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Showing results for tags 'Safety process'.
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Content ArticleRyan's Rule is a three step process to support patients of any age, their families and carers, to raise concerns if a patient’s health condition is getting worse or not improving as well as expected. Ryan’s Rule applies to all patients admitted to any Queensland Health public hospital including the emergency department, and in some Hospital in the Home (HITH) services.Ryan’s Rule has been developed in response to the tragic death of Ryan Saunders, who died in 2007 from an undiagnosed Streptococcal infection, which led to Toxic Shock Syndrome. When Ryan’s parents were worried he was getting worse they did not feel their concerns were acted on in time. In light of his death, the Department of Health made a commitment to introduce a patient, family, carer escalation process (Ryan’s Rule), to minimise the possibility of a similar event occurring.Follow the link below to the Queensland Government website to find out more about Ryan's Rule and how it works in practice.
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Content ArticleAnnie's story is an example of how healthcare organisations seeking high reliability embrace a just culture in all they do. This includes a system's approach to analysing near misses and harm events – looking to analyse events without a blame and shame approach.
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Content Article
The process of informed consent: A presentation
Shamim Odera RN posted an article in Consent and privacy
This presentation explains the process of informed consent and has been adapted from the National Institute for Health Research (NIHR) Introduction to Good Clinical Practice (GCP) Training.- Posted
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Content Article
Postnatal Risk Assessment Matrix (PRAM)
PatientSafetyLearning Team posted an article in Maternity
This Postnatal Risk Assessment Matrix (PRAM) resource was developed by Dr Cindy Shawley, Quality Improvement Lead for Maternity at Hampshire Hospitals NHS Foundation Trust. The pack includes a number of monitoring and assessment tools to help keep mums and babies safe. The following two sections have been selected for the finals of the Nursing Times Awards, under the Patient Safety category: The First Hour of Care: Keeping mums and babies together (a proforma and pathway to promote normal adaptation to life) Holding your baby safely poster (as referenced in the recent National Learning Report, Neonatal collapse alongside skin-to-skin contact) Please open the attached documents to view the full PRAM resource pack as well as the two award-nominated sections that can be downloaded independently. Many thanks to Dr Shawley for giving permission to share these important patient safety resources on the hub. -
Content ArticleThe ability to speak up to express concerns is a key safety behaviour all health and care staff should have. Teaching and using the 'probe, alert, challenge and escalate' (PACE) tool can allow any health or care professional of any type or seniority to use graded assertiveness to challenge any action or behaviour they may feel is inappropriate or unsafe.
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Content ArticleThere has been growing interest in the concept of safety cases for medical devices and health information technology, but questions remain about how safety cases can be developed and used meaningfully in the safety management of healthcare services and processes. This paper in Reliability Engineering & System Safety presents two examples of the development and use of safety cases at a service level in healthcare. These first practical experiences at the service level suggest that safety cases might be a useful tool to support service improvement and communication of safety in healthcare. Sujan et al. argue that safety cases might be helpful in supporting healthcare organisations with the adoption of proactive and rigorous safety management practices. However, it is also important to consider the different level of maturity of safety management and regulatory oversight in healthcare. Adaptations to the purpose and use of safety cases might be required, complemented by the provision of education to both practitioners and regulators.
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Content ArticleA joint National Patient Safety Alert has been issued by NHS Improvement and NHS England national patient safety team, Royal College of General Practitioners, Royal College of Physicians and Society for Endocrinology, regarding the introduction of a new Steroid Emergency Card to support the early recognition and treatment of adrenal crisis in adults.
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Content ArticleAuthors of this article, published by Health Europa, argue that proactive patient safety and risk prevention are key to helping healthcare organisations surveil and mitigate global and local risks.
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Content ArticleThis report by the Center for Health and the Public Interest, brings together what is known about patient safety in private hospitals. It offers insights into the number of patient safety incidents in private hospitals, analyses the potential risks inherent in the way that these services operate, and makes recommendations to improve transparency in the private sector.
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Keeping patients safe from falls
Claire Cox posted an article in International patient safety
Tens of thousands of patients fall in health care facilities every year and many of these falls result in moderate to severe injuries. Find out how the participants in the Center for Transforming Healthcare’s seventh project are working to keep patients safe from falls.- Posted
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Content ArticleEach year more people die in health care accidents than in road accidents. Increasingly complex medical treatments and overstretched health systems create more opportunities for things to go wrong, and they do. Patient safety is now a major regulatory issue around the world, and Australia has been at its leading edge. Self-regulation by professional and industry groups is now widely regarded as insufficient, and government is stepping in. In Patient Safety First leading experts survey the governance of clinical care. Framed within a theory of responsive regulation, core regulatory approaches to patient safety are analysed for their effectiveness, including information systems, corporate and public institution governance models, the design of safe systems, the role of medical boards, open disclosure and public inquiries. Patient Safety First includes chapters by Bruce Barraclough, John Braithwaite, Stephen Duckett and Ian Freckleton SC. It is essential reading for all medical and legal professionals working in patient safety as well as readers in public health, health policy and governance.
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How do audits influence intentions to improve practice?
