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Showing results for tags 'Safety assessment'.
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Content ArticleIn this multi-centre randomised clinical vignette survey study, published in JAMA, diagnostic accuracy significantly increased by 4.4% when clinicians reviewed a patient clinical vignette with standard AI model predictions and model explanations compared with baseline accuracy. However, accuracy significantly decreased by 11.3% when clinicians were shown systematically biased AI model predictions and model explanations did not mitigate the negative effects of such predictions.
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Content ArticleIn this article, published by the Institute for Government, Sam Freedman looks at the state of the NHS pre and post pandemic and how staffing, bed shortages, staff churn and other issues have had an impact. Sam argues we are drifting further into crisis due to a stubborn refusal by the government to to engage properly with these issues.
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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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- Safety assessment
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- Medication - related
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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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- Hospital ward
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- Pharmacist
- Integrated Care System (ICS)
- Decision making
- Information processing
- Knowledge issue
- Non-compliance
- Omissions
- Climate change
- AI
- Digital health
- Innovation
- Interoperability
- Precision medicine
- Start-Up
- Safety assessment
- Safety behaviour
- Safety management
- Improved productivity
- Medication - related
- Patient identification
- Patient safety strategy
- Policies
- protocols and procedures
- User-centred design
- Workforce management
- Information sharing
- Staff engagement
- Training
- Time management
- Allergies
- Deep vein thrombosis
- Falls
- Parkinsons disease
- Substance / Drug abuse
- Urinary tract infections
- Antimicrobial resistance (AMR)
- Benchmarking
- Dashboard
- Indicators
- Meta analysis
- Task analysis
- Workload analysis
- NRLS
- Policies / Protocols / Procedures
- Quality improvement
- Risk management
- Healthcare
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News Article
Patients asked to return Emerade adrenaline pens for replacement
Patient Safety Learning posted a news article in News
Patients, or carers of patients, who carry Emerade 300 or 500 microgram adrenaline auto-injector pens should immediately contact their GP to obtain a prescription for, and be supplied with two auto-injectors of a different brand. Pharmacists and pharmacy teams can also help with obtaining new prescriptions and dispensing of new pens. Patients or carers should then return all Emerade 300 and 500 micrograms auto-injectors to their local pharmacy. Patients should only return their Emerade pens when they have received a replacement from their pharmacy which will be an alternative brand - either EpiPen or Jext. They should ensure they know how to use the replacement pen, as each brand of pen works differently. Patients should ask their doctor, pharmacist, or nurse for help with this. Instructions are included inside the pack, along with details of the manufacturer’s website that also provides information, including videos, on how to use a new EpiPen or Jext adrenaline pen. This precautionary recall is because some 300 microgram and 500 microgram Emerade auto-injector pens may rarely fail to activate if they are dropped, meaning a dose of adrenaline would not be delivered. Premature activation has also been detected in some of the 300 microgram and 500 microgram pens after they have been dropped, meaning that a dose of adrenaline is delivered too early. The activation failure and premature activation was detected during a design assessment conducted by the manufacturer and therefore means there is a potential for some 300 microgram and 500 microgram Emerade pens to fail during use after having been dropped. Read MHRA Press Release. 9 May 2023- Posted
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News Article
Cough medicines containing pholcodine withdrawn over safety fears
Patient Safety Learning posted a news article in News
Certain cough medicines sold behind the counter at pharmacies are being withdrawn over safety concerns. Health experts say there is a very rare chance that some people could experience an allergic reaction linked to an ingredient called pholcodine. People should check the packaging of any cough tablets or syrups they have at home to see if pholcodine is listed among the ingredients. If it is, talk to your pharmacist about taking a different medicine. Products containing pholcodine do not need a prescription, but cannot be bought without consultation with the pharmacist as they are kept behind the counter. The Medicines and Healthcare Products Regulatory Agency (MHRA) described removing the products from sale as a precautionary measure. Read full story Source: BBC News. 15 March 2023- Posted
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News Article
Trust ‘missed opportunities’ to prevent sex offender working as locum
Patient Safety Learning posted a news article in News
A trust has admitted it ‘missed opportunities’ to identify that a locum doctor – who was arrested on hospital premises for two sexual offences — had already been cautioned for indecent exposure. Salman Siddiqi admitted two offences – attempting to engage in sexual communication with a child and attempting to arrange or facilitate a meeting with a child for sexual offences – last month. East Kent Hospitals University Foundation Trust, where he was working as a locum paediatric registrar at the time of the January offences, has now said there had been “missed opportunities” to identify his previous caution. Chief medical officer Rebecca Martin told HSJ the trust had taken steps to ensure that these missed opportunities could not happen again. She said in a statement: “This includes standardising DBS checks for temporary workers booked through an agency and escalating all DBS and General Medical Council checks that feature conditions, cautions or warnings.” Read full story (paywalled) Source: HSJ, 23 February 2023- Posted
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Content ArticleIn this document, Charles Vincent and colleagues from Imperial College London, propose a new framework to help find the elusive answer to the question – how safe is care today?
