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Showing results for tags 'Risk management'.
Found 338 results
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Content ArticleIn this blog, Jonathan Back, Intelligence Analyst at the Healthcare Safety Investigation Branch (HSIB), looks at the opportunities the healthcare system has to adopt proactive risk management to improve patient safety. He highlights that understanding the value of different perspectives may provide new opportunities for improvement if applied across the health and care system. He also outlines the role of the new integrated care boards (ICBs) in achieving this whole-system approach, which should include a clinical governance perspective, organisational and local system perspective and societal perspective.
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Content ArticleThis article, published by MendWell, looks at the benefits of stopping smoking before surgery and the risks of continuing to do so. It includes tips on how to stop smoking.
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Content ArticleHospital boards generally focus attention on measures to answer questions about risk, such as 'How safe are we now?' They are ultimately accountable for the quality of care delivered in hospitals, and data review is a key component of effective board governance. This editorial in BMJ Quality & Safety highlights the lack of guidance on the most effective format for presenting data to determine progress against key risks and targets. The authors argue that data must not be overly simplified and that charts prepared for boards should include monthly data points in graphic format over a longer period of time. This allows trends to be more visible and denotes whether an observed change is significant, helping hospital boards avoid erroneous conclusions tied to random variation.
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Content ArticleLinda Millband is the national practice lead for medical negligence at Thompsons Solicitors. She led the team responsible for fighting, and winning, a legal battle on behalf of 650 ex-patients of disgraced breast surgeon Ian Paterson. Ahead of the publication of the Independent Inquiry into Ian Paterson, Linda reflects on how it should be used as a catalyst for positive change in private hospitals.
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Content ArticleThis article, published in The international journal for quality in healthcare, looks at the Hierarchy of Risk Controls 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.
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Content ArticleThe Patient Safety Education Project (PSEP) uses a high impact, conference-based education program grounded in adult learning principles to teach systems-based patient safety methodology to healthcare professionals. This PSEP participants handbook covers: Gaps in patient safety: A call to action External influences: Law and other factors What is patient safety?: A conceptual framework Advancing patient safety: How to teach and implement Systems thinking: Moving beyond blame to safety Human Factors design: Application for healthcare Communication: Building understanding Teamwork: Being an effective team member Organization and culture: Essential to patient safety Technology: Impact on patient safety Patients as partners: Engaging patients and families Leadership: Everybody’s job
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Content ArticleWith record-long waits for treatment, it has never been so important for NHS trusts to understand the level of risk to patients on the waiting lists. But while it’s one thing to assess and categorise the patients and their risks while waiting, it’s quite another to then subsequently intervene to effectively care for patients during that wait. With the use of technology, there are potentially enormous gains to be made on waiting list management, and one integrated care system is forging ahead on this front. The ICS in question is Cheshire and Merseyside. HSJ takes a look at the progress Cheshire and Merseyside are making.
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Content ArticleWhether beginning a new effort or trying to keep people motivated to better prepare for future hazards, applying risk communication principles will lead to more effective results. This self-guided module introduces seven best practices, numerous techniques, and examples to help you improve your communication efforts. Please note that this training focuses on improving risk communication skills for coastal hazards planning and preparedness, however the principles can be adapted for any setting, including healthcare.
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Content Article
Nursing notes on a scandal (31 March 2023)
Patient-Safety-Learning posted an article in Nursing
The tenth anniversary this year of the publication of the Francis Report in 20131 is marked by the largest scale of industrial action ever taken by nurses in the UK for better pay and conditions and, especially, safe staffing. In this article in the Future Healthcare Journal Alison Leary and Anne Marie Rafferty reflect on opportunities missed in the last decade in the attempt to secure safe staffing in nursing. They consider the aftermath of the public inquiry into Mid Staffordshire NHS Foundation Trust and its consequences for nursing, and how policymakers have consistently ignored a growing body of evidence outlining the benefits of safe staffing. -
Content ArticleMIT Sloan experts offer a systematic approach to organisational resilience that can help leaders manage risk and rebound rapidly when catastrophic events strike.
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Content ArticleSleep deprivation and fatigue lead to a wide range of performance issues that may pose risks to workers and others in the work environment. This review in Frontiers in Neuroscience discusses relevant literature on the topic of fatigue-related performance effects, with a special emphasis physiological and behavioural response variables that have shown to be sensitive to changes in fatigue. It also looks at methods for mitigating these performance effects and discusses their usefulness in regulating them.
