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Showing results for tags 'Risk management'.
Found 338 results
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Content ArticleHelen Marie Bousquet tragically passed away after what has been described by her son as 'a basic routine procedure' for knee surgery. He argues that her tragic and avoidable death highlights the need for better assessment of patients for sleep apnea and for better treatment and monitoring of these patients before, during and after surgery. The recent jury finding that a hospital nurse was negligent in the care of Helen Marie Bousquet raises the question whether negligence can result in safer patient care. In his blog, Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety), looks at this case and the lessons that can be learned.
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Content ArticleIn this article published in the British Columbia Medical Journal, Drs Richard Merchant and Matt Kurrek encourage the use of capnographic monitoring to improve the safety of patients undergoing procedural sedation.
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Content ArticleA dilemma is a situation in which a difficult choice has to be made between two or more alternatives, especially ones that are equally undesirable. Healthcare is full of dilemmas as a result of the huge number of stakeholders with conflicting goals, multifaceted interactions and constraints, and multiple perspectives, which change daily. Dilemmas are created when safety conflicts with productivity, cost efficiency, and flow. A focus on one patent’s safety may conflict with a focus on all patients’ safety. It is vital that the different stakeholders talk to expose dilemmas and reveal the hidden trade-offs or adjustments that are kept secret because people are fearful of the consequences. Articulating dilemmas helps us to find a way to bring people with different interests and incentives into a conversation that meets everyone’s needs.
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Content ArticleThe Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, presents evidence-based recommendations on the preferred methods for cleaning, disinfection and sterilisation of patient-care medical devices and for cleaning and disinfecting the healthcare environment. This is an American guidance from the Centers for Disease Control and Prevention.
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Content ArticleThe American based ECRI Institute Patient Safety Organization (PSO), identified 234 events in its database pertaining to dirty surgical instruments. This report contains several recommendations based on the findings.
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Content ArticleThis American report describes events involving dirty instruments submitted to ECRI Institute Patient Safety Organization and other reporting agencies. It provides recommendations to improve reprocessing practices, with a focus on instrument decontamination and the cleaning that occurs before disinfection or sterilisation.
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Content ArticleThis is a Health Technical Memorandum (HTM) published by the Department of Health and Social Care (DHSC) called Management and decontamination of surgical instruments (medical devices) used in acute care. Part A: Management and provision. The purpose of this HTM is to help health organisations to develop policies regarding the management, use and decontamination of reusable medical devices at controlled costs using risk control, which will enable them to comply with Regulations 12(2)(h) and 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 . It is designed to reflect the need to continuously improve outcomes in terms of: patient safety clinical effectiveness patient experience.
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Content ArticleThis study, published in US journal Chest, looks at the case of a patient who experienced severe hypoglycemia due to an infusion of a higher-than-ordered insulin dose. The event could have been prevented if the insulin syringe pump was checked during the nursing shift handoff. Risk management exploration included direct observations of nursing shift handoffs, which highlighted common deficiencies in the process. This led to the development and implementation of a handoff protocol and the incorporation of handoff training into a simulation-based teamwork and communication workshop.
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Content ArticleIn his article for KevinMD.com, Ashish Jha looks at the metrics associated with hospital acquired conditions (HACs) in the US. He discusses the imperfections of HAC scored and argues that we need better measures in order to make further progress in the field of patient safety.
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Content ArticleEighteen years after the advent of the National Patient Safety Agency (NPSA) why is investigating in such a parlous state? Ed Marsden, Managing Director of independent investigative consultants Verita, discusses why making improvements to patient safety comes second place to sorting out problems with the investigative process.
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Content ArticlePublished by wbur, an American news station, this account from a doctor tells the story of his father's admission to hospital. Dr. Ashish Jha lists a catalogue of errors that took place over those few days, notes how common these mistakes are and argues we should be less tolerant of poor patient safety in healthcare.
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Content ArticleWhen patients are harmed as a result of the care they receive through Alberta Health Services (AHS), the organisation has a responsibility to understand how the harm happened and, where appropriate, respond to improve the healthcare system. This handbook has been developed to assist and support AHS staff and medical staff to retrospectively review clinical adverse events, hazards and close calls using Systems Analysis Methodologies (SAM). It is not an administrative review of individual healthcare provider performance. Using these methodologies, the complex interactions of all the components within the health system are considered, not the individual contributions of healthcare providers that have or may have led to harm. This creates opportunities to identify vulnerabilities in structures, processes and practices that can be improved and ultimately make care safer.
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Content ArticleTackling antimicrobial resistance (AMR) and Healthcare Associated Infection (HAI) are currently a priority within healthcare and antimicrobial stewardship is an essential element of national and local programmes to address AMR. The aim of this webinar is to provide an overview of antimicrobial stewardship (AS), its importance in tackling Healthcare Associated Infection (HAI) and how pharmacists can contribute.
