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Showing results for tags 'Risk management'.
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Content ArticleIn this blog, Dr Nadeem Moghal looks at the recent case of a 30 year-old patient who died after a physician associate (PA) at her GP surgery failed to diagnose her with a pulmonary embolism. He outlines a recent debate about the role of PAs in general practice and why employing them has become an attractive option for GP partnerships, which run as businesses. He highlights the need for PAs to be adequately trained and supervised to ensure patient safety and argues that the role is here to stay as PAs play an important role in tackling gaps in the NHS workforce.
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EventISO 45003:2021(E) is a guidance document that provides practical advice on managing psychosocial risks in the workplace. This document is designed to help organisations prevent work-related injury and ill health of their workers and other interested parties, and to promote well-being at work. This masterclass will explore the key concepts of ISO 45003:2021(E) and how they apply specifically to healthcare settings. It will discuss strategies for identifying and assessing psychosocial risks, implementing preventive measures, monitoring effectiveness, and promoting well-being in the workplace. The goal is for you to leave this masterclass with a comprehensive understanding of how ISO 45003:2021(E) can be used to manage psychosocial risks in your own organization. You will also have an opportunity to share best practices with colleagues from other healthcare organisations. Who should attend: Clinical staff, Managers, Admin staff, Policy makers and Board members. Key learning objectives: Participants will have a comprehensive understanding of psychosocial risks in the healthcare workplace. Participants will be able to identify preventive measures that can be implemented to manage these risks. Participants will understand the importance of monitoring and evaluating the effectiveness of these measures. Participants will have an increased awareness of their own well-being and safety in the workplace. Participants will have an opportunity to share best practices with colleagues from other healthcare organisations. Register
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Content ArticleThis study in the American Journal of Surgery aimed to understand the impact of operating room temperature and humidity on surgical site infection (SSI). The authors found that large deviations in operating theatre temperature and humidity do not increase the risk of SSI.
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Content ArticleThis resource published by pharmaceutical company BD provides information on common complications of IV catheter therapy, including signs and symptoms and prevention. It covers the following complications: Catheter-related bloodstream infection Dislodgement Extravasation Infiltration Occlusion Phlebitis Thrombosis
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Content Article
Can you measure safety? Part 1
NMacLeod posted an article in Improving patient safety
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In a three-part series of blogs for the hub, Norman Macleod explores how systems behave and how the actions of humans and organisations increase risk. He argues that, to measure safety, we need to understand the creation of risk. In this first blog, Norman looks at the problems of measuring safety, using an example from aviation to illustrate his points.- Posted
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Content ArticleThis report makes several recommendations to unlock the preventative potential of Prevention of Future Deaths (PFD) Reports. These reports should be viewed as an opportunity for organisations to improve, share good practice, and ultimately prevent custodial deaths – not as criticism to be avoided at all costs. PFD reports have an integral function in ensuring compliance with the state’s duties under Article 2 of the European Convention of Human Rights (ECHR), the right to life, both locally and nationally. This, as well as their immense importance to bereaved families, must be borne firmly in mind.
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Content ArticleThese charts have been collaboratively developed by clinical teams across England to standardise how the deterioration of children in hospital is tracked. There are four charts for children of different ages, designed to be used on general children’s wards. PEWS observation and escalation chart: 0 to 11 months PEWS observation and escalation chart: 1-4 years PEWS observation and escalation chart: 5-12 years PEWS observation and escalation chart: ≥13 years
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Content ArticleDuring the pandemic, approximately 4.1 million people across the UK were identified as clinically extremely vulnerable (CEV) to Covid-19, and asked to shield for their own protection. This decision, made in the light of an unprecedented pandemic, would separate those with autoimmune inflammatory conditions, such as rheumatoid arthritis, from the rest of society for their own protection. This report by the charity Versus Arthritis presents qualitative research led by Dr Charlotte Sharp, a consultant rheumatologist, Lynn Laidlaw who has an autoimmune rheumatic disease and had to shield, and patient contributor Joyce Fox from the Centre for Epidemiology at the University of Manchester. It highlights the stories of people who lived through shielding and details the impact on their daily lives, their physical and mental wellbeing, their work, and their relationships with their families and the rest of society.
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News Article
Crumbling concrete: Raac found in 18 more hospitals in England
Patient-Safety-Learning posted a news article in News
Eighteen more hospitals in England contain potentially crumbling concrete, bring the total affected to 42, the Department of Health has confirmed. The reinforced autoclaved aerated concrete (Raac) has also been found in 214 schools and colleges in England as well as thousands of other buildings. NHS Providers, which represents hospitals, said the concrete "puts patients and staff at risk". Full structural surveys are taking place at all newly confirmed sites. The government said it was committed to eradicating Raac from NHS buildings completely by 2035. Seven of the worst-affected hospitals will be replaced by 2030 as part of the programme to build 40 new hospitals in England, it added. Sir Julian Hartley, chief executive of NHS Providers, said there had been fears that more of the material would be found following surveys of NHS buildings. "Trusts are doing everything they can, at huge cost, to keep patients safe where this concrete is found," he said. Read full story Source: BBC News, 21 October 2023 -
Content ArticleBowtie is a visual tool which effectively depicts risk, providing an opportunity to identify and assess the key safety barriers either in place or the ones lacking, between a safety event and an unsafe outcome. This guidance from the UK Civil Aviation Authority outlines how the bowtie model works and how to use it.
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Content ArticleThose who work in health and care are keenly aware of the need to identify and manage risks to protect patients from harm. But we are not the only industry that must take safety seriously. This video from the Healthcare Services Safety Investigation Branch (HSSIB) we compare notes with other safety-conscious industries – oil and gas, shipping, aviation, rail, road, nuclear and NASA – to understand their approach to safety management. In these fields, systems for organising and coordinating safety are often called Safety Management Systems (SMSs). See also HSSIB's report: Safety management systems: an introduction for healthcare.
