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Showing results for tags 'Risk management'.
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News ArticlePharmacy leaders in the black, Asian and minority ethnic (BAME) communities have expressed concern that assessments of BAME staff’s susceptibility to COVID-19 are not widespread enough in community pharmacy. NHS England wrote to community pharmacies on 29 April 2020 advising employers to “risk assess staff at potentially greater risk” of COVID-19 after “emerging UK and international data” suggested people from BAME backgrounds are “being disproportionately affected”. The Faculty of Occupational Medicine later published a risk reduction framework — backed by NHS England — to assist with the risk assessments on 14 May 2020. This was updated on 28 May 2020 to include guidance from the Health and Safety Executive to “help organisations identify who is at risk of harm”. But speaking to The Pharmaceutical Journal, Elsy Gomez Campos, president of the UK Black Pharmacists’ Association (UKBPA), said she had been told by a small number of community pharmacists that “nothing has been done” in terms of risk assessing BAME staff. “I know of a few people who have been assessed and that is mainly in hospital,” she said. “In terms of community pharmacists — who I’ve had contact with so far — they haven’t even been asked to have the risk assessment done.” However, she stressed that not many from the community pharmacy sector have come forward, but “the people who have come forward have said no, it has not been done”. “People are quite scared to ask as well because it can have repercussions on their employment or their relationships [at work],” she added. Read full story Source: The Pharmaceutical Journal, 29 May 2020
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News Article
UK sees coronavirus infections spike as global death toll hits 3,000
Patient Safety Learning posted a news article in News
Prime Minister Boris Johnson will say there is “little doubt” the coronavirus will present a “significant challenge” for the UK as he chairs a Cobra meeting to discuss the government’s response to the outbreak. The health secretary, Matt Hancock, has warned it was now “inevitable” the deadly virus would “become endemic” in the UK as 13 more cases of Covid-19 were announced, bringing the total number to 36. The Cobra meeting will bring together senior ministers and the Chief Medical Officer, Professor Chris Whitty and Chief Scientific Adviser Sir Patrick Vallance. Meanwhile the worldwide death toll from the disease has passed 3,000, with more than 80,000 cases worldwide. Several countries in Europe, the Middle East and the Americas have banned large gatherings and imposed stricter travel restrictions in an attempt to limit infections.the Americas have banned large gatherings and imposed stricter travel restrictions in an attempt to limit infections. Read full story Source: The Indpendent, 2 March 2020 -
News Article
Fast response to terror attacks saves lives. UK medics should not be held back
Patient Safety Learning posted a news article in News
The Streatham terrorist attack has again highlighted one of the most difficult decisions the emergency services face – deciding when it is safe to treat wounded people. In the aftermath of the stabbings by Sudesh Amman, a passer-by who helped a man lying on the pavement bleeding claimed ambulance crews took 30 minutes to arrive. The London Ambulance Service (LAS) said the first medics arrived in four minutes, but waited at the assigned rendezvous point until the Metropolitan police confirmed it was safe to move in. Last summer, the inquest into the London Bridge attack heard it took three hours for paramedics to reach some of the wounded. Prompt treatment might have saved the life of French chef Sebastian Belanger, who received CPR from members of the public and police officers for half an hour. A LAS debriefing revealed paramedics’ frustration at not being deployed sooner. A group of UK and international experts in delivering medical care during terrorist attacks have highlighted alternative approaches in the BMJ. In Paris in 2015, the integration of doctors with specialist police teams enabled about 100 wounded people in the Bataclan concert hall to be triaged and evacuated 30 minutes before the terrorists were killed. The experts writing in the BMJ believe the UK approach would have delayed any medical care reaching these victims for three hours. These are perilously hard judgment calls. Policymakers and commanders on the scene have to balance the likelihood that long delays in intervening will lead to more victims dying from their injuries against the increased risk to the lives of medical staff who are potentially putting themselves in the line of fire by entering the so-called 'hot zone'. First responders themselves need to be at the forefront of this debate. As the people who have the experience, face the risks and want more than anyone to save as many lives as possible, their leadership and insights are vital. In the wake of the Streatham attack the government is looking at everything from sentencing policy to deradicalisation. Deciding how best to save the wounded needs equal priority in the response to terrorism. Read full story Source: The Guardian, 7 February 2020 -
Content ArticleThis article in the Journal of Global Health aimed to consider which patient safety interventions are the most effective and appropriate in fragile, conflict-affected, and vulnerable (FCV) settings. The authors examined available literature published between 2003 and 2020, using an evidence-scanning approach. They found that the existing literature is dominated by infection prevention and control interventions for multiple reasons, including strength of evidence, acceptability, feasibility and impact on patient and healthcare worker wellbeing. They identified an urgent need to further develop the evidence base, specialist knowledge and field guidance on a range of other patient safety interventions such as education and training, patient identification, subject specific safety actions and risk management.
