity of the model. The model successfully identified both direct and indirect violations against existing safety constraints that resulted in the accident at each level of the organisation.
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Content ArticleThe Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, presents evidence-based recommendations on the preferred methods for cleaning, disinfection and sterilisation of patient-care medical devices and for cleaning and disinfecting the healthcare environment. This is an American guidance from the Centers for Disease Control and Prevention.
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Content ArticleThe American based ECRI Institute Patient Safety Organization (PSO), identified 234 events in its database pertaining to dirty surgical instruments. This report contains several recommendations based on the findings.
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Content ArticleThis American report describes events involving dirty instruments submitted to ECRI Institute Patient Safety Organization and other reporting agencies. It provides recommendations to improve reprocessing practices, with a focus on instrument decontamination and the cleaning that occurs before disinfection or sterilisation.
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Content ArticleThis is a Health Technical Memorandum (HTM) published by the Department of Health and Social Care (DHSC) called Management and decontamination of surgical instruments (medical devices) used in acute care. Part A: Management and provision. The purpose of this HTM is to help health organisations to develop policies regarding the management, use and decontamination of reusable medical devices at controlled costs using risk control, which will enable them to comply with Regulations 12(2)(h) and 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 . It is designed to reflect the need to continuously improve outcomes in terms of: patient safety clinical effectiveness patient experience.
