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Found 339 results
  1. Content Article
    Fires on the operating field are rare events that should never happen, but do. They are dangerous not only to the patient but to the operating room (OR) team members as well. Surgical fires remain a significant enough risk to justify use of a Fire Risk Assessment Score and adherence to the recommendations of the American Society of Anesthesiologists Task Force on Operating Room Fires and those of the Anesthesia Patient Safety Foundation. Here, the Pennsylvania Patient Safety Authority shares key data and statistics, educational tools, multimedia and related links on surgical fires.
  2. News Article
    No single solution will stop the virus’s spread, but combining different layers of public measures and personal actions can make a big difference. It’s im­por­tant to un­der­stand that a vac­cine, on its own, won’t be enough to rapidly ex­tin­guish a pan­demic as per­ni­cious as Covid-19. The pan­demic can­not be stopped through just one in­ter­ven­tion, be­cause even vac­cines are im­per­fect. Once in­tro­duced into the hu­man pop­u­la­tion, viruses con­tinue to cir­cu­late among us for a long time. Fur­ther­more, it’s likely to be as long as a year be­fore a Covid-19 vac­cine is in wide-spread use, given in­evitable dif­fi­cul­ties with man­u­fac­tur­ing, dis­tri­b­u­tion and pub­lic ac­ceptance. Con­trol­ling Covid-19 will take a good deal more than a vac­cine. For at least an­other year, the world will have to rely on a mul­ti­pronged ap­proach, one that goes be­yond sim­plis­tic bro­mides and all-or-noth­ing re­sponses. In­di­vid­u­als, work-places and gov­ern­ments will need to con­sider a di­verse and some­times dis­rup­tive range of in­ter­ven­tions. It helps to think of these in terms of lay­ers of de­fence, with each layer pro­vid­ing a bar­rier that isn’t fully im­per­vi­ous, like slices of Swiss cheese in a stack. The ‘Swiss cheese model’ is a clas­sic way to con­cep­tu­al­ize deal­ing with a haz­ard that in­volves a mix­ture of hu­man, tech­no­log­i­cal and nat­ural el­e­ments. This article can be read in full on the WSJ website, but is paywalled. The illustration showing the swiss cheese pandemic model is hyperlinked to this hub Learn post.
  3. Content Article
    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.
  4. Content Article
    Risks 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.
  5. Content Article
    A set of 5 infographics describing the the factors that influence the risk of nosocomial transmission of infections (such as Covid19), and how health and care staff can take action to manage the risks and reduce the infection rate. The factors explained are: People Equipment Task Environment Organisation
  6. Content Article
    On 17 November, there will be a Parliamentary launch event of the Surgical Fires Expert Working Group’s report 'A case for the prevention and management of surgical fires in the UK, which focuses on the prevention of surgical fires in the NHS'. Unfortunately surgical fires are still a patient safety issue. Each year patients needlessly suffer burns during surgical procedures which leave them with long-lasting, life-changing injuries and burdens the NHS with millions of pounds of avoidable costs and liabilities. Despite this, there is not a consistent, standardised approach across the NHS to prevent them. Kathy Nabbie, a theatre scrub nurse practitioner, shares how she implemented Fire Risk Assessment Score (FRAS) into her department.
  7. News Article
    Old age and having a wide range of initial symptoms increase the risk of "long Covid", say scientists. The study estimates one in 20 people are sick for least eight weeks. The research at King's College London also showed being female, excess weight and asthma raised the risk. The aim is to develop an early warning signal that can identify patients who need extra care or who might benefit from early treatment. The findings come from an analysis of people entering their symptoms and test results into the COVID Symptom Study app. Scientists scoured the data for patterns that could predict who would get long-lasting illness. "Having more than five different symptoms in the first week was one of the key risk factors," Dr Claire Steves, from Kings College London, told BBC News. COVID-19 is more than just a cough - and the virus that causes it can affect organs throughout the body. Somebody who had a cough, fatigue, headache and diarrhoea, and lost their sense of smell, which are all potential symptoms,- would be at higher risk than somebody who had a cough alone. The risk also rises with age, particularly over 50, as did being female. Dr Steves said: "We've seen from the early data coming out that men were at much more risk of very severe disease and sadly of dying from Covid, it appears that women are more at risk of long Covid." No previous medical conditions were linked to long Covid except asthma and lung disease. Read full story Source: BBC News, 21 October 2020
  8. News Article
    UK researchers have developed a new risk prediction tool that estimates a person’s chance of hospitalisation and death from COVID-19. The algorithm, which was constructed using data from more than eight million people across England, uses key factors such as age, ethnicity and body mass index to help identify individuals in the UK at risk of developing severe illness. It’s hoped that the risk prediction tool, known as QCOVID, will be used to support public health policy throughout the rest of the pandemic, in shaping decisions over shielding, treatment or vaccine prioritisation. The research, published in The BMJ, was put together by a team of scientists across the UK, and has been praised for the depth and accuracy of its findings. “This study presents robust risk prediction models that could be used to stratify risk in populations for public health purposes in the event of a ‘second wave’ of the pandemic and support shared management of risk,” the researchers say. “We anticipate that the algorithms will be updated regularly as understanding of COVID-19 increases, as more data become available, as behaviour in the population changes, or in response to new policy interventions.” Read full story Source: The Independent, 21 October 2020
  9. Content Article
    Clift et al. have developed a new risk prediction tool that estimates a person’s chance of hospitalisation and death from COVID-19. The algorithm, which was constructed using data from more than eight million people across England, uses key factors such as age, ethnicity and body mass index to help identify individuals in the UK at risk of developing severe illness.
