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Found 338 results
  1. Content Article
    In this blog, Dr Nadeem Moghal looks at the recent case of a 30 year-old patient who died after a physician associate (PA) at her GP surgery failed to diagnose her with a pulmonary embolism. He outlines a recent debate about the role of PAs in general practice and why employing them has become an attractive option for GP partnerships, which run as businesses. He highlights the need for PAs to be adequately trained and supervised to ensure patient safety and argues that the role is here to stay as PAs play an important role in tackling gaps in the NHS workforce.
  2. Event
    ISO 45003:2021(E) is a guidance document that provides practical advice on managing psychosocial risks in the workplace. This document is designed to help organisations prevent work-related injury and ill health of their workers and other interested parties, and to promote well-being at work. This masterclass will explore the key concepts of ISO 45003:2021(E) and how they apply specifically to healthcare settings. It will discuss strategies for identifying and assessing psychosocial risks, implementing preventive measures, monitoring effectiveness, and promoting well-being in the workplace. The goal is for you to leave this masterclass with a comprehensive understanding of how ISO 45003:2021(E) can be used to manage psychosocial risks in your own organization. You will also have an opportunity to share best practices with colleagues from other healthcare organisations. Who should attend: Clinical staff, Managers, Admin staff, Policy makers and Board members. Key learning objectives: Participants will have a comprehensive understanding of psychosocial risks in the healthcare workplace. Participants will be able to identify preventive measures that can be implemented to manage these risks. Participants will understand the importance of monitoring and evaluating the effectiveness of these measures. Participants will have an increased awareness of their own well-being and safety in the workplace. Participants will have an opportunity to share best practices with colleagues from other healthcare organisations. Register
  3. Content Article
    This study in the American Journal of Surgery aimed to understand the impact of operating room temperature and humidity on surgical site infection (SSI). The authors found that large deviations in operating theatre temperature and humidity do not increase the risk of SSI.
  4. Content Article
    This resource published by pharmaceutical company BD provides information on common complications of IV catheter therapy, including signs and symptoms and prevention. It covers the following complications: Catheter-related bloodstream infection Dislodgement Extravasation Infiltration Occlusion Phlebitis Thrombosis
  5. Content Article
    In a three-part series of blogs for the hub, Norman Macleod explores how systems behave and how the actions of humans and organisations increase risk.  He argues that, to measure safety, we need to understand the creation of risk. In this first blog, Norman looks at the problems of measuring safety, using an example from aviation to illustrate his points.
  6. Content Article
    This report makes several recommendations to unlock the preventative potential of Prevention of Future Deaths (PFD) Reports. These reports should be viewed as an opportunity for organisations to improve, share good practice, and ultimately prevent custodial deaths – not as criticism to be avoided at all costs. PFD reports have an integral function in ensuring compliance with the state’s duties under Article 2 of the European Convention of Human Rights (ECHR), the right to life, both locally and nationally. This, as well as their immense importance to bereaved families, must be borne firmly in mind.
  7. Content Article
    These charts have been collaboratively developed by clinical teams across England to standardise how the deterioration of children in hospital is tracked. There are four charts for children of different ages, designed to be used on general children’s wards. PEWS observation and escalation chart: 0 to 11 months PEWS observation and escalation chart: 1-4 years PEWS observation and escalation chart: 5-12 years PEWS observation and escalation chart: ≥13 years
  8. Content Article
    During the pandemic, approximately 4.1 million people across the UK were identified as clinically extremely vulnerable (CEV) to Covid-19, and asked to shield for their own protection. This decision, made in the light of an unprecedented pandemic, would separate those with autoimmune inflammatory conditions, such as rheumatoid arthritis, from the rest of society for their own protection. This report by the charity Versus Arthritis presents qualitative research led by Dr Charlotte Sharp, a consultant rheumatologist, Lynn Laidlaw who has an autoimmune rheumatic disease and had to shield, and patient contributor Joyce Fox from the Centre for Epidemiology at the University of Manchester. It highlights the stories of people who lived through shielding and details the impact on their daily lives, their physical and mental wellbeing, their work, and their relationships with their families and the rest of society.