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News Article
Care home killing: No risk assessment done on attacker
Patient Safety Learning posted a news article in News
No formal risk assessment was done on a man who beat a fellow care home resident to death, a review has found. Alexander Rawson attacked 93-year-old Eileen Dean with a metal walking stick at a care home in south-east London. Mrs Dean suffered catastrophic injuries to her head and body and died later in hospital. A review found Fieldside Care Home in Catford did not provide the specialist mental health services that Rawson - who had a history of violence - needed. Rawson, who had a history of mental health problems caused by alcoholism, was 62 when he was placed in the home a few days before Christmas 2020. He was put in the room next to Mrs Dean and, in the first week of 2021, he went into her room at night and attacked her. In a review published on Friday, the Lewisham Safeguarding Adults Board said Rawson had been moved into the home after being an inpatient at a psychiatric unit run by the South London and Maudsley NHS Foundation Trust. The care home was the only place that agreed to take him after his discharge from hospital. In the months before he was moved into the care home, Rawson was involved in at least 34 recorded incidents of violence or threats to patients and health staff, including a threat to kill. Before he was placed in the home, no attempts were made to find out whether Rawson had come into contact with the criminal justice system over his behaviour, the report found. It states that the care home had asked about the risks Rawson posed before they took him and had been reassured by a social worker and medical staff. Read full story Source: BBC News, 12 November 2022- Posted
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- Patient death
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Content ArticlePatients are becoming increasingly involved in their health through technology such as health apps, and regulators are already struggling to control the market without constraining innovation. Clinical Safety must therefore adapt to the ever-changing world of health apps, if it is to fulfil its purpose and ensure that only the safest technologies are used by patients. In this blog, GP Tom Micklewright looks at some of the safety issues relating to health apps. He highlights that unlike with other new systems, health apps are rarely deployed in a controlled environment, which can cause problems when trying to apply clinical safety standards to them. He looks at five of the issues health apps can cause for safety teams: Intended scope and use Updated health apps Clinical safety, health apps and AI Different places, different features Monitoring clinical safety He then offers some potential solutions to these problems: Continuous assessment of health apps Centralise clinical safety, don’t localise Differentiated approach to clinical safety Aggregated incident reporting
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- Health and Care Apps
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Content ArticleThe Care Quality Commission (CQC) has introduced a new assessment framework that it will use to set out its view of quality and make judgements about health services. The framework is being introduced in phases, and the CQC has published it before it comes into use so that providers and other stakeholders can start to become familiar with it.
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Content ArticleThis article, published in Surgical Patient Care, looks at the importance of developing surgical standards to mitigate risks and the subsequent development of the Surgical Safety Checklist to improve quality of care.
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Content ArticleIn this systematic review published in BMJ Open, the authors analyse and compare the focus of 694 studies about safety culture in hospitals. The review identifies 11 key themes relating to safety culture across the studies. The authors suggest that the wide range of methods and tools available highlights a persistent lack of consensus in defining patient safety. They also highlight the value of qualitative and mixed method approaches in providing context and meaning to quantitative surveys that assess safety culture.
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News ArticleConsultants at a major tertiary centre have written to their chief executive, warning services are in ‘an extremely unsafe situation’ and calling for elective work to be diverted elsewhere. Surgeons and anaesthetists at the former Brighton and Sussex University Hospitals Trust — now part of University Hospitals Sussex Foundation Trust — said: “We are devastated to report that the care we aspire to is not being provided at UHS… we are forced to contemplate that it is not safe to be open as a trauma tertiary centre and we feel elective activity must be proactively diverted elsewhere.” The letter from BSUH’s anaesthetist and surgical consultant body is dated yesterday and was sent to UHSussex chief executive Dame Marianne Griffiths. The Royal Sussex County Hospital in Brighton — part of the trust — is the major trauma centre for the South East coast, from Chichester to parts of Kent. In the letter, seen by HSJ, the consultants claimed a shortage of theatre staff is leading to “clinical safety issues, gross operational inefficiencies and burnout within our remaining depleted staff groups”. Read full story (paywalled) Source: HSJ, 21 September 2021
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Content ArticleThe Serenity Integrated Mentoring (SIM) model is described as "an innovative mental health workforce transformation model that brings together the police and community mental health services, in order to better support 'high intensity users' of Section 136 of the Mental Health Act (MHA) and public services." The SIM model is part of a 'High Intensity Network' (HIN) approach, which is now live in all south London boroughs. In this hub post, Steve Turner highlights the benefits and risks of this approach and seek your views on it.
