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Showing results for tags 'Risk management'.
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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
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Content ArticleFor some time now I've been looking to find out more about mental health services in Trieste, Italy. Then I met Vincenzo Passante Spaccapietra, co-host of the Place of Safety? podcast series. This has enabled me to learn more about the closure of the mental institutions in Trieste, Italy, and the work of Franco Basaglia. I was keen to find out what really took place, what this really means in practice and how we can adopt this model in the UK. We were delighted to have become involved and to have recorded a couple of podcasts. I recommend this resource to everyone interested in safe, compassionate, patient led mental health care.
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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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News Article
CQC orders ‘significant improvements’ at trust criticised over deaths
Patient Safety Learning posted a news article in News
The Care Quality Commission (CQC) has ordered ‘significant improvements’ from a mental health trust which has been criticised over the deaths of vulnerable patients. The watchdog has warned Tees, Esk and Wear Valleys Foundation Trust (TEWV FT) it has “serious concerns” about risk management processes at its inpatient wards following inspections of three of its hospitals in January. It follows a string of severe problems in child and adolescent services run by the trust. In a formal letter and a separate warning notice to TEWV FT, the CQC ordered the trust to carry out “significant improvements” to the safety of adult acute wards, and psychiatric intensive care, after a visit to Roseberry Park, West Park and Cross Lane hospitals on the week of 18 January. Sources have told HSJ the trust’s leadership is working towards a May deadline to make sufficient improvements or it could potentially risk further enforcement action. However, neither the trust nor the CQC have confirmed this. Families and campaigners — including Labour MP Andy McDonald, who represents Middlesbrough — have called for a public inquiry into alleged “systematic failures” at the trust following the deaths of around 14 patients under the trust’s care within two years. Read full story (paywalled) Source: HSJ, 12 March 2021 -
Content ArticlePleural effusions are the accumulation of fluid between the lung and chest wall, which may cause breathlessness, low oxygen saturation and can lead to collapsed lung(s). They are a common medical problem and have over 50 recognised causes and various treatments. Large effusions, such as those caused by pleural malignancy, may require insertion of a chest drain and controlled drainage of fluid to allow the lung to inflate. If large volumes of pleural fluid are drained too quickly, patients can rapidly deteriorate. Their blood pressure drops, and they can become increasingly breathless from the potentially life-threatening complication of re-expansion pulmonary oedema. T A review of the National Reporting and Learning System (NRLS) over a recent three-year period identified 16 incidents where patients experienced acute and significant deterioration after uncontrolled or unmonitored drainage of a pleural effusion; two of these patients died and a cardiac arrest call was made for one patient although the outcome was not reported.
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Content ArticleThis chapter from the 'Textbook of Patient Safety and Clinical Risk Management' reviews the most common adverse events that happen in a psychiatric unit and the safety measures that are needed to decrease the risk of errors and adverse events. It also highlights the role of staff members and patients in preventing or causing the error.
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Content Article
UCLPartners proactive care programme
PatientSafetyLearning Team posted an article in Exit strategies
UCLPartners have developed a series of proactive care frameworks to restore routine care by prioritising patients at highest risk of deterioration, with pathways that mobilise the wider workforce and digital/tech, to optimise remote care and self-care, while reducing GP workload. The frameworks include: atrial fibrillation high blood pressure high cholesterol type 2 diabetes asthma COPD. The frameworks are being implemented by GPs across the country, helping practices to identify who needs priority care, and those whose care can safely be delayed. Find out more by following the link below. -
Content ArticleBioPhorum has developed a risk-based deviation management system (DMS). 13 member companies have implemented this approach, and summary data from these companies shows improved quality performance plus an average time saving of 22,200 work hours per site per year, which is equivalent to a $888k cost saving. An effective deviation management process is one that identifies and removes risk from processes using root cause analysis (RCA) principles and a corrective and preventive action (CAPA) programme. The current model used by many biopharmaceutical companies considers all deviations or events are equal and require a 30-day closure, known as the ‘30-day rule’1. Treating all events as equal and following the ‘30-day rule’ drives an inefficient process and wasteful behaviours. This guide outlines the work of the BioPhorum DMS Workstream in defining and creating a simplified and effective risk-based deviation management system with advanced RCA methodologies, and a track-and-trending process of low-risk events. It includes everything required to build a risk-based approach to DMS, including the business case for change, the new process, risk-based tools, and a detailed sharing of post-implementation benefit.