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Content ArticleSafety Management Systems (SMSs) are an organised approach to managing safety which are widely used in different industries. In this report, the Health Services Safety Investigations Body (HSSIB) identifies the requirements for effective SMSs, how these are used in other safety-critical industries and considers the potential of application of this approach in healthcare. It makes safety recommendations for NHS England and the Care Quality Commission in relation to this. See also HSSIB's video Introduction to safety management systems.
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Content ArticleAllergic reactions vary in severity. People with food allergy tend to have reactions which affect the skin or gut, but around one third of reactions involve the breathing: these more serious allergic reactions are known as anaphylaxis. Very rarely, anaphylaxis can be severe and therefore life-threatening. This leaflet created by Allergy UK and Anaphylaxis UK explains how you can reduce the risk of this happening. Anaphylaxis is unpredictable and can occur in people who have never had this type of reaction before, but most people will recover fully.
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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: Andrew Harvey IG Consultant BJM IG Privacy Ltd Register hub members receive a 20% discount code. Email info@pslhub.org for discount code.
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Content Article
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Healthcare often uses the experience of aviation to set its patient safety agenda, and the benefits of a ‘safety management system’ (SMS) are currently being espoused, possibly because the former chief investigator for HSIB, Keith Conradi, had an aviation background. So, what does an SMS look like and would it be beneficial in healthcare? In this blog, Norman MacLeod discusses aviation's SMS, its many component parts, the four pillars of an SMS, just culture and its role in healthcare.- Posted
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Content Article
NHS: Consent to treatment
Patient_Safety_Learning posted an article in Consent issues
Consent to treatment means a person must give permission before they receive any type of medical treatment, test or examination. This must be done on the basis of an explanation by a clinician. Consent from a patient is needed regardless of the procedure, whether it's a physical examination or something else. The principle of consent is an important part of medical ethics and international human rights law. This webpage from the NHS includes information on: how consent is given and what we mean by consent assessing capacity consent from children and young people assessing capacity when consent is not needed consent and life support. -
Content ArticleThis is one of a series of 'Learning from safety incidents' resources published by the Care Quality Commission (CQC). Each one briefly describes a critical issue—what happened, what the CQC and the provider have done about it, and the steps you can take to avoid it happening in your service. This edition is about ensuring the safety of people using wheelchairs in health and social care. The CQC recently prosecuted a care home provider for exposing someone using their service to a significant risk of avoidable harm, which resulted in a life-changing injury.
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Content ArticleWales' national policy on patient safety incident reporting and management.
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Community Post
Better use of data for medication safety in hospitals
Kenny Fraser posted a topic in Medicine management
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NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. I have just published a post about this challenge and Triscribe's solution. I would love to hear any comments or feedback on the topic... How could we use this information better? What are hospitals already doing? Where are the gaps? Thanks- Posted
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Content ArticleIn this report, Professor Brian Edwards summarises contributions given to the UK Covid-19 Inquiry by various politicians and senior civil servants, relating to how prepared the UK and Scottish Governments were for the Covid-19 pandemic. It contains reflections on the contributions of: Nicola Sturgeon (First Minister of Scotland during the pandemic) Matt Hancock (Secretary of State for Health and Social Care during the pandemic) Jenny Harries (Chief Executive of the UK Health Security Agency) Emma Reed (civil servant, DHSC)
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Content ArticleGenerative AI is being heralded in the medical field for its potential to ease the burden of medical documentation by generating visit notes, treatment codes and medical summaries. Doctors and patients might also turn to generative AI to answer medical questions about symptoms, treatment recommendations or potential diagnoses. This article in JAMA Network looks at the liability implications of using AI to generate health information, highlighting that no court in the US has yet considered the question of liability for medical injuries caused by relying on AI-generated information.
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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 organization. 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. 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 a 20% discount. Email info@pslhub.org for a discount code.
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Content ArticleThe Regional Patient Safety Observatory of the Community of Madrid is an initiative aimed at increasing the quality of healthcare and the safety of professionals and patients in the healthcare environment. The Observatory is a consultative and advisory body of the Ministry of Health in matters of health risks and is functional in nature. Its objectives are: Promote and spread the culture of health risk management in the Community of Madrid. Obtain, analyse and disseminate regular and systematic information on health risks. Propose measures to prevent, eliminate or reduce health risks. It hosts the Patient Safety Brief Library, a tool for disseminating scientific knowledge developed by a group of experts within the framework of the Patient Safety Strategy 2027 of the Ministry of Health.
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Content ArticleThis is a plain English summary from the National Institute for Health and Care Research (NIHR). Many women who have an assisted vaginal birth (using forceps or a vacuum cup) develop infections. A previous study showed that a single dose of preventive antibiotics protected women; this research led to a change in UK and WHO guidelines. However, most women in the study had an episiotomy (surgical cut), so it was unclear if antibiotics also protected those with a tear of the perineum (the area between vagina and anus). To address this uncertainty, researchers re-analysed the ANODE study data. They found that preventive antibiotics reduced infections after an assisted vaginal birth, irrespective of whether women had a perineal tear, an episiotomy, or both. Read the article in full and access the research via the link below.
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Content ArticleAuthors of this article, published by Anaesthesia Patient Safety Foundation, look at various factors that exacerbate alarm fatigue and subsequent effects of nonoptimal medical alarms. They provide examples of a novel alarm versus a traditional alarm and conclude by saying: "By focusing on patient and provider safety, clinical workflow, and alarm technology, researchers, and policy makers can transform the medical alarm realm into one that is evidence-based and personnel-focused."
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