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Guiding principles for determining work shift duration and addressing the effects of work shift duration on performance, safety, and health: guidance from the American Academy of Sleep Medicine and the Sleep Research Society (1 November 2021)
Patient-Safety-Learning posted an article in Workforce and resources
Regulators, organisations, communities and workers often struggle with how to manage shift duration and address associated risks from fatigue and sleepiness, while continuing to meet the societal demands for work. This article in the Journal of Clinical Sleep Medicine proposes a series of guiding principles help design a shift duration decision-making process that effectively balances the need to meet operational demands with the need to manage fatigue-related risks. -
Content Article
Psychosocial risk webinar series (FEFO, October 2022)
Patient-Safety-Learning posted an article in Staff safety
This series of webinars by FEFO Consulting looks at how to identify psychosocial hazards at work and manage the associated risks. You can watch the four webinars on FEFO's YouTube channel: ISO 45003 vs Model code of practice – Getting started Change management – Managing psychosocial risks Mental fitness – Opening up conversations HR vs safety – Psychosocial ownership -
Content ArticleThis article in Social Science & Medicine aims to show how patients’ contributions to their safety in hospital are less about involvement as a deliberate intervention, and more about how patients manage their own vulnerability in their interactions with staff. The article outlines the conflict between the current focus on encouraging patients to speak up, raise queries and take ownership of their healthcare, and the relational vulnerability created by the 'sick role'—an established societal role that excuses people from their normal duties in society and entitles them to seek help. The authors highlight that supporting staff to elicit concerns from patients, and offer assurance that challenge is welcome, will be crucial in creating an environment where patients can become fully involved in own safety.
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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 Article
Infiltration is when fluid or intravenous drugs administered to a patient (which are given to patients into a vein through a cannula or other device) inadvertently leak into the tissue surrounding a vein by mistake. Extravasation is when infiltration occurs but the drugs involved are called vesicants which can damage the tissue and cause serious harm to the patient. The National Infusion and Vascular Access Society (NIVAS) are leading a campaign to improve awareness of infiltration and extravasation and reduce avoidable harm. In this interview Andrew Barton, Chair of NIVAS, explains why this is such an important issue and what needs to happen to improve patient safety. -
Content Article
In a series of blogs for the hub, Emma Plunkett and Nancy Redfern, part of the Joint Working Group on Fatigue, will highlight the impact staff fatigue has not only on the staff themselves but also on patient safety, and why healthcare needs a robust fatigue risk management system like other safety-critical industries. In their first blog, Emma and Nancy share how they became involved in investigating night shift fatigue after the death of a colleague driving home tired. They discuss how they set up the Joint Working Group on Fatigue and the aims of the #FightFatigue campaign. -
Content ArticleThe OptiBreech project is a research study exploring the feasibility of evaluating a new care pathway for women with a breech pregnancy. About 1 in 25 babies are born bottom-down (breech) after 37 weeks of pregnancy. Women who wish to plan a vaginal breech birth have asked for more reliable support from an experienced professional. This aligns with national policy to enable maternal choice. In this video, Dr Shawn Walker explains why the combination of meconium and tachycardia, particularly in the first stage of labour, indicates increased risk in breech births.
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Content ArticleThis guidance from the Office of Rail and Road outlines how to manage the risk of fatigue that may arise from a working pattern. It defines 'fatigue factors', highlighting that the more a working pattern features these fatigue factors, the greater the likely need to assess, avoid and control potential fatigue risks.
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Content ArticleFatigue has increasingly been viewed by society as a safety hazard. This has lead to increased regulation of fatigue by governments. The most common control process has been compliance with prescriptive hours of service (HOS) rule sets. Despite the frequent use of prescriptive rule sets, there is an emerging consensus that they are an ineffective hazard control, based on poor scientific defensibility and lack of operational flexibility. In exploring potential alternatives, we propose a shift from prescriptive HOS limitations toward a broader Safety management system (SMS) approach. Rather than limiting HOS, this approach provides multiple layers of defence, whereby fatigue-related incidents are the final layer of many in an error trajectory. This review presents a conceptual basis for managing the first two levels of an error trajectory for fatigue.
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Content ArticleFatigue is increasingly considered as one of the most significant hazards to aviation safety and other safety-critical industries. Both the academic community and industry have focused on understanding the phenomenon of fatigue and the factors that contribute to it in order to prevent it, but also to mitigate its possible consequences. As a result, procedures and regulations have been developed for operators to comply with and there is now a requirement for operators to demonstrate that they are actively managing fatigue. The aim of this white paper by Clockwork Research is to provide safety practitioners with a better understanding of the process of investigating fatigue.
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Content Article
MDU: Cautionary tales - Real member stories
Patient Safety Learning posted an article in Legal matters
These case studies, based on MDU members' real-life experiences, provide a valuable opportunity for shared learning across a wide range of specialties and situations. MDU is a UK medical defence organisation. -
News ArticleRLDatix, 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
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News Article
COVID-19: Many trusts have not done risk assessments for ethnic minority staff
Patient Safety Learning posted a news article in News
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 -
News Article
New tool could be used to identify those most at risk from coronavirus
Patient Safety Learning posted a news article in News
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