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News Article
CQC to expand inspection programme from April
Patient Safety Learning posted a news article in News
More Care Quality Commission (CQC) inspections will take place from next month as pressures from COVID-19 continue to ease. Board papers published ahead of a meeting on Wednesday have revealed the CQC will return to inspecting and rating NHS trusts and independent healthcare services which are rated “inadequate” or “requires improvement”, alongside those where new risks have come to light. From April, the CQC also plans to carry out well-led inspections of NHS and private mental healthcare providers, and programmes of focused inspections on the safety of maternity departments and providers’ infection prevention processes. Focused inspections into emergency departments, which the CQC began in February, will continue. Inspections into GP services rated “requires improvement” and “inadequate” will also resume in April, focusing on safety, effectiveness and leadership. Finally, the papers said the watchdog would prioritise inspections of “high-risk” independent healthcare services, such as ambulances, cosmetic surgery or where closed cultures may exist. Read full story (paywalled) Source: HSJ, 24 March 2021- Posted
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Content Article
Why investigate? Part 7 – The questions and answers
MartinL posted an article in Why investigate? Blog series
In part 1 of my blog series, I said "This will be a series of short blogs that will cover the investigation process, answer questions about humans, and shine a light on the method of forensic investigations”. It is time to answer some questions- Posted
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Content ArticleAs set out in Implementing Better Births: Continuity of Carer, continuity of carer means each woman: • Has consistency in the midwife or clinical team that provides hands on care for a woman and her baby throughout the three phases of her maternity journey: pregnancy, labour, and the postnatal period. • Has a named midwife who takes on responsibility for coordinating her care, and for ensuring all her needs and those of her baby are met, at the right time and in the right place, throughout the antenatal, intrapartum and postnatal periods. • Has “a midwife she knows at the birth”. • Is enabled to develop an ongoing relationship of trust with her midwife who cares for her over time.
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Content ArticlePatient safety is an activity to mitigate preventable patient harm that may occur during the delivery of medical care. The European Board of Anaesthesiology (EBA)/European Union of Medical Specialists had previously published safety recommendations on minimal monitoring and postanaesthesia care, but with the growing public and professional interest it was decided to produce a much more encompassing document. The EBA and the European Society of Anaesthesiology (ESA) published a consensus on what needs to be done/achieved for improvement of peri-operative patient safety. During the Euroanaesthesia meeting in Helsinki/Finland in 2010, this vision was presented to anaesthesiologists, patients, industry and others involved in health care as the ‘Helsinki Declaration on Patient Safety in Anaesthesiology’. Authors of this article, published in the European Journal of Anaesthesiology, hope to further stimulate implementation of the Helsinki Declaration on Patient Safety in Anaesthesiology, as well as initiating relevant research in the future.
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Content ArticleThis interview is part of the hub's 'Frontline insights during the pandemic' series where Martin Hogan interviews healthcare professionals from various specialties to capture their experience and insights during the coronavirus pandemic. Here Martin interviews an advanced specialist paramedic working in central London with four years' experience of working on the frontline.
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- Paramedic
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Content ArticleThis table was included in the report Patient Safety Concerns in COVID-19 related events: a study of 343 event reports from 71 Hospitals in Pennsylvania, published by the Patient Safety Authority. It outlines 13 factors associated with patient safety concerns within COVID-19 related events. These include admssion screening, communication, knowledge deficit and medication. The full list with more detailed explanations of each can be downloaded via the attachment.
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- Pandemic
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Content ArticleEnhanced Significant Event Analysis (enhancedSEA) is a NHS Education for Scotland (NES) innovation which aims to guide healthcare teams to apply human factors thinking when performing a significant event analysis, particularly where the event has had an emotional impact on staff involved.Follow the link below for:guidance on how to perform enhancedSEA the updated report format, new Guide Tools, a short e-learning module basic educational resources on human factors science and practice.Although enhancedSEA was developed and tested with primary care teams the approach is also highly suitable for any health and social care setting.
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Content ArticleThis editorial, published by the Lancet, highlights that racism is the root cause of continued disparities in health and mortality rates between black and white people in the USA and a global public health emergency. It discusses what medical journals can and must do to help.
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- Health inequalities
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