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Content ArticleThis report presents the findings and conclusions of an independent review into clinical governance arrangements within maternity services at The North West London Hospitals NHS Trust. The independent review was set up following three maternal deaths in one year and two other serious untoward incidents (SUIs) in the Trusts's maternity unit.
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In this blog Patient Safety Learning’s Chief Executive, Helen Hughes, discusses the connection between procurement, supply chains and patient safety, ahead of an upcoming Safety for All Campaign webinar on this topic. -
Content Article
Safety culture discussion cards (Eurocontrol)
Patient Safety Learning posted an article in Good practice
Safety culture has been shown to be a key predictor of safety performance in several industries. It is the difference between a safe organisation and an accident waiting to happen. Thinking and talking about our safety culture is essential for us to understand what we do well, and where we need to improve. These cards from Eurocontrol are designed to help us to do this. -
Content ArticleSurgical fires, which in the perioperative environment is a fire that occurs on or in a patient while in the operating theatre, are recognised as an international patient safety concern. This is due to the risks of injury to both patients and healthcare professionals. Surgical fires are categorised as either airway or non-airway and occur most commonly in the head, face, neck, upper chest or during ENT surgical procedures. The Association for Perioperative Practice (AfPP) along with a coalition of patient safety focused organisations are calling for more to be done to prevent surgical fires. Lindsay Keeley, patient safety and quality lead for the AfPP, explains why such incidents must be classified as ‘Never Events’, the common causes of surgical fires and the AfPP recommendations and standards for safe use of devices.
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Content ArticleA review of government policies tackling smoking, poor diet, physical inactivity and harmful alcohol use in England.
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Content ArticleThis study in the Journal of Patient Safety examined how hospitals outside mandatory 'never event' regulations identify, register, and manage 'never events', and whether practices are associated with hospital size. In Switzerland, there is no mandatory reporting of 'never events' and little is known about how hospitals in countries without 'never event' policies deal with these incidents in terms of registration and analyses. The study found that many Swiss hospitals do not have valid data on the occurrence of “never events” available, and do not have reliable processes installed for the registration and examination of these events. Surprisingly, larger hospitals do not seem to be better prepared for “never events” management.
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Content ArticleOn 8 April 2020 the coroner commenced an investigation into the death of Daniel France, age 17. Danny was 17 years old and was living at a YMCA hostel. He was on medication for depression and had been referred to secondary mental health services. He had made previous suicide attempts. On 3 April 2020 he took his own life. The medical cause of death was asphyxiation by hanging and the conclusion was suicide. Danny was a vulnerable teenager: he had left home and was living in hostel accommodation; he had changed his GP practice; he was trans, had changed his name and had been referred to the Gender Identity Clinic; he had recently been discharged from secondary mental health services in Suffolk and had been referred to mental health services in Cambridge; he had previously been under CAMHS and was now being referred to adult mental health services; he had diagnoses of anxiety and depression and had been prescribed medication; he had made previous suicide attempts and had long term suicidal thoughts He had been assessed by First Response Service but had been considered as not requiring urgent intervention. Safeguarding referrals about Danny were made to Cambridgeshire County Council in October 2019 and January 2020. Both referrals were closed and it was accepted that the decision to close both referrals was incorrect. In December 2019 Danny’s new GP referred him to Cambridgeshire & Peterborough NHS Foundation Trust (CPFT). He had been seen by the Primary Care Mental Health Services but was still awaiting assessment by the Adult Locality Team at the time of his death.
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Content Article
Surgical fires are a serious a patient safety issue. In this blog, Patient Safety Learning analyses a recent response from Maria Caulfield MP, Minister for Patient Safety and Primary Care, to several questions tabled in the House of Commons about surgical fires in the NHS, and outlines the need for further action to prevent these incidents.- Posted
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Content ArticleHarm reviews give assurance to patients, patient groups, commissioners and the public as to whether patients have been harmed, or are at risk of harm, as well as helping to avoid future harm to patient. Patients may be harmed not only by clinical treatment, but also as a result of the need to be on a waiting list for clinical treatment, as this may result in deterioration of their physical or mental condition. Royal Cornwall Hospitals standard operating procedure (SOP) identifies a standardised approach to harm reviews for all specialities at the Trust that support the Trusts' governance and assurance processes and maintains practice in line with national expectations.
