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Showing results for tags 'Risk management'.
Found 338 results
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Content ArticleDifficulty in swallowing—known as dysphagia—is a serious problem for some adults with learning disabilities and, in serious instances, can lead to death. Improving the safety of people with dysphagia is essential, and introducing individual patient management guidelines can reduce the risks associated with this potentially life-threatening condition. This document from the NHS National Patient Safety Agency outlines the issues facing adults with learning disabilities who have dysphagia and introduces support materials that can provide practical help for these people. The tools can be adapted for local use and for any adult who has dysphagia.
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Content ArticleThe OptiBreech project is a research study exploring the feasibility of evaluating a new care pathway for women with a breech pregnancy. About 1 in 25 babies are born bottom-down (breech) after 37 weeks of pregnancy. Women who wish to plan a vaginal breech birth have asked for more reliable support from an experienced professional. This aligns with national policy to enable maternal choice. In this video, Dr Shawn Walker explains why the combination of meconium and tachycardia, particularly in the first stage of labour, indicates increased risk in breech births.
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Content ArticleFatigue is increasingly considered as one of the most significant hazards to aviation safety and other safety-critical industries. Both the academic community and industry have focused on understanding the phenomenon of fatigue and the factors that contribute to it in order to prevent it, but also to mitigate its possible consequences. As a result, procedures and regulations have been developed for operators to comply with and there is now a requirement for operators to demonstrate that they are actively managing fatigue. The aim of this white paper by Clockwork Research is to provide safety practitioners with a better understanding of the process of investigating fatigue.
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Content ArticleQuality improvement is a methodology used routinely in emergency departments (EDs) to bring about change to improve outcomes such as waiting times, time to treatment and patient safety. However, introducing the changes needed to transform the system in this way is seldom straightforward with the risk of “not seeing the forest for the trees” when attempting to make changes. This article in Annals of Emergency Medicine aims to demonstrate how the functional resonance analysis method can be used to capture the experiences and perceptions of frontline staff to identify the key functions in the system (the trees), to understand the interactions and dependencies between them to make up the ED ecosystem (“the forest”) and to support quality improvement planning, identifying priorities and patient safety risks.
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Content ArticleThis guidance from the Office of Rail and Road outlines how to manage the risk of fatigue that may arise from a working pattern. It defines 'fatigue factors', highlighting that the more a working pattern features these fatigue factors, the greater the likely need to assess, avoid and control potential fatigue risks.
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Content ArticleFatigue has increasingly been viewed by society as a safety hazard. This has lead to increased regulation of fatigue by governments. The most common control process has been compliance with prescriptive hours of service (HOS) rule sets. Despite the frequent use of prescriptive rule sets, there is an emerging consensus that they are an ineffective hazard control, based on poor scientific defensibility and lack of operational flexibility. In exploring potential alternatives, we propose a shift from prescriptive HOS limitations toward a broader Safety management system (SMS) approach. Rather than limiting HOS, this approach provides multiple layers of defence, whereby fatigue-related incidents are the final layer of many in an error trajectory. This review presents a conceptual basis for managing the first two levels of an error trajectory for fatigue.
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News Article
Political will to tackle health security ‘melting away’, warns Tony Blair
Patient Safety Learning posted a news article in News
The impetus to tackle health security has started to “melt away”, despite the devastation wrought by the Covid pandemic, Tony Blair has warned. In the foreword to a new book, ‘Disease X’, the former British prime minister said that while there are “concurrent crises jostling for the attention of governments”, leaders should not miss the opportunity to implement the “hard-won lessons” of the past three years. “Covid-19 was an unprecedented global crisis and should mark a turning point in global health policy and preparedness,” Mr Blair wrote. “Our governments need to demonstrate the same level of political will, ambition and international cooperation that leaders demonstrated in the wake of World War II, when they coalesced around the objective of a sustainable peace. “This must be applied to the post pandemic order because, at its heart, health security is national security,” he added. “It is clear this will not be the last pandemic threat of our lifetimes … there is no excuse to be unprepared, again.” Read full story (paywalled) Source: The Telegraph, 25 January 2023 -
Content ArticleIn this blog, Jonathan Back, Intelligence Analyst at the Healthcare Safety Investigation Branch (HSIB), looks at the opportunities the healthcare system has to adopt proactive risk management to improve patient safety. He highlights that understanding the value of different perspectives may provide new opportunities for improvement if applied across the health and care system. He also outlines the role of the new integrated care boards (ICBs) in achieving this whole-system approach, which should include a clinical governance perspective, organisational and local system perspective and societal perspective.
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Content ArticleThis article, published by MendWell, looks at the benefits of stopping smoking before surgery and the risks of continuing to do so. It includes tips on how to stop smoking.
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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, 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 discount code.
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Content ArticleThis article, published in The international journal for quality in healthcare, looks at the Hierarchy of Risk Controls 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 ArticleHospital boards generally focus attention on measures to answer questions about risk, such as 'How safe are we now?' They are ultimately accountable for the quality of care delivered in hospitals, and data review is a key component of effective board governance. This editorial in BMJ Quality & Safety highlights the lack of guidance on the most effective format for presenting data to determine progress against key risks and targets. The authors argue that data must not be overly simplified and that charts prepared for boards should include monthly data points in graphic format over a longer period of time. This allows trends to be more visible and denotes whether an observed change is significant, helping hospital boards avoid erroneous conclusions tied to random variation.
