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Found 336 results
  1. Content Article
    These resource lists compiled by US insurance company MedPro Group, highlight a number of expert and evidence-based sources that can be used to increase awareness of safety issues, identify areas of risk and determine mitigation strategies. They cover a wide range of healthcare safety topics: Advanced practice providers Anaesthesia and surgery Artificial Intelligence Bed safety and entrapment in senior care Behavioural health Behavioural health in senior care Burnout in healthcare Culture of safety Cybersecurity Disclosure of unanticipated outcomes Disruptive behaviour Elder abuse Electronic Health Records Emergency medical Treatment and Labour Act Emergency preparedness and response Emergency preparedness and response in senior care organisations Ergonomics and safe patient handling Falls and fall risk in older adults Handoffs and care transitions Health equity and social determinants of health Health literacy and cultural competence Healthcare-associated infections Healthcare compliance HIPAA Human trafficking and trauma-informed care Infection prevention and control in ambulatory care settings Infection prevention and control in dentistry Infection prevention and control in senior care organisations Informed consent LGBT+-inclusive care Maternal morbidity and mortality Medical marijuana Medication safety during care transitions Obstetrics and gynaecology Opioid prescribing and pain management Patient engagement Pressure injuries in older adults Sepsis Social media in healthcare Staff shortages and workforce issues Suicide screening in primary care Telehealth/telemedicine Violence prevention in home healthcare Violence prevention in the Emergency Department Wrong-site procedures
  2. Content Article
    This open access book addresses the future of work and industry by 2040—a core interest for many disciplines inspiring a strong momentum for employment and training within the industrial world. The future of industrial safety in terms of technological risk-management, although of obvious concern to international actors in various industries, has been quite sparsely addressed. This brief reflects the viewpoints of experts who come from different academic disciplines and various sectors such as oil and gas, energy, transportation, and the digital and even the military worlds, as expressed in debates and discussions during a two-day international seminar. 'Managing future challenges for safety' will interest and influence researchers considering the future effects of a number of currently developing technologies and their practitioner counterparts working in industry and regulation.
  3. Content Article
    It won’t come as a surprise but more than in 9 in 10 of almost 200 NHS leaders that responded to the latest NHS Confederation survey said that risk to patient safety is going to increase as we approach winter. Almost all of them identified the biggest risks being demand for urgent and emergency care and ambulance waits. And most expect to have to make difficult decisions and compromises around safe staffing ratios and delayed transfers of care. As the health and care sector braces for a challenging winter, three key steps could support systems to manage risk and minimise harm, writes Matthew Taylor, chief executive at NHS Confederation: The need for a robust and honest assessment of harm. The role of systems in minimising harm. The role of the centre in providing a helping hand.
  4. Event
    This masterclass, facilitated by Faisal Ahmed, Governance Specialist Trainer, provides knowledge and skills in addressing and managing risks within a health Organisation. All staff who report and manage risks should attend. Risks are inherent in all organisations – implementing and managing control measures is pivotal to managing risk in order to prevent an incident taking place. By exploring drivers behind why risks happen we can understand how to mitigate and reduce the likelihood and severity of further risks and the occurrence of incidents. A risk can be viewed as a precursor to an incident. Prevention through the risk management process can be an effective mechanism for organisations to manage their risks. All staff have a duty to identify and escalate risk within an organisation. This masterclass will explore the key components of the risk management process that must be followed to reduce the likelihood and severity of the risk. hub members can receive a 10% discount with code hcuk10psl. Further information and registration
  5. Event
    This masterclass, facilitated by Barry Moult, a former Head of Information Governance for an NHS Trust, and his colleague Andrew Harvey, will focus on developing your role as a SIRO (Senior Information Risk Officer) in health and social care. Further information and to book your place or email kate@hc-uk.org.uk A discount is available to hub members by quoting reference hcuk20psl when booking (cannot be used in conjunction with any other offer; full T&Cs available upon request).
  6. Content Article
    Two decades ago, the Institute of Medicine published To Err Is Human, a landmark report that brought attention to medical error and became a catalyst for the patient safety movement. Around the 10-year anniversary of the report, a number of articles and studies were published that examined the impact of this movement. Nearly all concluded that it was too early to assess whether significant change had taken place. Now, new data indicates efforts after the 20-year anniversary mark have not progressed as expected. It raises vital questions and renewed areas of focus for the healthcare industry. In this article, Coverys, a provider of medical professional liability insurance, looks at the date and the key claim trends.
  7. Content Article
    Fires on the operating field are rare events that should never happen, but do. They are dangerous not only to the patient but to the operating room (OR) team members as well. Surgical fires remain a significant enough risk to justify use of a Fire Risk Assessment Score and adherence to the recommendations of the American Society of Anesthesiologists Task Force on Operating Room Fires and those of the Anesthesia Patient Safety Foundation. Here, the Pennsylvania Patient Safety Authority shares key data and statistics, educational tools, multimedia and related links on surgical fires.
