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Showing results for tags 'Safety process'.
Found 208 results
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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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EventuntilInfection is a leading cause of childhood deaths, but many of these deaths are avoidable with timely treatment. The national Before Arrival at Hospital Project (BeArH), funded by the National Institute for Health Research (NIHR), explored what happens to children under five years of age with serious infections before they are admitted to hospital. The aim of this research was to explore what helps children get help quickly and what might slow this process down, so that lessons could be learned for the care of this group of children in the future. This forum will be led by Professor Sarah Neill, Dr Damian Roland and Natasha Bayes. To join the research forum and hear the findings of this important research project from the study team, email lpt.research@nhs.net for the Microsoft Teams link.
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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 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 ArticleThere is an overall dearth of information on implementation and compliance with patient safety standards in developing countries. In recognition of this, the World Bank Group’s Health in Africa Initiative, WHO and the PharmAccess Foundation came together with the ministries of health to conduct an assessment of patient safety at Kenyan health facilities. The study is the first nationwide assessment of patient safety levels based on documented processes and levels of risk, and is meant to serve as a baseline against which future interventions can be measured.
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Content ArticleThe first two steps in making any process more reliable are to standardize or simplify the process thus turning a desired action into a default action. Standardisation reduces reliance on short-term memory and allows those unfamiliar with new location to follow an already experienced standard process or design thus leading to safe and efficient work practices. This study from Price and Lu reports on research into healthcare facility design and identifies the drivers, barriers, priorities and potential areas that can inform the design process and the adoption of standardisation aimed at significantly improving patient care and safety as well as enhancing staff productivity. Interviews were held with architects, project managers, healthcare planners and contractors to elicit their views. An interview protocol was developed based on initial literature findings. This paper highlights the need to think more deeply about why space standardisation is needed and which benefits need to be captured from space standardisation. Meanwhile, hospitals and Trusts provide very different situations and contexts, such as the model of care, the patient s journey, medical technologies and demographics. Innovative solutions to the space standardization must be in response to the context being considered, but there are some generic principles and concepts that apply to most situations.
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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 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 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 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 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 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 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 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. Tony talks to us about making patient safety everyone’s responsibility, the importance of open communication and how his understanding of different global health systems has broadened his perspective on what matters in patient care. -
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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 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 ArticleProgress enables the creation of more automated and intelligent machines with increasing abilities that open up new roles between humans and machines. Only with a proper design for the resulting cooperative human–machine systems, these advances will make our lives easier, safer and enjoyable rather than harder and miserable. Starting from examples of natural cooperative systems, the paper from Flemisch et al. investigates four cornerstone concepts for the design of such systems: ability, authority, control and responsibility, as well as their relationship to each other and to concepts like levels of automation and autonomy.
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Content ArticleThis study in Health Expectations aimed to identify barriers and facilitators to implementing a parent escalation of care process: Calling for Help (C4H). Guided by the Theoretical Domains Framework, the authors carried out audits, semi-structured interviews and focus groups in an Australian paediatric hospital where a parent escalation of care process was introduced in the previous six months. The authors found that although there was a low level of awareness about C4H in practice, there was in-principle support for the concept. Initial strategies had primarily targeted policy change without taking into account the need for practice and organisational behaviour changes.
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Content ArticleThis document outlines the Escalation Policy for Leicester Children’s Emergency Department. It identifies five particular factors that lead to difficulty within the department. Acknowledging that these issues can be closely interlinked and may not occur in isolation, it provides practical way to deal with these factors to try and prevent secondary events. Staffing Overcrowding Inflow Outflow Acuity
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On his last day in office at the Healthcare Safety Investigation Branch (HSIB), outgoing Chief Investigator Keith Conradi wrote to the Secretary of State for Health and Social Care reflecting on his time at HSIB. He outlined concerns about the approach of the Department of Health and Social Care (DHSC) and NHS England to patient safety work carried out by HSIB and the need to introduce a safety management system approach at all levels of healthcare. Patient Safety Learning also shared our thoughts on the issues raised in this letter and we were keen to explore these issues, and Keith’s experience as HSIB’s first Chief Investigator, in greater depth. Here, Patient Safety Learning provides an overview of the recent interview we had with Keith Conradi on this subject. The full transcript of the interview is available to download in the attachment at the end. -
Content ArticleBariatrics is the branch of medicine that deals with the causes, prevention and treatment of obesity and its associated diseases. This pathway written by East Kent Hospitals University Foundation NHS Trust (EKHUFT) provides guidance for multidisciplinary teams to allow them to provide appropriate care for each bariatric patient according to their unique shape, size and body dynamics.
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Content ArticleThis document defines the investigation framework in the event of a patient safety Serous Incident (SI) related to NHS Wales Informatics Service (NWIS) delivered or supported services, which affects one or more health body in Wales.
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Content ArticleDr Gordon Caldwell shares his hospital ward round sheet attached which follows a standard process, including quality and safety checking. Feel free to adapt.
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Content ArticleThe Comprehensive Unit-based Safety Program (CUSP) aims to improve the culture of safety while providing frontline caregivers with the tools and support that they need to identify and tackle the hazards that threaten their patients at the unit or clinic level. Developed by Johns Hopkins safety and quality researchers, the five-step programme has been used to target a wide range of hazards, including patient falls, hospital-acquired infections, medication administration errors, specimen labeling errors and teamwork and communication breakdowns. Notably, CUSP has been used in national and international quality improvement projects that have drastically reduced hospital-acquired infections. Whether your hospital has participated in such projects or is seeking to adopt CUSP, the Armstrong Institute provides resources to help you run a successful programme.
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