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Content ArticleA large proportion of the patient injuries or deaths attributable to medical device misuse can be eliminated and/or mitigated by adopting an effective human factors and ergonomics (HFE) approach. The implementation of a usability engineering process is now mandatory for medical devices manufacturers seeking to obtain the European Union’s CE Mark. In this article, Pelayo, Marcilly and Bellandi describe the European Union’s HFE regulation and highlight the challenges faced by (i) manufacturers implementing this regulation and (ii) regulatory bodies charged with assessing the compliance of usability files. In Europe, 95% of MD manufacturers are small- and medium-sized enterprises; compliance with the CE Mark regulations is a real challenge to their competitiveness. Levels of knowledge about HFE vary greatly from one regulatory organisation to another, which can sometimes lead to very different expectations. The authors also present the specific use-related risk management approach required by the HFE regulation. Lastly, they focus on the limitations of the HFE regulation for MDs and on future HFE challenges in further reducing and/or eliminating MD use errors. The main challenge is the need to go beyond technology design and the premarket assessment and to look at the postproduction stage; the coupling between an MD and a sociotechnical system can lead to consequences that were not predicted during the design process. This implies the need to consider the emerging properties of technologies in use by involving all the stakeholders.
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Event
Veracuity: Innovative approaches to drug safety
Sam posted an event in Community Calendar
Veracuity was conceived out of a recognition that the practice of pharmacovigilance is performed suboptimally. That is because it relies entirely on a voluntary reporting system – one in which consumers and healthcare professionals must devote considerable energy if they were so inclined to notify somebody about a side effect they attribute to a bio-pharmaceutical product. Adverse event reporting is infrequent and cumbersome because stakeholders are only vaguely aware of their responsibility and the current system is neither easy nor fast to use. Nor does it provide reporters with any immediate helpful feedback. With only a very small percentage of adverse drug events ever reaching the attention of manufacturers or regulators, it is easy to conclude that the medical community and the public may be wholly unaware of tremendous risks and liabilities that may be attributed to drug products. This workshop allows participation in insightful conversation on the future of our industry. Program: Fishbein, J: Introduction and closing remarks. Barrett, CP: Implementation of Post-marketing Risk Management Commitment. Laugel, I: The future of pharmacovigilance with the use of artificial intelligence sounds good. Marschler, M: The use of pharmacogenomic methodologies in the pharmacovigilance evaluation of medicinal products. This webinar meets two times. Fri, Jan 29, 2021 12:00 PM - 2:00 PM GMT Fri, Jan 29, 2021 6:00 PM - 8:00 PM GMT Register 2021-workshop-flier.pdf -
Content Article
NHS: Extraordinary You
Patient Safety Learning posted an article in Workforce and resources
The 55,000 strong healthcare science workforce of the NHS and its related bodies, the Health Protection Agency and NHS Blood and Transplant, represent the largest group of scientists in a single employment sector in the UK. Their vast scientific knowledge and skill base stretches across some 45 scientific specialisms encompassing biology, genetics, physiology, physics and bioengineering. This knowledge lies at the foundation of the profession’s crucial and often unique role in: providing complex and specialist diagnostic services, analysis and clinical interpretation offering direct therapeutic service provision and support introducing technological and scientific advances into healthcare, and undertaking research, development and innovation providing performance and quality assurance, risk management and clinical safety design and management teaching, training and providing a specialist consultancy and clinical advice service to other clinicians with respect to all of the key functions above. The healthcare science workforce plays a critical part in delivering healthcare. More than 80% of all diagnoses are reached with a contribution from healthcare scientists. This document highlights some of these roles. -
Content Article
Fatigue and alertness: Keeping the rail industry alert
Patient Safety Learning posted an article in Techniques
Whether you work in an office or on the front line, drive your car home from work or a train full of passengers, you need to be awake and alert to do your job safely and efficiently. Managing fatigue is everybody’s responsibility. RSSB's aim is to make sure that everyone, at all levels, understands their role in managing fatigue. Based on their research and consultation with the rail industry, RSSB have put together a range of resources to help with this. -
Content Article
ECRI: Wrong-site surgery (14 December 2020)
Patient Safety Learning posted an article in Surgery
Wrong-site surgery is a broad, generic term that encompasses all surgical procedures performed on the wrong patient, the wrong body part, or the wrong side of the body; it can also describe performing the wrong procedure on, or performing on the wrong part of, a correctly identified anatomic site. This guidance from ECRI reviews the various types of wrong-site surgery; discusses the incidence, risk factors, and causes of wrong-site surgery; examines barriers to effective risk reduction; highlights Joint Commission’s elements of performance for the Universal Protocol and other accreditation and regulatory issues; and offers guidance for implementing strategies to prevent the occurrence of wrong-site surgery -
EventuntilOne of the great opportunities for ICSs may be around reducing future demand for healthcare by ensuring that people remain healthy or are helped to reduce the chances of deteriorating if they do develop an illness or long-term condition. Prevention and early intervention underlie much of the NHS Long Term Plan, with a recognition that the NHS can no longer simply be an “ill health” service and instead bends to think about prevention and reducing health inequalities. Many ICSs are keen to develop this role and bring together the organisations they represent – across both the NHS and local authorities –to work collaboratively on this. But with resources and time limited, they may need to concentrate their efforts on particular areas. The second wave of covid – and the prospect of widespread vaccination starting within weeks - has added a new dimension to this with an urgent need to reduce the pressure covid places on the NHS and on normal life in general. This webinar will ask: has covid helped focus the NHS’s eyes on prevention? where are the “easy wins” for ICSs where interventions are most likely to have significant results within a reasonable timeframe? what key steps do ICSs need to take to get the maximum benefit from these? How can they build common purpose among their members to ensure these happen? how can public health be made “business as usual” for everyone working in the NHS – including those in hospitals? how can ICSs balance the preventative interventions which deliver short-term benefits with those which take longer to offer a “return on investment”? Register
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Content ArticleDespite the extensive attention and public commitments towards patient safety over the last two decades, levels of avoidable harm in healthcare around the world remain unacceptably high. This book is free to download.