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Content ArticleUptake of open-source automated insulin delivery systems is increasing globally and there is growing real-world, user-driven evidence around the safety and effectiveness of these systems. This article in The Lancet Diabetes & Endocrinology seeks to provide, from an international perspective: a review of the current evidence a description of the technologies discussion of the ethical and legal considerations a healthcare consensus supporting the implementation of open-source systems in clinical settings, with detailed clinical guidance. The authors make recommendations for key stakeholders involved in diabetes technologies, including developers, regulators, and industry.
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Content Article
CDC: Hierarchy of controls
Patient Safety Learning posted an article in Occupational health and safety
Controlling exposures to occupational hazards is the fundamental method of protecting workers. Traditionally, a hierarchy of controls has been used as a means of determining how to implement feasible and effective control solutions.This Centers for Disease Control and Prevention (CDC) summarises the hierarchy of controls. -
Content ArticleHazards and risks to workers’ safety and health should be identified and assessed on an ongoing basis. There are several ‘hierarchies of control measures’ in the health and safety field, each having an importance in its own right given the circumstances to which it is to be applied. This Health and Safety Blog explains the general hierarchy of control measures.
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Content Article
WorkSafe: The hierarchy of control
Patient Safety Learning posted an article in Occupational health and safety
The hierarchy of control is a system for controlling risks in the workplace. Guidance on this page explains the hierarchy of control and can help employers understand and use the hierarchy of control to eliminate or reduce risks at work. -
Content ArticleRisks should be reduced to the lowest reasonably practicable level by taking preventative measures, in order of priority. This table from the was developed by the construction industry’s Leadership and Worker Engagement Forum and sets out an ideal order to follow when planning to reduce risk from construction activities. This could be adapted for healthcare.
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Content ArticleThis paper by Biophorum, a membership organisation for the biopharmaceutical industry, looks at how companies in the sector can adopt a human performance approach to operations. It highlights the need to move away from a focus on reducing human error and towards integrating fundamental systems changes that will enhance human performance.
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Content ArticleThe authors of this research study, published in BMJ Quality & Safety looked at the issues of hazardous prescribing and inadequate monitoring in patients with mental health issues being managed in primary care. They identified a lack of data in this area, despite most patients with mental illness receiving treatment in a primary care setting. The study found that: 9.4% of patients ‘at risk’ triggered at least one indicator for potentially hazardous prescribing. The risk was greatest for patients aged 35–44, females and those receiving more than 10 repeat prescriptions. 90.2% of patients ‘at risk’ triggered at least one indicator for inadequate monitoring. The risk was particularly high in people under the age of 25, females and those with one or no repeat prescription. The authors of the study hope their findings will support providers to reduce risk and improve care for patients who receive mental health treatment in primary care.
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Content ArticleRegina Hoffman, executive director of Pennsylvania’s Patient Safety Authority, explains why we sometimes need to look beyond the accepted 'best practice' and provide the best care instead.
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Content Article
In this video, Helen Hughes, Chief Executive of Patient Safety Learning, speaks to Phil Taylor, Chief Product Officer at RLDatix, about the importance of culture in achieving high reliability in healthcare. They discuss the impact of culture on incident reporting, examples of where safety culture is key to making improvements and consider what is needed to create the right safety culture. -
Content ArticleThe Clinical Risk Management and Patient Safety Centre (GRC) is a clinical governance structure instituted in 2003 by the Italian Tuscan regional council. GRC builds on the expertise and vision of the former Ergonomics and Human Factors Research Centre in Healthcare (CRE), founded in 2000 as a joint endeavor of the Florence Heathcare Trust, the University of Florence and Siena. The GRC now enrolls professionals of different disciplines (public health, clinical risk management, industrial design, human factors, organisation studies, communication science, law, psicology, international relations). It promotes the safety culture through the active and cross disciplinary learning from adverse events and errors. The GRC aims to construct a shared vision for safety through the sharing of experiences and the development of collaborative projects for patient safety.
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Content ArticleThis blog is the introduction to a joint series of blogs and video conversations exploring how we can improve patient safety through the application of principles of high reliability in healthcare, made collaboratively by Patient Safety Learning and RLDatix.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) report highlights a gap between the NHS and other safety-critical industries in identifying and managing barriers to reduce the risk of serious incidents occurring.
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