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Showing results for tags 'Risk management'.
Found 339 results
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EventThis one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been re-designed in line with the new Patient Safety Syllabus. It will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on risk and behaviour to improve patient safety. Key learning objectives: Evaluating risk Using mapping techniques Safety interventions Behaviour Assessing safety culture Register
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EventThis 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. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/masterclass-developing-your-role-as-a-senior-information-risk-owner-siro or email kate@hc-uk.org.uk hub members receive 20% discount. Email info@pslhub.org for discount code.
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Community Post
Better use of data for medication safety in hospitals
Kenny Fraser posted a topic in Medicine management
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NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. I have just published a post about this challenge and Triscribe's solution. I would love to hear any comments or feedback on the topic... How could we use this information better? What are hospitals already doing? Where are the gaps? Thanks- Posted
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Content ArticleThis 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.
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Content ArticleWales' national policy on patient safety incident reporting and management.
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Community PostHi everybody This is Jaione from Spain (we are in the North, Basque Region) and i am a nurse working in collaboration with the Patient Safety Team in our local NHS (Basque Health Service). First of all, I would like to congratulate the team for this hub which i think is a wonderful idea. Secondly, i would like to apologize for the language, since, although i lived in England many years ago, that is not the case anymore and I'm afraid i don't speak as well as I used to. I would like to comment a problem that we encounter very often in our organization which is related to patient's regular medications when they are admitted to hospital. We do have online prescriptions for both acute and community settings but the programs don't really speak to each other so, for example, if I take a blood pressure pill everyday and i get admitted into hospital, chances are that my blood pressure tablet won't get prescribed during my in-hospital stay. The logical thing to do would be to change both online systems so they communicate to each other, but that's not possible at the moment. I wanted to ask whether other systems have the same problem and, if so, if there is any strategy implemented to alleviate this issue. I hope i have expressed myself as clearly as possible. Thanks very much once more for this hub! Kind regards Jaione
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Community PostArtificial Intelligence is creating a lot of buzz in the US and around the world. This perspective from the US site AHRQ Patient Safety Net explores a range of issues that could affect the uptake artificial intelligence systems in health care. What do hub members think? Are we destined to encounter Hal (from 2001: a Space Odyssey) or Samantha (from Her)? Emerging safety issues in artificial intelligence
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Community Post
What are safe staffing levels?
Claire Cox posted a topic in Stories from the front line
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I can’t find any guidance for safe staffing here in the UK. I would like to know how Trusts decide their staffing template. Who decides, how it’s decided and if that is adhered to.- Posted
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Content ArticleIn this report, Professor Brian Edwards summarises contributions given to the UK Covid-19 Inquiry by various politicians and senior civil servants, relating to how prepared the UK and Scottish Governments were for the Covid-19 pandemic. It contains reflections on the contributions of: Nicola Sturgeon (First Minister of Scotland during the pandemic) Matt Hancock (Secretary of State for Health and Social Care during the pandemic) Jenny Harries (Chief Executive of the UK Health Security Agency) Emma Reed (civil servant, DHSC)
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Content ArticleGenerative AI is being heralded in the medical field for its potential to ease the burden of medical documentation by generating visit notes, treatment codes and medical summaries. Doctors and patients might also turn to generative AI to answer medical questions about symptoms, treatment recommendations or potential diagnoses. This article in JAMA Network looks at the liability implications of using AI to generate health information, highlighting that no court in the US has yet considered the question of liability for medical injuries caused by relying on AI-generated information.
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Content ArticleThe Regional Patient Safety Observatory of the Community of Madrid is an initiative aimed at increasing the quality of healthcare and the safety of professionals and patients in the healthcare environment. The Observatory is a consultative and advisory body of the Ministry of Health in matters of health risks and is functional in nature. Its objectives are: Promote and spread the culture of health risk management in the Community of Madrid. Obtain, analyse and disseminate regular and systematic information on health risks. Propose measures to prevent, eliminate or reduce health risks. It hosts the Patient Safety Brief Library, a tool for disseminating scientific knowledge developed by a group of experts within the framework of the Patient Safety Strategy 2027 of the Ministry of Health.
