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Found 338 results
  1. 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.
  2. 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
  3. 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
  4. 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)
  5. News Article
    The Care Quality Commission (CQC) has ordered ‘significant improvements’ from a mental health trust which has been criticised over the deaths of vulnerable patients. The watchdog has warned Tees, Esk and Wear Valleys Foundation Trust (TEWV FT) it has “serious concerns” about risk management processes at its inpatient wards following inspections of three of its hospitals in January. It follows a string of severe problems in child and adolescent services run by the trust. In a formal letter and a separate warning notice to TEWV FT, the CQC ordered the trust to carry out “significant improvements” to the safety of adult acute wards, and psychiatric intensive care, after a visit to Roseberry Park, West Park and Cross Lane hospitals on the week of 18 January. Sources have told HSJ the trust’s leadership is working towards a May deadline to make sufficient improvements or it could potentially risk further enforcement action. However, neither the trust nor the CQC have confirmed this. Families and campaigners — including Labour MP Andy McDonald, who represents Middlesbrough — have called for a public inquiry into alleged “systematic failures” at the trust following the deaths of around 14 patients under the trust’s care within two years. Read full story (paywalled) Source: HSJ, 12 March 2021
  6. News Article
    NHS hospitals have been advised to protect all staff wearing PPE during the warmer weather amid concerns the higher temperatures could increase the risk of heat stress. A letter from Public Health England sent across GP surgeries, pharmacies and hospitals, have recommended that staff wearing PPE should be given regular breaks and have a buddy system so that signs of heat stress can be spotted early on. The letter describes how PPE may need to be changed more frequently which may increase demand. Symptoms of heat stress are similar to heat exhaustion and the necessary actions should be taken to help avoid overheating. Read full story. Source: The Independent, 10 June 2021
  7. Event
    This one day masterclass will focus on Safety Management Systems (SMS) in healthcare. It will look at how other sectors and organisations have developed SMS to improve safety. SMS is a systematic and proactive approach to managing safety risks. A formal management system or framework can help you manage health and safety. Use of SMS can be generally interpreted as applying a quality management approach to control safety risks. Put simply, effective safety management systems use risk and quality management methods to achieve their safety goals. All Clinical Staff and Team Leads should attend. Further information: https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/safety-management-systems-in-healthcare or email kerry@hc-uk.org.uk hub members receive 20% discount. Email info@pslhub.org for discount code.
  8. Event
    COVID-19 has been incredibly stressful—personally and professionally—and has profoundly affected everyone in healthcare, including those of us in patient safety, quality, and risk management. Join this Patient Safety Association's virtual round table to decompress and share your experiences. Some of your colleagues have offered to discuss their coping strategies, and please feel free to do the same. Resources from professionals trained to handle stress will be provided. Register
  9. Event
    until
    COVID-19 has been incredibly stressful—personally and professionally—and has profoundly affected everyone in healthcare, including those of us in patient safety, quality, and risk management. Grab a cup of coffee or tea and join this virtual round table to decompress and share your experiences. Some of your colleagues have offered to discuss their coping strategies, and please feel free to do the same. We will also be providing resources from professionals trained to handle stress. Register
  10. Event
    Veracuity was conceived out of a recognition that the practice of pharmacovigilance is performed suboptimally. That is because it relies entirely on a voluntary reporting system – one in which consumers and healthcare professionals must devote considerable energy if they were so inclined to notify somebody about a side effect they attribute to a bio-pharmaceutical product. Adverse event reporting is infrequent and cumbersome because stakeholders are only vaguely aware of their responsibility and the current system is neither easy nor fast to use. Nor does it provide reporters with any immediate helpful feedback. With only a very small percentage of adverse drug events ever reaching the attention of manufacturers or regulators, it is easy to conclude that the medical community and the public may be wholly unaware of tremendous risks and liabilities that may be attributed to drug products. This workshop allows participation in insightful conversation on the future of our industry. Program: Fishbein, J: Introduction and closing remarks. Barrett, CP: Implementation of Post-marketing Risk Management Commitment. Laugel, I: The future of pharmacovigilance with the use of artificial intelligence sounds good. Marschler, M: The use of pharmacogenomic methodologies in the pharmacovigilance evaluation of medicinal products. This webinar meets two times. Fri, Jan 29, 2021 12:00 PM - 2:00 PM GMT Fri, Jan 29, 2021 6:00 PM - 8:00 PM GMT Register 2021-workshop-flier.pdf
  11. Event
    until
    One of the great opportunities for ICSs may be around reducing future demand for healthcare by ensuring that people remain healthy or are helped to reduce the chances of deteriorating if they do develop an illness or long-term condition. Prevention and early intervention underlie much of the NHS Long Term Plan, with a recognition that the NHS can no longer simply be an “ill health” service and instead bends to think about prevention and reducing health inequalities. Many ICSs are keen to develop this role and bring together the organisations they represent – across both the NHS and local authorities –to work collaboratively on this. But with resources and time limited, they may need to concentrate their efforts on particular areas. The second wave of covid – and the prospect of widespread vaccination starting within weeks - has added a new dimension to this with an urgent need to reduce the pressure covid places on the NHS and on normal life in general. This webinar will ask: has covid helped focus the NHS’s eyes on prevention? where are the “easy wins” for ICSs where interventions are most likely to have significant results within a reasonable timeframe? what key steps do ICSs need to take to get the maximum benefit from these? How can they build common purpose among their members to ensure these happen? how can public health be made “business as usual” for everyone working in the NHS – including those in hospitals? how can ICSs balance the preventative interventions which deliver short-term benefits with those which take longer to offer a “return on investment”? Register
  12. Event
    This virtual one day course is designed to provide attendees with the knowledge and skills to complete risk assessments in their work place. The completion of risk assessments is a core component within an organisations ability to manage its risks. Risk assessments support the prevention of incidents and an organisations achievement of its objectives. By carrying out risk assessments we can understand the current and future impact of the risk to the organisation. All staff have a duty to identify and escalate risks within their workplace. This masterclass will explore the key components of the risk assessment process that must be followed to reduce the likelihood and severity of the risk. Further information and book your place or email kate@hc-uk.org.uk hub members receive 10% discount. Email info@pslhub.org for code
  13. Content Article
    Krista Haugen is National Director of Patient Safety for US-based emergency and patient relocation services provider Global Medical Response. In this interview, she describes how her 25-year career as an emergency medicine nurse has influenced her approach to safety and patient care. She discusses her personal experience of being involved in an accident as an air-ambulance flight nurse, and how this caused her to look at safety and risk management from a systems perspective, focussing on building a just culture where safety is optimised through organisational reflection and learning.