  8. Content Article
    When a patient's safety is compromised, or even if someone just comes close to having an incident, you need to know you are taking the right measures to address it, now and in the future. The Canadian Patient Safety Institute (CPSI) provides you with practical strategies and resources to manage incidents effectively and keep your patients safe. This integrated toolkit considers the needs and concerns of patients and their families, and how to properly engage them throughout the process. Drawn from the best available evidence and expert advice, this newly designed toolkit is for those responsible for managing patient safety, quality improvement, risk management, and staff training in any healthcare setting.
  9. Content Article
    A set of 5 infographics describing the the factors that influence the risk of nosocomial transmission of infections (such as Covid19), and how health and care staff can take action to manage the risks and reduce the infection rate. The factors explained are: People Equipment Task Environment Organisation
  10. Content Article
    A surgical fire is potentially devastating for a patient. Fire has been recognised as a potential complication of surgery for many years. Surgical fires continue to happen with alarming frequency. Yardley and Donaldson present a review of the literature and an examination of possible solutions to this problem.
  11. Content Article
    On 17 November, there will be a Parliamentary launch event of the Surgical Fires Expert Working Group’s report 'A case for the prevention and management of surgical fires in the UK, which focuses on the prevention of surgical fires in the NHS'. Unfortunately surgical fires are still a patient safety issue. Each year patients needlessly suffer burns during surgical procedures which leave them with long-lasting, life-changing injuries and burdens the NHS with millions of pounds of avoidable costs and liabilities. Despite this, there is not a consistent, standardised approach across the NHS to prevent them. Kathy Nabbie, a theatre scrub nurse practitioner, shares how she implemented Fire Risk Assessment Score (FRAS) into her department.
  12. Content Article
    Clift et al. 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.
  13. Content Article
    Effective teamwork is critical to successful outcomes in pediatric cardiac surgery. Unfortunately, lapses in professional performance and conduct by those who treat paediatric cardiac patients pose threats to quality and safety. One hallmark of a profession is self regulation. Therefore, healthcare leaders need specific means for identifying and addressing those lapses and indicators of unsafe systems or individuals. This article from Pichert et al. describes an initial “near miss” event involving a paediatric cardiac surgeon. While fictional, the case represents a composite of events involving several paediatric cardiac surgeons who practice at different medical centers throughout the US.
  14. Content Article
    ScienceDirect uses heuristic and machine-learning approaches to extract relevant information from their extensive collection of content. They compile this information on a topic-by-topic basis providing the reader both depth and breadth on a specific area of interest. This collection of research and data focuses on safety risk management.
  15. Content Article
    The 55,000 strong healthcare science workforce of the NHS and its related bodies, the Health Protection Agency and NHS Blood and Transplant, represent the largest group of scientists in a single employment sector in the UK. Their vast scientific knowledge and skill base stretches across some 45 scientific specialisms encompassing biology, genetics, physiology, physics and bioengineering. This knowledge lies at the foundation of the profession’s crucial and often unique role in: providing complex and specialist diagnostic services, analysis and clinical interpretation offering direct therapeutic service provision and support introducing technological and scientific advances into healthcare, and undertaking research, development and innovation providing performance and quality assurance, risk management and clinical safety design and management teaching, training and providing a specialist consultancy and clinical advice service to other clinicians with respect to all of the key functions above. The healthcare science workforce plays a critical part in delivering healthcare. More than 80% of all diagnoses are reached with a contribution from healthcare scientists. This document highlights some of these roles.
  16. Content Article
    BioPhorum has developed a risk-based deviation management system (DMS). 13 member companies have implemented this approach, and summary data from these companies shows improved quality performance plus an average time saving of 22,200 work hours per site per year, which is equivalent to a $888k cost saving. An effective deviation management process is one that identifies and removes risk from processes using root cause analysis (RCA) principles and a corrective and preventive action (CAPA) programme. The current model used by many biopharmaceutical companies considers all deviations or events are equal and require a 30-day closure, known as the ‘30-day rule’1. Treating all events as equal and following the ‘30-day rule’ drives an inefficient process and wasteful behaviours. This guide outlines the work of the BioPhorum DMS Workstream in defining and creating a simplified and effective risk-based deviation management system with advanced RCA methodologies, and a track-and-trending process of low-risk events. It includes everything required to build a risk-based approach to DMS, including the business case for change, the new process, risk-based tools, and a detailed sharing of post-implementation benefit.