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Content ArticleAuthors of this article, published by Anaesthesia Patient Safety Foundation, look at various factors that exacerbate alarm fatigue and subsequent effects of nonoptimal medical alarms. They provide examples of a novel alarm versus a traditional alarm and conclude by saying: "By focusing on patient and provider safety, clinical workflow, and alarm technology, researchers, and policy makers can transform the medical alarm realm into one that is evidence-based and personnel-focused."
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Content ArticleThis is a plain English summary from the National Institute for Health and Care Research (NIHR). Many women who have an assisted vaginal birth (using forceps or a vacuum cup) develop infections. A previous study showed that a single dose of preventive antibiotics protected women; this research led to a change in UK and WHO guidelines. However, most women in the study had an episiotomy (surgical cut), so it was unclear if antibiotics also protected those with a tear of the perineum (the area between vagina and anus). To address this uncertainty, researchers re-analysed the ANODE study data. They found that preventive antibiotics reduced infections after an assisted vaginal birth, irrespective of whether women had a perineal tear, an episiotomy, or both. Read the article in full and access the research via the link below.
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Content ArticleThis is the recording of a roundtable hosted by the Institute of Health & Social Care Management (IHSCM) about virtual wards. Roy Lilley, IHSCM Chair and health policy analyst, discusses reducing waiting times, being innovative and sustainable and improving patient outcomes and patient journeys with a panel of speakers. The panel includes: Kris Glover, MD & Founder of Neon Health Solutions Paul Rylance, CTO, JKMCare Dr Folarin Majekodunmi, Director at Peopletoo
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Content ArticleDoes your manufacturing facility experience an undesirable frequency of costly product losses? Are recurring operational issues impacting productivity and morale? Do people believe the causes of these production issues are ‘human error’? Do Quality Differently will show you: How to take a systems-based risk management approach to create more operational success. Practical examples to guide improvement in your operations. Ways to apply comprehensive approaches that reveal and address the combination of factors that influence performance outcomes.
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Content Article
Patient Safety Indicator Measures (AHRQ)
Patient_Safety_Learning posted an article in Improving patient safety
The Patient Safety Indicators (PSIs) provide information on potentially avoidable safety events that represent opportunities for improvement in the delivery of care. More specifically, they focus on potential in-hospital complications and adverse events following surgeries, procedures, and childbirth. You can find out more about PSIs and access related resources, on the Agency for Healthcare Research and Quality (AHRQ) website via the link below. -
Content ArticleThis blog by Operations Insider looks at the Gemba Walk approach to problem solving in systems. Gemba Walks involve looking at problems where they occur and discussing them on site, in the real world. The blog includes a series of questions to consider when using the Gemba Walk approach,
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Content Article
What is a Gemba Walk? (SSDSI)
Patient-Safety-Learning posted an article in Improving systems of care
This blog describes the Gemba Walk technique, a popular LEAN management method. During a Gemba Walk, leaders gain valuable insight into the flow of value within the organisation by visiting the workplace and interacting with employees. Leaders also learn new ways to support their employees. The approach encourages collaboration between employees and the leaders. The article covers: What is a Gemba Walk? Three important components of the Gemba Walk Gemba Walk planning, execution and follow-up Get the team ready Develop a plan Follow the Value Stream Never lose sight that the process as a problem (not the people) Keep a record of your observations Ask questions Do not suggest changes during the walk Participate in teams Who should go on a Gemba Walk? Follow up with employees Return to the Gemba An example Gemba Walk Checklist -
Content ArticleTo overcome the problem of development teams losing sight of the detail of processes they are trying to improve, Toyota developed what they call a 'Gemba Walk'. The translation of the term from the root Japanese word is 'the real place' or 'the place where value is created'. This article describes how a Gemba Walk works, how it has been adapted for different industries and the value of engaging both leaders and employees in the process.