  9. Content Article
    Those who work in health and care are keenly aware of the need to identify and manage risks to protect patients from harm. But we are not the only industry that must take safety seriously. This video from the Healthcare Services Safety Investigation Branch (HSSIB) we compare notes with other safety-conscious industries – oil and gas, shipping, aviation, rail, road, nuclear and NASA – to understand their approach to safety management. In these fields, systems for organising and coordinating safety are often called Safety Management Systems (SMSs). See also HSSIB's report: Safety management systems: an introduction for healthcare.
  10. News Article
    Eighteen more hospitals in England contain potentially crumbling concrete, bring the total affected to 42, the Department of Health has confirmed. The reinforced autoclaved aerated concrete (Raac) has also been found in 214 schools and colleges in England as well as thousands of other buildings. NHS Providers, which represents hospitals, said the concrete "puts patients and staff at risk". Full structural surveys are taking place at all newly confirmed sites. The government said it was committed to eradicating Raac from NHS buildings completely by 2035. Seven of the worst-affected hospitals will be replaced by 2030 as part of the programme to build 40 new hospitals in England, it added. Sir Julian Hartley, chief executive of NHS Providers, said there had been fears that more of the material would be found following surveys of NHS buildings. "Trusts are doing everything they can, at huge cost, to keep patients safe where this concrete is found," he said. Read full story Source: BBC News, 21 October 2023
  11. Content Article
    Bowtie is a visual tool which effectively depicts risk, providing an opportunity to identify and assess the key safety barriers either in place or the ones lacking, between a safety event and an unsafe outcome. This guidance from the UK Civil Aviation Authority outlines how the bowtie model works and how to use it.
  12. Content Article
    Safety Management Systems (SMSs) are an organised approach to managing safety which are widely used in different industries. In this report, the Health Services Safety Investigations Body (HSSIB) identifies the requirements for effective SMSs, how these are used in other safety-critical industries and considers the potential of application of this approach in healthcare. It makes safety recommendations for NHS England and the Care Quality Commission in relation to this. See also HSSIB's video Introduction to safety management systems.
  13. Content Article
    Allergic reactions vary in severity. People with food allergy tend to have reactions which affect the skin or gut, but around one third of reactions involve the breathing: these more serious allergic reactions are known as anaphylaxis. Very rarely, anaphylaxis can be severe and therefore life-threatening. This leaflet created by Allergy UK and Anaphylaxis UK explains how you can reduce the risk of this happening. Anaphylaxis is unpredictable and can occur in people who have never had this type of reaction before, but most people will recover fully. 
  14. Event
    This masterclass will focus on developing your role as a SIRO (Senior Information Risk Owner) in health and social care. Key learning objectives Understanding the role of the Senior Information Risk Owner Identifying Information Risks across the organisation Working with others to mitigate the risk to patients, staff and organisation. Confidence that all reasonable technical and organisation measure are in place Giving assurance to the Board that risks have been considered, mitigated or owned Understand the requirements of external confidence that policies, procedures are in place to deal with Data Breaches Facilitated by: Andrew Harvey IG Consultant BJM IG Privacy Ltd Register hub members receive a 20% discount code. Email info@pslhub.org for discount code.
  15. Content Article
    Healthcare often uses the experience of aviation to set its patient safety agenda, and the benefits of a ‘safety management system’ (SMS) are currently being espoused, possibly because the former chief investigator for HSIB, Keith Conradi, had an aviation background. So, what does an SMS look like and would it be beneficial in healthcare? In this blog, Norman MacLeod discusses aviation's SMS, its many component parts, the four pillars of an SMS, just culture and its role in healthcare.
  16. Content Article
    Consent to treatment means a person must give permission before they receive any type of medical treatment, test or examination. This must be done on the basis of an explanation by a clinician. Consent from a patient is needed regardless of the procedure, whether it's a physical examination or something else. The principle of consent is an important part of medical ethics and international human rights law. This webpage from the NHS includes information on: how consent is given and what we mean by consent assessing capacity consent from children and young people assessing capacity when consent is not needed consent and life support.
