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Found 218 results
  1. Content Article
    This poster from the National Association of Theatre Nurses (ATN) aims to give an overview of electrosurgery in the perioperative setting. It identifies and defines some of the common forms of electrosurgery used in perioperative practice and identifies some of the hazards that can be associated with these products.
  2. Content Article
    In January 2017, I read an article in Outpatient Surgery involving an elderly patient in the US who suffered multiple burns following the use of chlorohexidine bottled alcoholic prep. The Oregon woman filed a million-dollar lawsuit against the Oregon Outpatient Surgery Center in Tigard, Ore., saying she suffered severe burns when her face caught on fire during an electrocautery procedure. Having read this tragic story and escalated it to my theatre manager and colleagues, I decided to design and evaluate a FRAS (Fire Risk Assessment Score) and use it as part of the WHO Surgical Checklist at "time out" to raise awareness of fires in operating theatres.
  3. Content Article
    This report from Saaiq and colleagues, published in the Annals of Burns and Fire Disasters, highlights three cases of iatrogenic electrocautery burns with review of the relevant published literature. The aim is to prompt awareness among surgeons and theatre staff regarding this avoidable hazard associated with the equipment frequently used for the purpose of electrocautery. This may serve as a reminder to professionals to be cautious about the pitfalls that lead to such preventable injuries.
  4. Content Article
    Postoperative delirium is common and has multiple adverse consequences. Guidelines recommend routine screening for postoperative delirium beginning in the post-anaesthesia care unit. The 4 A’s test (4AT) is a widely used assessment tool for delirium; however, there are no studies evaluating its use in the post-anaesthesia care unit.  Saller et al. evaluated the performance of the 4AT in the post-anaesthesia care unit in a tertiary German medical centre. The findings published in Anaesthesia suggest that the 4AT is an effective and robust instrument for delirium detection in the post-anaesthesia care unit. suggest that the 4AT is an effective and robust instrument for delirium detection in the post-anaesthesia care unit.
  5. Content Article
    This video by theatre staff from  East Lancashire Hospitals NHS Trust explains how the 10,000 feet initiative promotes patient safety within the operating theatre.
  6. Content Article
    Pete Smith is nothing without the energy and commitment of the amazing people who surround him. Increasing the technical skill of a healthcare clinician makes for incremental change. Improve the culture within which they work, think and communicate and suddenly quantum change is possible. Two perioperative nurses from a regional hospital in Victoria, Australia, innovated a simple, elegant solution to the problem of noise and distraction in the operating room. Pete Smith was one of them.
  7. Content Article
    Below Ten Thousand is a language-based safety tool for any clinical arena where 'noise and distraction' is a problem, and where high performance teams need to quickly gain 'situational awareness' and ‘directed focus’ in order to successfully navigate the perils of acute healthcare whilst providing first class interventions. 
  8. Content Article
    "It’s time to halt, take a break, and redraw the relationship between patient care and self-care. Self-care isn’t an optional luxury. It must sit at the heart of what we do, to ensure our teams can continue to rise to the challenges of working in the 21st century NHS, to give our patients the best of both ourselves, and the organisation so many of us are proud to be a part of."
  9. Content Article
    This report from the King's Fund explores in more detail the role of leaders in engaging a range of significant others in improving health and healthcare. 
  10. Content Article
    Potentially preventable adverse events remain a formidable cause of patient harm and health care expenditure despite advances in systems-based risk-reduction strategies. This quality improvement study from Suliburk et al., published in JAMA Network Open, analysed the incidence of human performance deficiencies during the provision of surgical care to identify opportunities to enhance patient safety.
  11. Content Article
    PatientSafe Network in Australia has been promoting the theatre cap challenge across the world. By wearing your name on your theatre cap it can improve team work and patient safety. The PatientSafe Network is a registered non for profit charity. It has been developed by front line healthcare staff and is for anyone to use – patients, relatives, doctors, nurses, pharmacists, healthcare managers, equipment and system developers, insurers – who wants to improve patient safety.
  12. Content Article
    This leaflet produced by the World Health Organization (WHO) is aimed at patients who are undergoing a surgical procedure. It aims to enable communication between you and your surgical team, including you in safety checks.
  13. Content Article
    Dr Clare Dollery reflects on a retained swab 'never event' in Churchill Hospital theatres. Incidents, such as operating on the wrong body part or leaving instruments inside patients are categorised by the Department of Health as 'never events'. Dr Dollery is Oxford University Hospital's Deputy Medical Director. The Surgical Grand Rounds lecture series, hosted by the Nuffield Department of Surgical Sciences at Oxford University, is the key educational meeting for consultants, juniors and medical students. Presentations revolve around clinical cases.
  14. Content Article
    A great animated video brought to you by No More Throw Away People – voiced by Brian Blessed, this tale of blobs and squares paints an accurate picture of how co-production matters. This short animation shows why its vitally important to engage and include our patients and service users in clinical system design.  It explains simply what may happen if we don't listen to all parts of our system to make care safer.
  15. Content Article
    The WHO surgical safety checklist is an essential aide to patient safety. This video demonstrates how the checklist is used at Great Ormond Street Hospital.
  16. Content Article
    Getting It Right First Time (GIRFT) is designed to improve the quality of care within the NHS by reducing unwarranted variations. By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings.
  17. Content Article
    Richard Greenwood is Trust Decontamination Lead & Head of Sterile Services at University Hospitals of Morecambe Bay (UHMB) NHS Foundation Trust. As with many NHS Trusts, UHMB were faced with problem of managing surgical instrument stocks, migration of the instruments from sets, and tracking and tracing single instruments through the decontamination process back to the patient. This case study shows how they solved this problem.
  18. Content Article
    Traditionally, clinicians present complications at surgical morbidity and mortality (M&M) conferences, and the AHRQ Patient Safety Indicators (PSIs) use inpatient administrative data to identify certain adverse outcomes. Although both methods are used to identify adverse events and inform quality improvement efforts, these two methods might not overlap. This is a retrospective observational study from Anderson et al. of all hospitalisations at a single academic department of surgery (including subspecialties) in 2016 involving a PSI-defined event identified by surgery faculty and residents for review by departmental M&M conference or administrative data. The authors analysed the degree to which these two processes captured PSI-defined events and reasons for exclusion by each process. The study found that surgical M&M and the PSIs are complementary approaches to identifying complications. Both case-finding processes should be used to inform quality improvement efforts.
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