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Found 41 results
  1. Content Article
    In this blog, Martin Hogan shares his experience of working as an agency nurse and how different behaviours can impact on the safety of both staff and patients.  
  2. Content Article
    Expanding on his previous commentary 'What does all this safety stuff have to do with me', Dan Cohen, Patient Safety Learning's Trustee and former Chief Medical Officer at DATIX, has written this article for the hub on personal responsibility in patient safe care.
  3. News Article
    Proposals by the Scottish Government to give a licence to unregistered professionals to carry out cosmetic procedures are “fundamentally flawed” and put lives at risk, leading nurses in the field have warned. A consultation has been launched seeking views on plans for a new regulatory regime of non-surgical aesthetic treatments that pierce or penetrate the skin like dermal fillers or lip enhancements. Ministers want to bring non-health professionals under existing legislation allowing them to obtain a licence to perform these procedures in unregulated premises such as beauty salons and hairdressers. The move comes after a UK-wide review carried out in 2013, by then NHS medical director Sir Bruce Keogh, identified that little regulation existed within the cosmetic industry. Since then there has been growing concern that people are coming to physical and psychological harm from treatments gone wrong. Leaders at the British Association of Cosmetic Nurses (BACN) told Nursing Times that they were “totally opposed” to non-medical practitioners carrying out injectable beauty procedures. BACN Chair Sharon Bennett said holding a medical, nursing or dentistry qualification should be a “basic prerequisite” before being accepted to an aesthetics training course. SHe said BACN believed even clinically trained practitioners, including nurses, needed further training in aesthetics before working in this “specialist” area. “[This is] because there is no educational framework, training or statutory provision to establish or task beauty therapists to detect disease, care for patients or carry out medical treatment, so to do so would breach public health safety and endanger lives.” Read full story Source: The Nursing Times, 20 January 2020
  4. Content Article
    Human factors and ergonomics (HFE) approaches to patient safety have addressed five different domains: usability of technology; human error and its role in patient safety; the role of healthcare worker performance in patient safety; system resilience; and HFE systems approaches to patient safety.
  5. News Article
    Hundreds of people with haemophilia in England and Wales could have avoided infection from HIV and hepatitis if officials had accepted help from Scotland, newly released documents suggest. A letter dated January 1990 said Scotland’s blood transfusion service could have supplied the NHS in England and Wales with the blood product factor VIII, but officials rejected the offer repeatedly. Large volumes of factor VIII were imported from the US instead, but it was far more contaminated with the HIV and hepatitis C viruses because US supplies often came from infected prison inmates, sex workers and drug addicts who were paid to give blood but not screened. The death of scores of people with haemophilia and blood transfusion patients and the infection of thousands of others across the UK in the contaminated blood scandal has been described as the worst health disaster to hit the NHS. The latest document was released under the Freedom of Information Act to campaigner Jason Evans, whose father died in 1993 having contracted hepatitis and HIV. In it, Prof John Cash, a former director of the Scottish Blood Transfusion Service, said the decision not to use Scotland's spare capacity to produce Factor VIII for England was "a grave error of judgement". Read full story Source: The Guardian, 3 January 2020
  6. News Article
    A woman has died after being set on fire during surgery in Romania, the country’s health ministry has said, in a case that has cast a spotlight on the ailing Romanian health system. The patient, who had pancreatic cancer, died on Sunday after suffering burns to 40% of her body when surgeons used an electric scalpel despite her being treated with an alcohol-based disinfectant. Contact with the flammable disinfectant caused combustion and the patient “ignited like a torch”, Emanuel Ungureanu, a Romanian politician, said. A nurse threw a bucket of water on the 66-year-old woman to prevent the fire from spreading. The health ministry said it would investigate the “unfortunate incident”, which took place on 22 December. “The surgeons should have been aware that it is prohibited to use an alcohol-based disinfectant during surgical procedures performed with an electric scalpel,” the Deputy Minister, Horatiu Moldovan, said. Read full story Source: The Guardian, 30 December 2019 the hub has a number of posts on preventing surgical fires: Surgical fires: nightmarish “never events” persist MHRA. Paraffin-based skin emollients on dressings or clothing: fire risk (18 April 2016) National Patient Safety Agency: Fire hazard with paraffin-based skin products (Nov 2007) How I raised awareness of fires in the operating theatre
  7. Content Article
    Homerton University Hospital describes how they have embedded the Redthread Youth Violence Intervention Programme into their A&E department.
  8. Content Article
    Harold Shipman was an English doctor who killed approximately 15 patients while working as a junior hospital doctor in the 1970s, and another 235 or so when working subsequently as a general practitioner. Is it possible to learn general lessons to improve patient safety from such extraordinary events? In this paper, published in the US Journal of the Royal Society of Medicine, it is argued that it is not possible fully to understand how Shipman came to be such a successful and prolific serial killer, nor to learn how the safety of healthcare systems can be improved, unless his diabolical activities are studied using approaches developed to investigate patient safety.
  9. Content Article
    Connor Sparrowhawk died in July 2013 while he was in the care of Southern Health NHS Foundation Trust. An independent report concluded that Connor’s death was preventable and that there were significant failings in his care and treatment. This moving film describes what Connor was like by his friends and family and highlights the failings that caused the avoidable death of Connor.
  10. Content Article
    The patient safety movement started almost fifteen years ago when it was energised by the release of the Institute of Medicine report “To err is human”. Despite efforts since then to improve quality and safety many believe that little progress has been made in reducing harm caused by errors, accidents and unforeseen occurrences. There is a sense of frustration with current approaches to safety (Safety I) and disappointment that more progress has not been made. Recent developments in safety science, termed Safety II, focus on resilience, adaptive capacity and complexity science and show promise for advancing the safety agenda.
  11. Content Article
    Fake medicines and medical devices bought online can lead to serious negative health consequences. Buying from dodgy websites also increases the risk of being ripped off through credit card fraud or having your identity stolen. The #FakeMeds campaign, run by Medicines and Healthcare products Regulatory Agency (MHRA), helps you protect your health and money by providing quick and easy tools so you can avoid fake medical products when you shop online.
  12. Content Article
    This blog highlights: The juxtaposition of how work is carried out by healthcare staff compared to the work that policy makers are 'imagining' healthcare workers are doing. The need for healthcare staff to be part of patient safety solutions.
  13. Content Article
    This is the Freedom to Speak Up Guardian job description. Use it for reference or for a template to advertise for a Freedom to Speak Up Guardian in you trust/sector.
  14. Content Article
    In this BMJ article, James Reason discusses how the human error problem can be viewed in two ways: the person approach and the system approach. Each has its model of error causation and each model gives rise to quite different philosophies of error management. Understanding these differences has important practical implications for coping with the ever present risk of mishaps in clinical practice.
  15. Content Article
    This document sets out the General Medical Council's (GMC) expectation that all doctors will, whatever their role, take appropriate action to raise and act on concerns about patient care, dignity and safety. 
  16. Content Article
    In his blog, published by onthewards website, Joe Farmer (a doctor working in psychiatry) discusses rudeness in the workplace and the impact it can have on clinical performance and subsequently patient safety.
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