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Content Article
The term 'Gemba Walk' is derived from the Japanese word 'Gemba' or 'Gembutsu' which means 'the real place', so it can be literally defined as the act of seeing where the actual work happens. A safety Gemba Walk, or Gemba safety walk, is a safety walk integrated with the Gemba method, emphasising the continuous improvement of safety by watching the actions required to complete daily tasks and determine ways to make work safer. While a typical site safety walk through aims to maintain compliance with safety standards, a safety Gemba Walk focuses on looking for opportunities to continuously improve workplace safety. This article describes the Gemba Walk method and includes information on: What is a Safety Gemba Walk? What is a Virtual Gemba Walk? Why are Gemba Walks important? Benefits How to do a Gemba Walk Process How often should you do a Gemba Walk? Effective ways to do a Gemba Walk Examples -
Content Article
Medical device safety: effective testing is key
NicholasTHFarr posted an article in Medical devices (new)
In this blog, University of Sheffield based researcher Dr Nicholas Farr explains why investing in the development of testing methods is key to ensuring medical devices are safe to use. His current work focuses on how the materials used in medical devices react within the body. Most recently, he has looked at mesh implants and how they degrade and change over time. Nicholas and colleagues at the University of Sheffield have developed innovative testing methods that mimic key features of the human body within the lab. He believes this will improve our understanding of the materials being used in the development of medical devices at an early stage in the process – saving time and money, and reducing the risk of patient harm. -
News Article
Safety fears found at home where gran was killed
Patient Safety Learning posted a news article in News
A watchdog found there were safety concerns at a south-east London care home weeks after a resident killed a woman in her bedroom, it has emerged. Alexander Rawson, 63, beat 93-year-old Eileen Dean to death at Fieldside Care Home in Catford on 3 January. Inspectors visited the care home on 26 January after the murder of the grandmother-of-five triggered alarm about patient safety. Inspectors concluded that the home failed to record dangers properly and residents "were not always safe". Mrs Dean suffered catastrophic injuries after she was attacked by Rawson with a walking stick, about two weeks after he had been moved into the home from a mental health unit. According to the Local Democracy Reporting Service, the report said: "People were not always safe. The provider had not ensured risks to people were always documented and mitigated. "Risk assessments and care plans contained conflicting information which could potentially lead to people being exposed to harm." Specific concerns were also raised to the watchdog about the home's "risk management processes." The 63-year-old was sentenced to indefinite detention in a secure psychiatric unit on Monday. Read full story Source: BBC News, 22 November 2021 -
News ArticleA hospital trust has been told to "immediately improve" its maternity and surgical services. The Care Quality Commission (CQC) made unannounced inspections in September and October at four of the hospitals run by University Hospitals Sussex NHS Foundation Trust. Inspectors raised concerns about staff shortages, skills training and risk management. At the trust's four maternity services, inspectors found departments "did not have enough staff to keep women and babies safe" and staff were "not up to date" with training. Infection prevention measures in surgical services at the Royal Sussex County Hospital were "not consistently applied" and managers were not running services well, inspectors noted. The report also said morale was low and often staff "did not have time to report incidents". The trust said it has taken "urgent action" to make improvements. Read full story Source: BBC News, 10 December 2021
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News Article
'Some progress' made at failing Shropshire hospital trust
Patient Safety Learning posted a news article in News
An inspection at a failing hospital trust has identified "some progress" but its services are still inadequate. The Care Quality Commission (CQC) inspected the Shrewsbury and Telford Hospital NHS Trust (SaTH) in August. The Trust has been in special measures since 2018 and its maternity services are subject of a review following a high rate of baby and maternal deaths. The CQC said SaTH still had "significant work to do" to improve its patient care and safety standards. Inspectors highlighted particular concerns around risk management at the Trust which it said was "inconsistent" and and urgent and emergency care where patients "did not always receive timely assessment". The CQC also reported a shortage of staff working in end-of-life care and midwifery, however maternity staff were said to have "an exceptionally dedicated and caring approach". "I recognise the enormous pressure NHS services are under across the country and that usual expectations cannot always be maintained, but it is important they do all they can to mitigate risks to patient safety while facing these pressures," chief inspector of hospitals, Ted Baker, said. "While the trust continues to have significant work to do to provide care that meets standards people have a right to expect, it is providing more effective care overall. "However, its risk management remains inconsistent and we are not assured it is doing all it can to ensure people's safety." Read full story Source: BBC News, 18 November 2021 -
News Article
Wall Street Journal: How the Swiss Cheese Model can help us beat COVID-19
Clive Flashman posted a news article in News
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.