Claire Cox posted an article in Improving patient safety
Do you know the science behind what works and doesn’t work when it comes to keeping people safe in your organisation? Dr Drew Rae and Dr David Provan from the Safety Science Innovation Lab at Griffith University as they break down the latest safety research and provide you with practical management tips.- Posted
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Content ArticleImplementation of high reliability principles in healthcare delivery is recognized as an effective strategy for reducing harm to patients and healthcare workers. With the coronavirus disease 2019 (COVID-19) pandemic upon us, our emergency departments (EDs) are facing an unprecedented safety threat. How does a high reliability ED function during a pandemic, and what are the most important strategies for keeping ourselves and our patients safe? Thull-Freedman et al. discuss this in a commentary in the Canadian Journal of Emergency Medicine.
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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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Content ArticleDelivering world-class cancer research is at the heart of what they do at The Christie. Developing new treatments to improve outcomes for patients is one of their key priorities. They lead research into innovative techniques such as using DNA to personalise treatment and to help people’s immune systems fight cancer and there are more than 650 clinical research studies and trials running at any given time. The Christie have internationally recognised expertise in cancer research. Their research makes a difference for people living with cancer and their friends and families. Cancer research expertise at The Christie includes: running research studies and trials across all types of cancer delivering the highest quality clinical trials identifying appropriate research participants and involving them in the right research studies providing an excellent service and patient support Watch Professor John Radford's video explaining the importance of research at The Christie
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Improving safety for oncology healthcare workers and patients
Claire Cox posted an article in Cancers
Philippa Jones, past head of acute oncology, speaks to ecancer at UKONS 2019 in Telford about safety with regards to not only patients, carers and families but also healthcare workers. She explains that measures include appropriate training, qualifications and understanding of treatments so that they can give good advice and support to patients. Philippa highlights some training resources, guidelines and development opportunities for nurses and other healthcare workers.- Posted
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Chemotherapy safety - precautions for the public
Claire Cox posted an article in Cancers
Chemotherapy is strong medicine, so it is safest for people without cancer to avoid direct contact with the drugs. That’s why oncology nurses and doctors wear gloves, goggles, gowns and, sometimes, masks. When the treatment session is over, these items are disposed of in special bags or bins. After each chemotherapy session, the drugs may remain in your body for up to a week. This depends on the type of drugs used. The drugs are then released into urine, faeces and vomit. They could also be passed to other body fluids such as saliva, sweat, semen or vaginal discharge, and breast milk. Some people having chemotherapy worry about the safety of family and friends. There is little risk to visitors, including children, babies and pregnant women, because they aren’t likely to come into contact with any chemotherapy drugs or body fluids.- Posted
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Content ArticleFor senior managers and safety professionals within organisations wishing to develop performance indicators to give improved assurance of control over major hazard risks. Although primarily addressed to major hazard operators, the generic model for establishing a performance measurement system, as given in this guide, can equally apply to other enterprises requiring similar levels of assurance. Offering a six-stage process to adopt in order to implement a programme of performance monitoring for process safety risks.
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Content ArticleThis paper, published by BMJ Quality & Safety, argues that discharge handovers are often haphazard. Healthcare professionals do not consider current handover practices safe, with patients expected to transfer information without being empowered to understand and act on it. This can lead to misinformation, omission or duplication of tests or interventions and, potentially, patient harm. Vulnerable patients may be at greater risk given their limited language, cognitive and social resources. Patient safety at discharge could benefit from strategies to enhance patient education and promote empowerment.
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Content ArticleThe safe management of a patient’s airway is one of the most challenging and complex tasks undertaken by a health professional - complications can result in devastating outcomes. How can anaesthetists improve safety, prevent complications, and be prepared to manage difficulties when they arise? How, in a crisis, can we ensure that human and technical resources are best utilised? This free course from Future Learn, endorsed by the Difficult Airway Society, will provide answers to these key questions and help you develop strategies to improve patient safety in your area of practice, discussing safe airway management in patient groups and multidisciplinary clinical settings.
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- Training
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Stroke VTE safety recommendations (February 2015)
PatientSafetyLearning Team posted an article in Processes
The US based, Stroke VTE (venous thromboembolism) Safety Recommendations provide four key steps to help prevent deep vein thrombosis (DVT) and pulmonary embolism (PE) in stroke patients. -
Content ArticleThe Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, presents evidence-based recommendations on the preferred methods for cleaning, disinfection and sterilisation of patient-care medical devices and for cleaning and disinfecting the healthcare environment. This is an American guidance from the Centers for Disease Control and Prevention.
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- Healthcare associated infection
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Content ArticleThis American report describes events involving dirty instruments submitted to ECRI Institute Patient Safety Organization and other reporting agencies. It provides recommendations to improve reprocessing practices, with a focus on instrument decontamination and the cleaning that occurs before disinfection or sterilisation.
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Content ArticleThe current approach to patient safety, labelled Safety-I, is predicated on a ‘find and fix’ model. It identifies things going wrong, after the event, and aims to stamp them out, in order to ensure that the number of errors is as low as possible. Healthcare is much more complex than such a linear model suggests. This article, published by the International Journal for Quality in Health Care, argues that we need to switch the focus to what we have come to call Safety-II, a concerted effort to enable things to go right more often. The key is to appreciate that healthcare is resilient to a large extent, and everyday performance succeeds much more often than it fails.
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Content ArticleRecently, there have been a number of advances in technology, including in mobile devices, globalization of companies, display technologies and healthcare, all of which require significant input and evaluation from human factors specialists. Accordingly, this textbook has been completely updated, with some chapters folded into other chapters and new chapters added where needed. The text continues to fill the need for a textbook that bridges the gap between the conceptual and empirical foundations of the field.
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