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Content ArticleThe Patient Safety Education Project (PSEP) uses a high impact, conference-based education program grounded in adult learning principles to teach systems-based patient safety methodology to healthcare professionals. This PSEP participants handbook covers: Gaps in patient safety: A call to action External influences: Law and other factors What is patient safety?: A conceptual framework Advancing patient safety: How to teach and implement Systems thinking: Moving beyond blame to safety Human Factors design: Application for healthcare Communication: Building understanding Teamwork: Being an effective team member Organization and culture: Essential to patient safety Technology: Impact on patient safety Patients as partners: Engaging patients and families Leadership: Everybody’s job
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Sharon talks to us about why manual handling needs to be more than tick-box training, and describes its significance for patient safety. -
Content ArticleThe Royal College of Emergency Medicine’s Safety Resources hub has information and resources about alerts, safety resources, safety in the Emergency Department and safety events. This page is managed by the Safer Care Committee, which is part of the Quality in Emergency Care Committee (QECC). The QECC has produced a series of strategy documents, explaining the role of RCEM, and these committees, in improving patient care.
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Content ArticleThis survey by In-FACT (Independent Fetal Anti Convulsant Trust) is intended to provide patients, no matter what anti-epileptic drug (AED) they are prescribed or what condition the AED is prescribed for, the opportunity to report problems and worries about taking their medication during pregnancy. The results will be used to inform In-FACT's ongoing work to improve medication safety and their engagement with the Medicines and Healthcare products Regulatory Agency (MHRA).
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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. Facilitated by Andrew Harvey IG Consultant BJM IG Privacy Ltd. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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Content ArticleMike Fell, executive director of national cybersecurity operations at NHS Digital,, discusses the WannaCry cyberattack, teaching GP surgeries to up their game and how data can save lives.
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Content ArticleMaternity costs make up the largest cost to the NHS in value of claims. The Early Notification Scheme provides a faster and more caring response to families whose babies may have suffered severe harm. 'The second report: The evolution of the Early Notification Scheme' provides an overview of progress made since the report into the first year of the scheme, which was published in 2019. The report updates on the progress of the key recommendations which were made in the first report and reflects on modifications and improvements made to the scheme since its launch five years ago. It provides an analysis of the main clinical themes, based on a small cohort of cases, and makes recommendations to further improve outcomes for affected families.
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EventuntilThis webinar from The Yorkshire Quality and Safety Research Group explores a recent research study into how vulnerable patients are able to contribute to their safety. Over the last decade a wealth of studies have explored the way that patients are involved in patient safety internationally. Most begin from the premise that patients can and should take on the role of identifying and reporting safety concerns. Most give little attention, however, to the impact of the patient’s health status and vulnerability on their ability to participate in their safety. Drawing on qualitative interviews with 28 acute medical patients, this article aims to demonstrate how patients’ contributions to their safety in the acute medical context are less about involvement as a deliberate intervention, and more about how patients manage their own vulnerability in their interactions with staff. Our analysis is underpinned by theories of vulnerability and risk. This enables us to provide a deeper understanding of the ways vulnerability shapes patients’ involvement in their safety. Acute medical patients engage in reassurance-seeking, relational and vigilance work to manage their vulnerability. Patients undertake reassurance seeking to obtain evidence that they can trust the organisation and the professionals who work in it and relational and vigilance work to manage the vulnerability associated with dependence on others and the unpredictability of their status as acute medical patients. We argue that patients are involved in the process of creating patient safety at the point of care. Foregrounding the theory of vulnerability and its relationship to risk offers new insights into the potentials and limits of patient involvement in patient safety in the acute care context. Liz Sutton is a Research Associate in the Social Science Applied to Healthcare Improvement Research (SAPPHIRE) Group, Department of Health Sciences, University of Leicester. She has considerable expertise in qualitative research including: qualitative interviewing, focus group facilitation and ethnography. Her ethnographic projects have been conducted in different settings including hospital acute care and in care homes, where she has explored such issues as the quality and safety of care and how context affects antibiotic prescribing. Her PhD research explored how vulnerability affects patient involvement in patient safety. Her other interests include dementia care, healthcare quality improvement and health inequalities. Register for the webinar
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Content ArticleThis open access book addresses the future of work and industry by 2040—a core interest for many disciplines inspiring a strong momentum for employment and training within the industrial world. The future of industrial safety in terms of technological risk-management, although of obvious concern to international actors in various industries, has been quite sparsely addressed. This brief reflects the viewpoints of experts who come from different academic disciplines and various sectors such as oil and gas, energy, transportation, and the digital and even the military worlds, as expressed in debates and discussions during a two-day international seminar. 'Managing future challenges for safety' will interest and influence researchers considering the future effects of a number of currently developing technologies and their practitioner counterparts working in industry and regulation.
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Content ArticleIt won’t come as a surprise but more than in 9 in 10 of almost 200 NHS leaders that responded to the latest NHS Confederation survey said that risk to patient safety is going to increase as we approach winter. Almost all of them identified the biggest risks being demand for urgent and emergency care and ambulance waits. And most expect to have to make difficult decisions and compromises around safe staffing ratios and delayed transfers of care. As the health and care sector braces for a challenging winter, three key steps could support systems to manage risk and minimise harm, writes Matthew Taylor, chief executive at NHS Confederation: The need for a robust and honest assessment of harm. The role of systems in minimising harm. The role of the centre in providing a helping hand.
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Content ArticleIn this position statement, the National Quality Board (NQB) outlines: Key requirements for quality oversight in Integrated Care Systems (ICSs) The role of System Quality Groups (formally Quality Surveillance Groups) NQB work to support quality oversight in ICSs
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EventThis one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been re-designed in line with the new Patient Safety Syllabus. It will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on risk and behaviour to improve patient safety. Key learning objectives: Evaluating risk Using mapping techniques Safety interventions Behaviour Assessing safety culture Register
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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.