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Content ArticleWhile individual countries have gained considerable knowledge and experience of COVID-19 management, an international, comparative perspective is lacking, particularly regarding the measures taken by different countries to tackle the pandemic. This paper from Tartaglia et al. elicits the views of health system staff, tapping into their personal expertise on how the pandemic was initially handled.
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Event
Risk assessment masterclass
Sam posted an event in Community Calendar
This virtual one day course is designed to provide attendees with the knowledge and skills to complete risk assessments in their work place. The completion of risk assessments is a core component within an organisations ability to manage its risks. Risk assessments support the prevention of incidents and an organisations achievement of its objectives. By carrying out risk assessments we can understand the current and future impact of the risk to the organisation. All staff have a duty to identify and escalate risks within their workplace. This masterclass will explore the key components of the risk assessment process that must be followed to reduce the likelihood and severity of the risk. Further information and book your place or email kate@hc-uk.org.uk hub members receive 10% discount. Email info@pslhub.org for code- Posted
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Content ArticleThis survey tool from the Australian Commission on Safety and Quality in Health Care provides Australian health service organisations with a set of 14 principles supported by a variety of risk reduction strategies. The tool is intended for use in hospitals by all clinicians involved in the medication management pathway, including those with governance responsibilities within the health service. The survey tool is also intended to be applied within pharmacy and ward storage environments.
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Content ArticleThis project includes the design of templates for controlled drugs, Hypnotics/Z-drugs, DMARDs (each orally administered drug has individualized template), NOACs, Warfarin, Lithium and Amiodarone. These templates prompt the user to add compulsory details before the drug can be issued for the first time or for a repeat issue. This has led to better and safer prescribing and potential to identify group of patients who either have not been reviewed or have missed essential monitoring. To avoid visual fatigue templates are short and to the point and a clinician can navigate away by one click if the required fields have been captured recently. Audits of prescribing such drugs has shown better prescribing and more patient involvement in decision making. Read more about this case study on the NICE shared learning database, via the link below.
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Content ArticleThis case study is featured on the National Institute for Health and Care Excellence (NICE) shared learning database. The associated project aims to optimise the safe use of medicines and reduce avoidable harm to patients. Objectives: To ensure prescribers in GP practices identify and report medication related incidents and near misses via the National Reporting and Learning System (NRLS) (Each practice was required to share at least 4 records with the CCG between April 2017 and March 2018) To enable CCG-wide learning opportunities and prevent further incidents in order to improve patient safety across the CCG (Themes and trends will be disseminated at least quarterly through the Prescribing newsletter). To ensure practices responded to patient safety alerts from the MHRA in a timely manner.
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Content ArticleIn this letter to the British Medical Journal, a group of clinicians call for thorough assessment and investigation for patients with Long COVID, highlighting that many were initially advised to 'stay at home' and were unable to access usual care. The authors note: "Pathological consequences such as myocarditis or a thromboembolic episode may explain symptoms, and these have been noted to occur months after onset in long covid support groups. The medical profession needs to evolve rapid transformative pathways to deal with the long term sequelae of covid-19 that include full investigation of patients." To read the letter in full, follow the link below.
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Content ArticlePatient advocate Vonda Vaden Bates interviews Brandyn Lau, Assistant Professor of Radiology and Health Sciences Informatics, Johns Hopkins School of Medicine, around the importance of venous thromboembolism (VTE) prophylaxis for hospitalised patients.
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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 ArticleTwo decades ago, the Institute of Medicine published To Err Is Human, a landmark report that brought attention to medical error and became a catalyst for the patient safety movement. Around the 10-year anniversary of the report, a number of articles and studies were published that examined the impact of this movement. Nearly all concluded that it was too early to assess whether significant change had taken place. Now, new data indicates efforts after the 20-year anniversary mark have not progressed as expected. It raises vital questions and renewed areas of focus for the healthcare industry. In this article, Coverys, a provider of medical professional liability insurance, looks at the date and the key claim trends.
