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Showing results for tags 'Safety process'.
Found 208 results
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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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Content ArticleHypothermia is a common problem in the operating theatre, and it contributes to many poor outcomes including rising costs, increased complications and higher morbidity rates. This literature review in the Journal of PeriAnesthesia Nursing aimed to determine the best method and time to prewarm a patient in order to prevent hypothermia during or after surgery. The authors suggest that forced-air warming is most effective in preventing perioperative hypothermia. Eighty-one percent of the experimental studies reviewed found that there was a significantly higher temperature throughout surgery and in the post-operative care unit for patients who received forced-air prewarming.
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Content ArticleThis toolkit from the New South Wales Clinical Excellence Commission (CEC) provides information, resources and quality improvement (QI) tools for managers and clinicians to improve sepsis care. The resources can be adapted to suit local needs and cover: Getting started Making improvements Data for improvement Communicating changes Providing education Sustain and spread
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This year, the World Health Organisation’s annual World Patient Safety Day on 17 September 2022 will focus on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. Patient Safety Learning has pulled together some useful resources from the hub about different aspects of medication safety - here we list six helpful reads related to medication safety in hospital settings. -
Content ArticleThis article looks at the benefits and process of prewarming patients before surgery, in order to maintain normothermia (a normal, safe temperature) throughout the peri-operative process. Increasing the patient's core temperature helps prevent hypothermia later on in surgery, reducing the need to deal with temperature issues during and after surgery. The author highlights the link between warming and patient safety and describes different approaches that can be taken for different lengths and types of surgical procedure.
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Content ArticleIn this article, Anubha Taneja Mukherjee, Group Member Secretary of Thalassemia Patients Advocacy, writes about patient safety issues surrounding blood donation and transfusion in India. She looks at several recent cases of children with thalassemia being infected with HIV while having blood transfusions, and highlights growing concern about lack of regulation and inconsistent testing of donated blood in India. She argues that blood banks should use additional screening such as the Nucleic Acid Amplification Test (NAT) to provide a safety net and ensure that blood containing infectious diseases—such as HIV, hepatitis B and C, syphilis and malaria—is not unwittingly given to patients.
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Content ArticleThese tools and resources from the National Institute for Health and Care Excellence (NICE) accompany the NICE guidance on Hypothermia: prevention and management in adults having surgery. Resources available for download include: Audit and service improvement baseline assessment tool Implementation support advice document Education information Shared learning information Practical steps to improving the quality of care and services using NICE guidance
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Content ArticleIn order to prevent hypothermia during or after surgery, patients can be warmed before or during the induction of anaesthesia. If the patient is warmed before, this is known as prewarming, and if they are warmed at the same time that anaesthetics are given, this is known as cowarming. This study in the Journal of Anaesthesiology and Clinical Pharmacology aimed to investigate whether cowarming is as good as prewarming in preventing the occurrence of intraoperative hypothermia.
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Content ArticleThe NHS England National Patient Safety Team has produced two podcasts to provide an overview of the background and development of the new National Maternity Early Warning Score (MEWS) tool. In the first podcast, Professor Marian Knight, University of Oxford; Professor Peter Watkinson, Oxford University Hospitals NHS Foundation Trust; and Tony Kelly, National Clinical Advisor, Maternity & Neonatal Safety Improvement Programme NHS England, discuss the development of a new national Maternity Early Warning Score (MEWS) tool. In the second podcast, Tony Kelly, Hannah Rutter, Senior Improvement Manager at MatNeoSIP NHS England, Louise Page, Consultant Obstetrician and Gynaecologist, West Middlesex University Hospital and Chelsea and Westminster Hospital NHS Foundation Trust, Anita Banerjee, Consultant Obstetric Physician, Guys and St Thomas’s NHS Foundation Trust and Katherine Edwards, Director of Patient Safety and Clinical Improvement, Oxford Academic Health Science Network discuss the the benefits of implementing the new national MEWS tool.
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Content ArticleThe Regulation and Quality Improvement Authority (RQIA) is the independent body responsible for regulating and inspecting the quality and availability of Health and Social Care services in Northern Ireland. The (RQIA) was commissioned to examine the application and effectiveness of the Procedure for the Reporting and Follow-up of Serious Adverse Incidents in Northern Ireland. The review was conducted by an Expert Review Team established by the RQIA and made five recommendations for implementation.
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Content ArticleClosed-loop communication—when every test result is sent, received, acknowledged and acted upon without failure—is essential to reduce diagnostic error. This requires multiple parties within the healthcare system working together to refer, carry out tests, interpret the results and communicate them in language the patient can understand. If abnormal test results are not communicated in a timely manner, it can lead to patient harm. This Quick Safety case study looks at the case of a 47-year-old school teacher who had a screening mammogram. The radiologist identified a suspicious area of calcifications, which required follow up. The patient’s GP was not on the same electronic medical record (EMR) as the imaging centre and, because of front office changes, missed the notification to follow up. The patient was told that the radiologist would contact her if the results were abnormal and therefore assumed she was okay. A year later when seeing her GP, the patient was told that she needed follow-up testing and that she had stage 3 cancer. Her lesion had grown significantly, and she now required surgery, chemotherapy and radiation for advanced breast cancer. The case study suggests safety actions that should be considered to prevent this error from happening again.
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Content ArticleThis study in the journal Medical Devices: Evidence and Research aimed to assess health system experiences of implementing Unique Device Identifier (UDI) systems for medical devices. Although the US Food and Drug Administration (FDA formalised the Unique Device Identification System Rule in 2013, parallel regulatory requirement for US health systems to use UDIs is lacking. Through semi-structured interviews, the authors identified barriers to implementing UDI systems and strategies to overcome them.