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Content ArticleThe pharmacy contribution to antimicrobial stewardship document focuses on the pharmacist’s role as part of a multidisciplinary approach in tackling the challenges of inappropriate use of antibiotics. The recommendations in this policy have been produced in order to contribute to wider efforts in meeting the challenge set by the UK Government in 2016 of reducing inappropriate antibiotic prescribing by 50% by 2020.
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Content ArticleThe act of open disclosure of an adverse event alone may not be enough for patients or their families. Patients and patient advocates are asking for increased transparency and a greater role in the process of change. When properly handled, involving patients in post‐event analysis allows risk management professionals to further improve their organisation's systems analysis process while empowering patients to be part of the solution. First published by the US-based Journal of Health Care Risk Management, this article examines the legal and psychological considerations surrounding the involvement of patients in system failure analysis and provides tools for selecting patients who are able to benefit from this process and for adequately preparing patients and caregivers for what lies ahead.
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Content Article"Among many other opportunities created by the launch of the World Alliance for Patient Safety is the hope that one day the learning from the inadvertent death of a patient in a hospital in one country could save the lives of many others around the world." In his paper, Sir Liam Donaldson (Chair of the WHO World Alliance for Patient Safety at the time) talks about the importance of global collaboration for patient safety.
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Content ArticlePractice staff should use the GP e-form to report all patient safety incidents and near misses whether they result in harm or not. These reports are used by to spot any emerging patterns of similar incidents or anything of particular concern. This will help protect patients by raising awareness of the risks through shared learning with general practices and other health providers across the country.
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Content ArticleAbout one in ten patients are harmed during health care. Published on the OECD Library website, this paper estimates the health, financial and economic costs of this harm. Results indicate that patient harm exerts a considerable global health burden. The financial cost on health systems is also considerable and if the flow-on economic consequences such as lost productivity and income are included the costs of harm run into trillions of dollars annually. Because many of the incidents that cause harm can be prevented, these failures represent a considerable waste of healthcare resources, and the cost of failure dwarfs the investment required to implement effective prevention.
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Content ArticleRisk scores are widely used in healthcare, but their development and implementation do not usually involve input from practitioners and service users and carers (SU/C). This study from Dyson et al., published in BMJ Open contributes to the development of The Computer-Aided Risk Score (CARS) by eliciting views of staff and who provided important, often complex, insights to support the development and implementation of CARS to ensure successful implementation in routine clinical practice.
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Content ArticleOver the last two decades, safety improvements have flat-lined (as measured in fatalities and serious injury rates, for instance) despite a vast expansion of compliance and bureaucracy. The cost of compliance and bureaucracy can be mind-boggling – up to 10% of GDP, with every person working some 8 weeks per year just to cover the cost of compliance, paperwork and bureaucratic accountability demands. This is non-productive time. It has also stopped progressing safety.
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Content Article
Letter from America: A Grand Adventure
lzipperer posted an article in Letter from America
‘Letter from America’ is a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. The series will cover successes large and small. I share them here to generate conversations through the hub, over a coffee and in staff rooms to transfer these innovations to the frontline of UK care delivery.- Posted
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Content Article
NHS Digital’s Clinical Safety team – Our day to day work
HannahMcCann posted an article in NHS Digital
On a day to day basis, the NHS Digital Clinical Safety team are involved in several wide-ranging and very different projects. As you know, clinical safety should be part of everything the NHS do. Every project, every programme, every deployment. Clinical safety should be considered, understood and implemented to the highest calibre. So as you can imagine, we are a busy team. For those manufacturers with systems in use, we deal with live incidents, upgrades, further geographical or functionality deployments. For those creating new systems we are supporting them in their clinical risk management process, running hazard workshops, creating hazard logs and writing the supporting documentation. We are constantly reviewing and peer reviewing, assessing compliance and marking against the standard requirements. We assist suppliers and health organisations to self-audit their compliance against the standards so they may improve their clinical safety position. We are assessing new and emerging apps and mobile health solutions to ensure they are going through the same standard of assessment as the traditional computer-based systems and we are providing representation across the NHS to ensure clinical safety remains paramount to the work being done. One of the biggest branches of our role is training delivery. We know first-hand the importance of having a team that are educated and confident in clinical risk management. -
Content Article
MHRA: The Yellow Card Scheme
Claire Cox posted an article in Adverse interactions
The Yellow Card Scheme helps the Medicines and Healthcare products Regulatory Agency (MHRA) monitor the safety of all healthcare products in the UK to ensure they are acceptably safe for patients and those who use them. On the Yellow Card Scheme website you can report a suspected incident or problem. -
Content ArticleThe Institute for Safe Medication Practices (ISMP) is the only US nonprofit organisation devoted entirely to preventing medication errors. In this short video, produced by ISMP in partnership with the Temple University School of Pharmacy, experts discuss current medication safety concerns and offer practical error prevention recommendations.
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Content ArticleThe Institute for Safe Medication Practices (ISMP) is the only nonprofit organisation in the US devoted entirely to preventing medication errors. In this video, produced by ISMP in partnership with the Temple University School of Pharmacy, experts discuss medication safety concerns and offer practical error prevention recommendations.