  10. News Article
    The care model run by independent sector mental health and learning disability hospitals is ‘inherently risky’, a Care Quality Commission (CQC) chief inspector has warned. Speaking at the NHS Providers conference, Ted Baker, chief inspector of hospitals for the Care Quality Commission, unveiled the regulator’s plans to change how it inspects health and care services. When asked by HSJ how its new “streamlined” approach would be applied to inpatient units run by the independent sector for people with mental health and learning disability, Professor Baker said: ”One of the things we’ve been doing during the pandemic, and will continue in our transitional approach, is target risk. And one of the risks we have been targeting is exactly this, patients with learning disability and/or autism in some of these small units that have got closed cultures." “I think we do recognise that model of care is an inherently risky model of care and so we have been inspecting many of those under this risk driven model and taking action against many of them. But there is ongoing concern about that model of care and in a few weeks’ time we will be publishing a report on our assessment of that model of care and the importance of it being changed for the benefit of the people being looked after. The model of care needs to be improved but we need to make sure we are tackling the risk.” The chief’s comments come ahead of the regulator’s state of care report, which is due to be published next week. In its report published last year the CQC highlighted a concern regarding the quality and safety of independent learning disability and autism units. In particular it warned these were at a higher risk of developing closed cultures. Read full story (paywalled) Source: HSJ, 7 October 2020)
  11. Content Article
    Hazards 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.
  12. Content Article
    When a patient's safety is compromised, or even if someone just comes close to having an incident, you need to know you are taking the right measures to address it, now and in the future. The Canadian Patient Safety Institute (CPSI) provides you with practical strategies and resources to manage incidents effectively and keep your patients safe. This integrated toolkit considers the needs and concerns of patients and their families, and how to properly engage them throughout the process. Drawn from the best available evidence and expert advice, this newly designed toolkit is for those responsible for managing patient safety, quality improvement, risk management, and staff training in any healthcare setting.
  13. Content Article
    Concerns for patient safety persist in clinical oncology. Within several nonmedical areas (eg, aviation, nuclear power), concepts from Normal Accident Theory (NAT), a framework for analysing failure potential within and between systems, have been successfully applied to better understand system performance and improve system safety. Clinical oncology practice is interprofessional and interdisciplinary, and the therapies often have narrow therapeutic windows. Thus, many of the processes are, in NAT terms, interactively complex and tightly coupled within and across systems and are therefore prone to unexpected behaviours that can result in substantial patient harm. To improve safety at the University of North Carolina, Chera et al. have applied the concepts of NAT to their practice to better understand their systems’ behaviour and adopted strategies to reduce complexity and coupling. Furthermore, recognising that you cannot eliminate all risks, they have stressed safety mindfulness among their staff to further promote safety. Many specific examples are provided herein. The lessons from NAT are translatable to clinical oncology and may help to promote safety.
  14. Content Article
    Between 30 June - 05 July 2020, the College conducted a survey to assess its members' views on the current preparedness to restart planned services. 
  15. Content Article
    Maryanne Mariyaselvam, Clinical Research Fellow at Queen Elizabeth Hospital, presenting at this year's Improving Patient Safety & Care 2020 conference: Safer culture, safer systems, safer patients.
  16. News Article
    RLDatix, the leading provider of intelligent patient safety solutions, have announced a new framework—Applied Safety Intelligence™—that will tighten the relationship between patient safety and risk management by moving the industry from a retrospective review of adverse events toward a future of proactive prevention. This profound shift will usher in a new era of future-forward patient safety. Traditionally, patient safety and risk management efforts have been driven by a retrospective capture of harmful events, often resulting in long wait times to reach resolutions for patients and families, hefty litigation and punitive damages to health systems, and a profound negative impact on the care teams involved. With Applied Safety Intelligence, healthcare organisations will be able to reduce preventable harm and, in many cases, avoid it altogether. "As the global leader in patient safety, RLDatix is unmatched in its ability to drive innovation that leads to safer care," said Jeff Surges, CEO of RLDatix. "With Applied Safety Intelligence, we are putting patient and caregiver safety at the center of value-based care as we continue challenging traditional conventions around inevitable harm, provider burnout and enterprise risk. Together with our customers, we are catalysing a future where the human and financial impact of unsafe care is significantly reduced. " Read full story Source: CISION PR Newswire, 15 July 2020
  17. Content Article
    Group B Strep can be a complex topic, with some confusion about what exactly is the latest guidelines on testing, risk factors, recommended antibiotics, and the impact (if any) of GBS on homebirths, waterbirths, breastfeeding, and much more.This is why Group B Strep Support and the Royal College of Midwives (RCM) have produced an evidence-based group B Strep i-learn module.The group B Strep i-learn module focuses on the current UK guidelines for preventing group B Strep infection in newborn babies and on signs of these infections in babies. It will refresh clinician knowledge of the national guidelines, and help you tackle the FAQs you get from expectant and new parents.Follow the link below to find out how to sign up.
