Search the hub
Showing results for tags 'Risk management'.
Found 338 results
-
Content Article
We need to fix it (HindSite, 2021/22)
Sam posted an article in Digital health and care service provision
While ‘human error’ is often blamed when things go wrong, the ‘technical’ part of ‘sociotechnical systems’ often escapes the spotlight. In this article, Harold Thimbleby outlines how hidden risks with digitalisation have far-reaching consequences, and how we can start to fix them. -
Content ArticleThe UK government and devolved administrations, along with the emergency services and other local responders, have clear responsibilities for identifying, assessing, preparing for and responding to emergencies, as well as supporting affected communities to recover. The government has risk management processes in place that aim to identify risks, to ensure that plans are drawn up to mitigate risks and prepare for shocks, and to prevent risks from being overlooked despite short-term pressures. Cabinet Office guidance states that preparedness is the preparation of plans that are flexible enough both to address known risks and to provide a starting point for handling unforeseen events. This report sets out the facts on: the government’s approach to risk management and emergency planning the actions the government took to identify the risk of a pandemic like COVID-19 the actions the government took to prepare for a pandemic like COVID-19 recent developments. The report sets out central government’s risk analysis, planning, and mitigation strategies prior to the arrival of the COVID-19 pandemic, with the aim of drawing out wider learning for the government’s overall risk management approach.
-
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
- 1 comment
-
1
-
- (and 5 more)
-
News Article
'Some progress' made at failing Shropshire hospital trust
Patient Safety Learning posted a news article in News
An inspection at a failing hospital trust has identified "some progress" but its services are still inadequate. The Care Quality Commission (CQC) inspected the Shrewsbury and Telford Hospital NHS Trust (SaTH) in August. The Trust has been in special measures since 2018 and its maternity services are subject of a review following a high rate of baby and maternal deaths. The CQC said SaTH still had "significant work to do" to improve its patient care and safety standards. Inspectors highlighted particular concerns around risk management at the Trust which it said was "inconsistent" and and urgent and emergency care where patients "did not always receive timely assessment". The CQC also reported a shortage of staff working in end-of-life care and midwifery, however maternity staff were said to have "an exceptionally dedicated and caring approach". "I recognise the enormous pressure NHS services are under across the country and that usual expectations cannot always be maintained, but it is important they do all they can to mitigate risks to patient safety while facing these pressures," chief inspector of hospitals, Ted Baker, said. "While the trust continues to have significant work to do to provide care that meets standards people have a right to expect, it is providing more effective care overall. "However, its risk management remains inconsistent and we are not assured it is doing all it can to ensure people's safety." Read full story Source: BBC News, 18 November 2021 -
Content ArticleHealthcare can be risky. Adverse events carry a high cost – both human and financial – for health systems around the world. So in an effort to improve safety, many health systems have looked to learn from high-risk industries. The aviation and nuclear industries, for example, have excellent safety records despite operating in hazardous conditions. And increasingly, the tools and procedures these industries use to identify hazards are being adopted in healthcare. One prominent example involves the Hierarchy of Risk Controls (HoC) approach, which works by ranking the methods of controlling risks based on their expected effectiveness. According to HoC, the risks at the top are presumed to be more effective than those at the bottom. The ones at the top typically rely less on human behaviour: for example, a new piece of technology is considered to be a stronger risk control than training staff. This article looks more deeply at the (HoC) 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.
-
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.
-
Content Article
Getting It Right First Time (GIRFT)
PatientSafetyLearning Team posted an article in Quality Improvement
Getting It Right First Time (GIRFT) is an NHS improvement programme delivered in partnership with the Royal National Orthopaedic Hospital NHS Trust. -
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.
-
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.
-
Content ArticleThis article discusses how advising and supporting managers/employers in risk management and control is and should have been one of the main preventive roles of occupational health experts, particularly in regards to legal duties on health and safety. In the article, the authors recommend that, as employees have the right to a safe working environment, all appropriate health and safety risk assessments should be carried out, along with published documented input from occupational health experts in addition to gaining employee agreement on Respiratory Protective Equipment (RPE) for aerosol inhalation risk.
-
Content ArticleThis original research article describes how patients with mental health issues face similar risks as to those patients in other areas of healthcare, particularly in relation to measures taken to address unsafe behaviours from patients which may result in further risks to their safety. The authors of this research conducted a systematic review and meta-synthesis to identify and synthesise the literature on patient safety within inpatient mental health settings, and found patient safety research in this area of healthcare was under researched in comparison to other inpatient settings that are not related to mental health.
-
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 ArticleThis report considers the role and functions that clinical commissioning group medicines optimisation teams deliver in the existing healthcare structure to improve patient care. Medicines optimisation can be defined as a person-centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines.