  17. Content Article
    Wrong-site surgery is a broad, generic term that encompasses all surgical procedures performed on the wrong patient, the wrong body part, or the wrong side of the body; it can also describe performing the wrong procedure on, or performing on the wrong part of, a correctly identified anatomic site. This guidance from ECRI reviews the various types of wrong-site surgery; discusses the incidence, risk factors, and causes of wrong-site surgery; examines barriers to effective risk reduction; highlights Joint Commission’s elements of performance for the Universal Protocol and other accreditation and regulatory issues; and offers guidance for implementing strategies to prevent the occurrence of wrong-site surgery
  18. Content Article
    A large proportion of the patient injuries or deaths attributable to medical device misuse can be eliminated and/or mitigated by adopting an effective human factors and ergonomics (HFE) approach. The implementation of a usability engineering process is now mandatory for medical devices manufacturers seeking to obtain the European Union’s CE Mark. In this article, Pelayo, Marcilly and Bellandi describe the European Union’s HFE regulation and highlight the challenges faced by (i) manufacturers implementing this regulation and (ii) regulatory bodies charged with assessing the compliance of usability files. In Europe, 95% of MD manufacturers are small- and medium-sized enterprises; compliance with the CE Mark regulations is a real challenge to their competitiveness. Levels of knowledge about HFE vary greatly from one regulatory organisation to another, which can sometimes lead to very different expectations. The authors also present the specific use-related risk management approach required by the HFE regulation. Lastly, they focus on the limitations of the HFE regulation for MDs and on future HFE challenges in further reducing and/or eliminating MD use errors. The main challenge is the need to go beyond technology design and the premarket assessment and to look at the postproduction stage; the coupling between an MD and a sociotechnical system can lead to consequences that were not predicted during the design process. This implies the need to consider the emerging properties of technologies in use by involving all the stakeholders.
  19. Content Article
    Despite the extensive attention and public commitments towards patient safety over the last two decades, levels of avoidable harm in healthcare around the world remain unacceptably high.  This book is free to download.
  20. Content Article
    While individual countries have gained considerable knowledge and experience of COVID-19 management, an international, comparative perspective is lacking, particularly regarding the measures taken by different countries to tackle the pandemic. This paper from Tartaglia et al. elicits the views of health system staff, tapping into their personal expertise on how the pandemic was initially handled.
  21. Content Article
    This project includes the design of templates for controlled drugs, Hypnotics/Z-drugs, DMARDs (each orally administered drug has individualized template), NOACs, Warfarin, Lithium and Amiodarone. These templates prompt the user to add compulsory details before the drug can be issued for the first time or for a repeat issue. This has led to better and safer prescribing and potential to identify group of patients who either have not been reviewed or have missed essential monitoring. To avoid visual fatigue templates are short and to the point and a clinician can navigate away by one click if the required fields have been captured recently. Audits of prescribing such drugs has shown better prescribing and more patient involvement in decision making. Read more about this case study on the NICE shared learning database, via the link below.
  22. Content Article
    This case study is featured on the National Institute for Health and Care Excellence (NICE) shared learning database. The associated project aims to optimise the safe use of medicines and reduce avoidable harm to patients. Objectives: To ensure prescribers in GP practices identify and report medication related incidents and near misses via the National Reporting and Learning System (NRLS) (Each practice was required to share at least 4 records with the CCG between April 2017 and March 2018) To enable CCG-wide learning opportunities and prevent further incidents in order to improve patient safety across the CCG (Themes and trends will be disseminated at least quarterly through the Prescribing newsletter). To ensure practices responded to patient safety alerts from the MHRA in a timely manner.
  23. Content Article
    Threat and Error Management (TEM) is an overarching safety concept regarding aviation operations and human performance. TEM is not a revolutionary concept, but one that has evolved gradually, as a consequence of the constant drive to improve the margins of safety in aviation operations through the practical integration of Human Factors knowledge. TEM was developed as a product of collective aviation industry experience. Such experience fostered the recognition that past studies and, most importantly, operational consideration of human performance in aviation had largely overlooked the most important factor influencing human performance in dynamic work environments: the interaction between people and the operational context (i.e., organisational, regulatory and environmental factors) within which people discharged their operational duties. This article gives the background to TEM, components of the TEM Framework, related articles and further reading.
  24. Content Article
    Patient advocate Vonda Vaden Bates interviews Brandyn Lau, Assistant Professor of Radiology and Health Sciences Informatics, Johns Hopkins School of Medicine, around the importance of venous thromboembolism (VTE) prophylaxis for hospitalised patients.
  25. Content Article
    In this letter to the British Medical Journal, a group of clinicians call for thorough assessment and investigation for patients with Long COVID, highlighting that many were initially advised to 'stay at home' and were unable to access usual care. The authors note: "Pathological consequences such as myocarditis or a thromboembolic episode may explain symptoms, and these have been noted to occur months after onset in long covid support groups. The medical profession needs to evolve rapid transformative pathways to deal with the long term sequelae of covid-19 that include full investigation of patients." To read the letter in full, follow the link below.
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