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Content ArticleSpecialty referrals—when a clinician refers a patient to a specialist for evaluation or treatment—are on the rise in the US. Despite the introduction of electronic health records (EHRs), the referral process is often hindered by lack of clarity over roles, communication breakdowns, workloads and variations in requirements among specialists. These difficulties can lead to missed or delayed diagnoses, delays in treatment and other lapses in patient safety. This guide from the Institute for Healthcare Improvement offers recommendations that aim to help standardise how primary care practitioners activate referrals to specialists and then keep track of the information over time. It describes a nine-step, closed-loop process in which all relevant patient information is communicated to the correct person through the appropriate channels, in a timely manner.
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Content ArticleThe NHS Patient Safety Strategy was published in 2019 and describes the Patient Safety Incident Response Framework (PSIRF), a replacement for the NHS Serious Incident Framework. This document is North Bristol NHS Trust's Patient Safety Incident Response Plan (PSIRP). It describes what North Bristol NHS Trust did to prepare for “go live” with PSIRF, as an early adopter organisation, and what comes next
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Content ArticleThese resources by the Royal College of Nursing provide practical and clinical guidance for vaccine administration. All information supports guidance in The Green Book - Immunisation against infectious disease published by the UK Health Security Agency.
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This is part of our new series of Patient Safety Spotlight interviews, where we talk to people about their role and what motivates them to make health and social care safer. Roohil talks to us about the vital role of pharmacists in making sure medications help patients, rather than causing harm. She highlights the global threat of substandard and counterfeit medicines, the need to improve access to medicines and the importance of having pharmacists 'on the ground' to help patients understand how to take them. -
Content ArticleThis blog provides an overview of a roundtable webinar organised by the European Biosafety Network (EBN), which focused on the need to prevent exposure to hazardous medicinal products (HMPs) and other substances. It was chaired by Gitta Vanpeborgh, Belgian Federal Deputy, and included attendees from across Europe.
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This is the first in our new series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Josie tells us about the nursing error that first sparked her interest in patient safety, how a just culture helps healthcare workers and systems learn from their mistakes, and how her love of skiing has inspired her to think differently about risk in healthcare. -
Content Article'The Theatre: Surgical Learning & Innovation Podcast' is a podcast by the Royal College of Surgeons of England. This episode features a panel discussion on the nature of “human factors” in surgery, presented by Peter Brennan, consultant oral and maxillofacial surgeon, Louise Cousins, trainee general surgeon, Neil Tayler, British Airways pilot and trainer, and Graham Shaw, also a British Airways pilot and Director of Critical Factors, a consulting and training service for professionals operating in safety-critical environments.
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Content ArticleThis article, published in BMJ Quality and Safety, examines the relationships between non-routine events, teamwork and patient outcomes in paediatric cardiac surgery. Structured observation of effective teamwork in the operating room can identify deficiencies in the system and conduct of procedures, even in otherwise successful operations. High performing teams are more resilient, displaying effective teamwork when operations become more difficult.
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Content ArticleAlthough research has focused on safe disposal of sharps in healthcare settings, the issue of disposal by patients in the home setting has not often been addressed. This US study in the journal Diabetes Spectrum aimed to evaluate methods of disposal and patient demographic factors associated with correct disposal of diabetes-related sharps in the community.
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Content ArticleMedication errors are preventable events that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional or patient. This paper, published in the Cochrane Database of Systematic Reviews, considers the effectiveness of interventions to reduce medication errors in adults in hospital settings. The review covered 65 studies involving 110,875 participants.
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EventuntilThis webinar by the Institute for Safe Medication Practices in the US is aimed at: Pharmacists, physicians, nurses Medication safety officers Quality professionals Risk managers Leaders in pharmacy and nursing Pharmacy and anaesthesia technicians Although most medications in healthcare today have a wide margin of safety, there remains some which can cause serious harm or death if they are misused. To reduce the risk of error with these “high-alert” medications, special precautions and high leverage strategies should be implemented to avoid serious patient safety events. Numerous organizations have taken steps to identify these medications, but many are still less than confident that they have taken all the necessary precautions against serious patient harm. Join the ISMP faculty as we focus particular attention on the potential safe use risks with heparin, concentrated electrolytes, and magnesium using the results from ISMP’s National Medication Safety Self Assessment® for High-Alert Medications. Faculty will review specific safety characteristics of each these important drug classes, describe self-assessment findings related to the use of these medications, and discuss the necessary practice strategies for harm prevention when using these high-alert medications. Register for the webinar 3.00pm Eastern Time (US and Canada), 8.00pm GMT
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Content ArticleIn this podcast episode, host Aaron Harmon speaks to Dr Neil Vargesson, chair in developmental biology at the University of Aberdeen, about the importance of Good Laboratory Practice (GLP) and why pre-clinical studies are key to keeping people safe. They discuss the history of Primodos, a hormone-based pregnancy test that was given to women between 1959 and 1978. It was developed before GLP and before standardised testing for teratogenesis (causing birth defects). There are data that suggests Primodos caused birth defects, but more questions remain.
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Content ArticleWhere a new or under-recognised risk identified through the NHS England's review of patient safety events doesn’t meet the criteria for a National Patient Safety Alert, NHS England look to work with partner organisations, who may be better placed to take action to address the issue. To highlight this work and show the importance of recording patient safety events, they publish regular case studies. These case studies show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.
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