-
Content ArticleMedicines optimisation is a multidisciplinary and patient-focused approach to achieving the best patient outcomes from the use of medicines. It involves the use of medicines to control disease while ensuring that adverse effects are kept to a minimum. This article explores strategies that enable nurses to take an increasingly active role in medicines optimisation. In its conclusion the authors suggest that to ensure medicines optimisation, nurses should be involved in monitoring patients’ signs and symptoms using a structured checklist such as the ADRe (Adverse Drug Reaction Profile) to identify and address any medicines-related harms.
-
Content Article
Valproate Safety Implementation Group
Patient-Safety-Learning posted an article in Women's health
The Valporate Safety Implementation Group (VSIG) is a clinically-led group set up to help facilitate the reduction of the use of sodium valporate in women and girls where there is a safer alternative. -
Content Article
.png.06ca01cc678fb3ddc0ca52beca2f9945.png)
Sodium Valproate is a treatment for epilepsy and bipolar disorder. It can cause an increased risk of developmental, physical and neurological harms to the human embryo or fetus. This NHS letter is a reminder of information that every woman and girl of childbearing age should receive from their doctors when the drug is first prescribed. It contains important reminders of safety considerations, including around contraception, pregnancy and regular prescribing reviews. Further recommended reading: Sodium Valproate: The Fetal Valproate Syndrome Tragedy Analysing the Cumberlege Review: Who should join the dots for patient safety? (Patient Safety Learning) Findings of the Cumberlege Review: informed consent (Patient Safety Learning) First Do No Harm. The report of the Independent Medicines and Medical Devices Safety Review Regulatory flaws: Women were catastrophically failed in the mesh, Primodos and Sodium Valproate tragedies (Kath Sansom) -
News Article
Warning issued for staff wearing PPE during warm weather
Patient-Safety-Learning posted a news article in News
NHS hospitals have been advised to protect all staff wearing PPE during the warmer weather amid concerns the higher temperatures could increase the risk of heat stress. A letter from Public Health England sent across GP surgeries, pharmacies and hospitals, have recommended that staff wearing PPE should be given regular breaks and have a buddy system so that signs of heat stress can be spotted early on. The letter describes how PPE may need to be changed more frequently which may increase demand. Symptoms of heat stress are similar to heat exhaustion and the necessary actions should be taken to help avoid overheating. Read full story. Source: The Independent, 10 June 2021 -
Content ArticleResilient Healthcare is an emerging theoretical field that has developed with influence from engineering, safety science, psychology, ergonomics, human factors, and aeronautics. Resilient Healthcare research has centred on understanding and improving the quality and safety of healthcare delivery. Theory is increasingly well-developed, but so far has only been applied in limited ways with select settings and activities. In order to improve the quality and safety of healthcare, it is essential to first understand the sources of complexity in clinical work. This ethnographic study from Sanford et al. of five hospital teams in a large, teaching hospital in central London aims to contribute to this growing evidence base by presenting data on specific challenges faced by healthcare workers and the adaptations they use to overcome them in everyday clinical work. This paper will present a new framework for recognising misalignments between demand and capacity and corresponding mechanisms for adaptation, which can be used to understand work-as-done in complex settings and to manage risk.
-
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.
-
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. -
EventCOVID-19 has been incredibly stressful—personally and professionally—and has profoundly affected everyone in healthcare, including those of us in patient safety, quality, and risk management. Join this Patient Safety Association's virtual round table to decompress and share your experiences. Some of your colleagues have offered to discuss their coping strategies, and please feel free to do the same. Resources from professionals trained to handle stress will be provided. Register
-
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.
-
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.
-
Content ArticleThe Once for Wales Concerns Management System Programme was developed from the recommendations made by Keith Evans in the Welsh Government report – “The Gift of Complaints” and is aimed at bringing consistency to the use of the electronic tools used by all NHS Wales health bodies. All organisations currently have varying versions and modules of the DatixWeb and DatixRichClient systems. Following a successful competitive tender, which really tested and explored the market, RLDatix Ltd have been awarded the contract for 5 years, with an opportunity to extend this period if it is successful. The solution is known as DatixCloudIQ and has many enhanced features compared to other systems. It is a new Datix.
-
EventuntilCOVID-19 has been incredibly stressful—personally and professionally—and has profoundly affected everyone in healthcare, including those of us in patient safety, quality, and risk management. Grab a cup of coffee or tea and join this virtual round table to decompress and share your experiences. Some of your colleagues have offered to discuss their coping strategies, and please feel free to do the same. We will also be providing resources from professionals trained to handle stress. Register
.png.06ca01cc678fb3ddc0ca52beca2f9945.png)