  17. Content Article
    This is one of a series of 'Learning from safety incidents' resources published by the Care Quality Commission (CQC). Each one briefly describes a critical issue—what happened, what the CQC and the provider have done about it, and the steps you can take to avoid it happening in your service. This edition is about ensuring the safety of people using wheelchairs in health and social care. The CQC recently prosecuted a care home provider for exposing someone using their service to a significant risk of avoidable harm, which resulted in a life-changing injury.
  18. News Article
    A young woman died following “gross failings” and “neglect” by a mental health hospital in Essex which is also facing a major independent inquiry into patient deaths. Bethany Lilley, 28, died on 16 January whilst she was an inpatient at Basildon Mental Health unit, run by Essex Partnership University Hospitals. The inquest examined the circumstances of her death this week and concluded that her death was contributed by neglect due to a “plethora of failings by Essex University Partnership Trust”. Following the three week inquest, heard before coroner Sean Horstead, a jury found “neglect” contributed to Ms Lilley’s death and identified “gross failures” on behalf of the trust. The jury identified a number of failings in her care including evidence that cocaine had made its way onto a ward where she was an inpatient. There was evidence of “very considerable problems in the record-keeping at EPUT psychiatric units.” It was also concluded staff failed to carry out a risk assessment of Ms Lilley in the days leading up to her death, and failed to carry out observations. Ms Lilley’s death is one of a series of patients who have died under the care of mental health services in Essex, which have been brought into the light following the campaigning of bereaved families. Read full story Source: The Independent, 19 March 2022
  19. News Article
    Some care homes have "no choice" but to allow workers who have Covid to deliver care, a public health official said. According to Public Health England cases are rising the fastest in Somerset. As a result, care homes in the county are struggling to safely staff their services and schools are seeing a rise in staff sickness. Somerset Council said ensuring vulnerable residents received care was "lower risk" than them being infected. Health officials advised care workers to continue working only if they wore PPE and felt well enough. Council public health consultant Alison Bell said: "In some cases, we have no choice but to have people who are testing positive delivering care to people in Somerset. "That risk is actually less than that person not receiving care." She said the Omicron variant was more transmissible and people were getting re-infected with it, some within a matter of weeks. Read full story Source: BBC News, 16 March 2022
  20. News Article
    NHS England and the Care Quality Commission have asked systems with large numbers of ambulance handover delays to urgently hold a meeting to try to fix the problem by “balancing the risks” of long 999 waiting times. The request was made in an email to chief executives, which warned the service was “in a difficult position with all parts of the urgent and emergency care pathway under considerable strain… most acutely in ambulance response times which in turn is linked to challenges in handing patients over to emergency departments”. The NHSE headed letter was signed by its chief operating officer, nursing director and medical director, but also by the CQC’s chief inspector of hospitals Ted Baker. It said there was a “strong correlation” between handover delays at hospitals — which take place where A&Es are unable to receive patients from ambulances — and long delays for category two ambulances. This is because ambulances have to wait for long periods outside the hospitals. The letter said: ”It is vital that we have a whole-system approach to considering risks across the urgent and emergency care pathway to provide the best outcomes for our patients. This may mean consideration of actions to be taken downstream to help improve flow and reduce pressures on emergency departments.” Read full story (paywalled) Source: HSJ, 17 February 2022
  21. News Article
    Only a quarter of patients on valproate, who do not have appropriate contraception, are being referred by their pharmacist to their GP or a specialist about the issue, an audit carried out by NHS England has found. A report on the 2019/2020 Pharmacy Quality Scheme Valproate Audit — which was carried out in community pharmacies across England — published on 11 August 2022, has indicated that the Medicines and Healthcare products Regulatory Agency’s (MHRA’s) safety requirements for use of valproate in women and girls of childbearing age, and trans men who are biologically able to be pregnant, are “still not being fully met”. Since 2018, the MHRA has advised that valproate, a treatment for epilepsy and bipolar disorder, must not be used in anyone of childbearing potential, unless a Pregnancy Prevention Plan (PPP) is in place. As part of a PPP, pharmacists are required to remind patients of the risks of taking sodium valproate in pregnancy and the need for highly effective contraception; ensure patients have been given the patient guide; and remind patients of the need for an annual specialist review. However, the audit, which