  14. Content Article
    Early in the pandemic, neither the NHS’s clinical or ancillary staff nor social care workers were adequately protected from the risks of catching covid-19 in the course of their work. In the UK alone, hundreds of infected workers have died, thousands have been admitted to hospital, and tens of thousands have experienced long term effects, How do we improve staff protection next time? Here’s David Oliver's manifesto.
  15. Content Article
    While ‘human error’ is often blamed when things go wrong, the ‘technical’ part of ‘sociotechnical systems’ often escapes the spotlight. In this article, Harold Thimbleby outlines how hidden risks with digitalisation have far-reaching consequences, and how we can start to fix them.
  16. Content Article
    Alcoholism, more professionally termed alcohol use disorder (AUD), is a widespread and costly behavioural health condition. The aims of this paper from Zipperer et al. are draw attention to systemic gaps in care for patients with AUD and advocate for patient safety leaders to partner with both the mainstream medical and substance abuse treatment communities to reduce harm in this patient population.
  17. 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.
  18. Content Article
    Healthcare can be risky. Adverse events carry a high cost – both human and financial – for health systems around the world. So in an effort to improve safety, many health systems have looked to learn from high-risk industries. The aviation and nuclear industries, for example, have excellent safety records despite operating in hazardous conditions. And increasingly, the tools and procedures these industries use to identify hazards are being adopted in healthcare. One prominent example involves the Hierarchy of Risk Controls (HoC) approach, which works by ranking the methods of controlling risks based on their expected effectiveness. According to HoC, the risks at the top are presumed to be more effective than those at the bottom. The ones at the top typically rely less on human behaviour: for example, a new piece of technology is considered to be a stronger risk control than training staff. This article looks more deeply at the (HoC) 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.
  19. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Sharon talks to us about why manual handling needs to be more than tick-box training, and describes its significance for patient safety.
  20. Content Article
    The Royal College of Emergency Medicine’s Safety Resources hub has information and resources about alerts, safety resources, safety in the Emergency Department and safety events. This page is managed by the Safer Care Committee, which is part of the Quality in Emergency Care Committee (QECC). The QECC has produced a series of strategy documents, explaining the role of RCEM, and these committees, in improving patient care.
  21. Content Article
    This survey by In-FACT (Independent Fetal Anti Convulsant Trust) is intended to provide patients, no matter what anti-epileptic drug (AED) they are prescribed or what condition the AED is prescribed for, the opportunity to report problems and worries about taking their medication during pregnancy. The results will be used to inform In-FACT's ongoing work to improve medication safety and their engagement with the Medicines and Healthcare products Regulatory Agency (MHRA).
  22. Content Article
    Mike Fell, executive director of national cybersecurity operations at NHS Digital,, discusses the WannaCry cyberattack, teaching GP surgeries to up their game and how data can save lives.
  23. Content Article
    In this position statement, the National Quality Board (NQB) outlines: Key requirements for quality oversight in Integrated Care Systems (ICSs) The role of System Quality Groups (formally Quality Surveillance Groups) NQB work to support quality oversight in ICSs
  24. Content Article
    Maternity costs make up the largest cost to the NHS in value of claims. The Early Notification Scheme provides a faster and more caring response to families whose babies may have suffered severe harm. 'The second report: The evolution of the Early Notification Scheme' provides an overview of progress made since the report into the first year of the scheme, which was published in 2019. The report updates on the progress of the key recommendations which were made in the first report and reflects on modifications and improvements made to the scheme since its launch five years ago. It provides an analysis of the main clinical themes, based on a small cohort of cases, and makes recommendations to further improve outcomes for affected families.
  25. Content Article
    This guidance from NHS England aims to support Integrated Care System (ICS) leaders as they develop their approach to quality management, providing clarity on how quality concerns and risks should be managed through systems. It provides an overarching approach to quality risk response and escalation, including guidance on routine, enhanced and intensive quality assurance and improvement activity.
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