  18. Content Article
    PPROM is the acronym for Preterm Pre-labour Rupture Of Membranes. This is otherwise known as when the waters break prior to 37 weeks during pregnancy. These waters, known as the amniotic fluid, protect the baby from injury. It also helps in preventing infection being passed from mother to baby. As soon as the waters break the risks of infection to both mother and baby are high. Therefore good management of care at this stage is key to treating this condition successfully. Little Heartbeats raise awareness of PPROM, help patients share their experiences and promote the use of the Royal College of Obstetricians and Gynaecology leaflet which contains the guidelines set out for UK hospitals to follow in the event of PPROM.
  19. Content Article
    This table was included in the report Patient Safety Concerns in COVID-19 related events: a study of 343 event reports from 71 Hospitals in Pennsylvania, published by the Patient Safety Authority. It outlines 13 factors associated with patient safety concerns within COVID-19 related events. These include admssion screening, communication, knowledge deficit and medication. The full list with more detailed explanations of each can be downloaded via the attachment.
  20. Content Article
    Patient Safety Learning's Chief Digital Officer, Clive Flashman, discusses the patient safety concerns around the thousands of health and care apps in app stores today, and how we can ensure patients are kept safe.
  21. News Article
    Some NHS trusts in England are yet to complete /cOVID-19 risk assessments for their staff from ethnic minority groups more than two months after the NHS first told them to do so, an investigation by The BMJ has found. On 29 April NHS England’s chief executive, Simon Stevens, wrote to all NHS leaders telling them to carry out risk assessments and make “appropriate arrangements” to protect ethnic minority staff, amid growing evidence that they were at greater risk of contracting and dying from COVID-19. However, The BMJ asked England’s 140 acute care trusts for details of risk assessments they had carried out and what subsequent actions they had put in place. Seventy trusts responded. Of these, 27 (39%) said that assessments were yet to be completed for all ethnic minority staff, and 43 (61%) indicated that assessments had been completed. But the other 70 trusts were unable to provide a response within the 20 day deadline, citing “unprecedented challenges” posed by the COVID-19 pandemic, so it is not known what stage they are at in risk assessing staff. Commenting on The BMJ’s findings, Chaand Nagpaul, the BMA’s chair of council, said, “Clearly, we know that a significant number of doctors have not been risk assessed. It is a shame that it has taken so long, because the risk assessments and mitigations would have been most useful and impactful during the peak of the virus.” Doctors’ leaders have suggested that systemic race inequalities in the workplace may have exacerbated delays in risk assessing staff. Nagpaul said, “The BMA survey found that doctors from a BAME [black, Asian, and minority ethnic] background felt under more pressure to see patients without adequate protection. So it does beg the question of whether there’s also been this added factor of BAME healthcare staff feeling unable to demand their right to being assessed and protected." “This is something the NHS needs to tackle. This is an issue that predates covid. It’s vital that we have an NHS where anyone is able to voice their concerns. No one should have to suffer or have fear in silence.” Read full story Source: The BMJ, 10 July 2020
  22. Content Article
    Early clinical experiences have demonstrated the wide spectrum of COVID-19 presentations, including various reports of atypical presentations of COVID-19 and possible mimic conditions. This article, published in the BMJ, summarises the current evidence surrounding atypical presentations of COVID-19 including neurological, cardiovascular, gastrointestinal, otorhinolaryngology and geriatric features. 
  23. Content Article
    In this blog, intensive care doctor Jake Suett draws on his personal journey and that of others to highlight the prolonged and frightening symptoms many patients with confirmed or suspected COVID-19 are experiencing. Jake outlines his concerns and sets out recommendations for future action to address the needs of these 'Long COVID' patients. Included is an example letter that can be adapted by others to call on MPs to raise awareness of those suffering persisting symptoms of COVID-19. 
  24. Content Article
    Every year, avoidable unsafe care harms and kills thousands of people in the UK, with the NHS estimating that there are 11,000 deaths annually due to patient safety incidents. This causes not only untold physical and emotional damage but it also creates a huge financial burden, with the annual cost to the NHS of unsafe care and litigation standing at close to £5 billion. It is important that when organisations are considering the workplace as a whole system, safety should be at the core of its design. This blog discusses the impact of COVID-19 and workforce pressures on patient safety and outlines key considerations for Boards as we return to 'normal'.
  25. News Article
    A new risk tool could be used to identify those most at threat from COVID-19, so GPs can give patients tailored advice, health officials have said. Scientists at Oxford University are working on a clinical risk prediction model, which aims to give individuals more precise information about the likely impact of the disease on them, instead of a blanket approach. Health officials said the plans aimed to allow “very individualised discussions” between patients and their doctors, in the event of future outbreaks, particularly as winter approaches. Read full story (paywalled) Source: The Telegraph, 23 June 2020
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