was conducted by 10,293 community pharmacies in England, including responses from 12,068 patients and patient representatives, found that pharmacists were not referring or signposting “a sizeable minority”, who appeared to be without appropriate contraception, back to the prescriber. The report said that community pharmacists should refer “all people aged 12–55 who are biologically able to be pregnant and have not had their valproate medication reviewed within the last 12 months to their GP or specialist, as well as to local contraception services as appropriate”. For patients not referred to their GP or specialist, the report said that the pharmacist should be able to confirm that the patient is fully informed, understands the risks of not using highly effective contraception and knows who to contact if their circumstances change. Read full story Source: The Pharmaceutical Journal, 12 August 2022
  22. News Article
    The impetus to tackle health security has started to “melt away”, despite the devastation wrought by the Covid pandemic, Tony Blair has warned. In the foreword to a new book, ‘Disease X’, the former British prime minister said that while there are “concurrent crises jostling for the attention of governments”, leaders should not miss the opportunity to implement the “hard-won lessons” of the past three years. “Covid-19 was an unprecedented global crisis and should mark a turning point in global health policy and preparedness,” Mr Blair wrote. “Our governments need to demonstrate the same level of political will, ambition and international cooperation that leaders demonstrated in the wake of World War II, when they coalesced around the objective of a sustainable peace. “This must be applied to the post pandemic order because, at its heart, health security is national security,” he added. “It is clear this will not be the last pandemic threat of our lifetimes … there is no excuse to be unprepared, again.” Read full story (paywalled) Source: The Telegraph, 25 January 2023
  23. News Article
    AI could harm the health of millions and pose an existential threat to humanity, doctors and public health experts have said as they called for a halt to the development of artificial general intelligence until it is regulated. Artificial intelligence has the potential to revolutionise healthcare by improving diagnosis of diseases, finding better ways to treat patients and extending care to more people. But the development of artificial intelligence also has the potential to produce negative health impacts, according to health professionals from the UK, US, Australia, Costa Rica and Malaysia writing in the journal BMJ Global Health. The risks associated with medicine and healthcare “include the potential for AI errors to cause patient harm, issues with data privacy and security and the use of AI in ways that will worsen social and health inequalities”, they said. One example of harm, they said, was the use of an AI-driven pulse oximeter that overestimated blood oxygen levels in patients with darker skin, resulting in the undertreatment of their hypoxia. Read full story Source: The Guardian, 10 May 2023
  24. News Article
    Thousands of children in mental health crisis are being treated on inappropriate general wards – with some forced to stay for more than a year and staff not properly trained to care for them, shocking new data reveals. New figures uncovered by The Independent show at least 2,838 children needing mental health care were admitted to non-psychiatric hospitals last year as the NHS battled with a lack of specialist staff and a surge in patients. Children with eating disorders – who often need to be restrained to be fed through tubes – are among those being routinely put on general wards. It means staff without any specialist training, including security guards, are sometimes left to restrain these young patients. One trust chief nurse told The Independent that porters had to be trained to restrain children on paediatric wards, causing trauma for both patients and staff. Dr Camilla Kingdon, president of the Royal College of Paediatrics and Child Health, said she was “deeply concerned” about the situation. “We now find ourselves in a situation where children and young people who have an eating disorder or mental ill health, and who may be on long waiting lists for treatment, are increasingly ending up in emergency settings and then being treated on general paediatric wards. This simply isn’t good enough,” she said. Read full story Source: The Independent, 1 May 2023
  25. Content Article
    Quality improvement is a methodology used routinely in emergency departments (EDs) to bring about change to improve outcomes such as waiting times, time to treatment and patient safety. However, introducing the changes needed to transform the system in this way is seldom straightforward with the risk of “not seeing the forest for the trees” when attempting to make changes. This article in Annals of Emergency Medicine aims to demonstrate how the functional resonance analysis method can be used to capture the experiences and perceptions of frontline staff to identify the key functions in the system (the trees), to understand the interactions and dependencies between them to make up the ED ecosystem (“the forest”) and to support quality improvement planning, identifying priorities and patient safety risks.
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