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Showing results for tags 'Surgery - Cardiothoracic'.
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News ArticleThe family of a man who needlessly died after a 12-hour delay in surgery have called for changes at a troubled NHS trust as regulators expressed alarm about patient safety and waiting times. The Care Quality Commission (CQC) upgraded the surgery department at the Royal Sussex county hospital in Brighton from “inadequate” to “requires improvement” at a time when it is at the centre of a police investigation into dozens of patient deaths, allegations of negligence and cover-up. In their report, the regulator expressed concern about already long and lengthening waiting times, repeated cancelled operations and staff shortages that could compromise safety. The inspection report comes as the Guardian can reveal the trust apologised and settled with the family of Ralph Sims, who died aged 65 after heart surgery in April 2019 when doctors failed to act appropriately to a drop in his blood pressure. Sims, who was a keen runner, suffered a drop in blood pressure and developed an irregular heart rhythm eight hours after surgery to replace an aortic valve at the hospital. An internal investigation into Sims’ treatment acknowledged that hospital staff failed to “recognise the significance of the fall in blood pressure”. University Hospitals Sussex NHS foundation trust, which runs the hospital, accepted that the father of three should have returned to surgery to identify the cause of his deterioration. Instead, medics decided that he should be observed overnight. Due to another emergency case, an angiogram was not carried out on Sims until just before noon the following day – 12 hours after the drop in pressure. The delay caused irreversible – and avoidable – heart muscle damage, leading to his death five weeks later. The family said: It added: “Whilst the trust has apologised to our family it feels hollow. Ralph’s death was entirely unnecessary, and despite the issues in his care, it took the trust several years to apologise.” Read full story Source: The Guardian, 14 February 2024
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- Patient death
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Content ArticleAndrew Guillaume was admitted to Warwick Hospital on the 6 June 2023. Following a review, it was agreed that the likely diagnosis was severe aortic stenosis requiring an urgent Consultant to Consultant referral to University Hospitals Coventry and Warwickshire (UHCW) cardiology team. However, no referral was made as the Consultant was unable to get through to the switchboard at UHCW, so Mr Guillaume remained at Warwick Hospital. Subsequently his condition worsened and on the 16 June 2023 a plan was made to update the cardiothoracic surgery team at UHCW to expedite his surgery, but again they were unable to reach the team through the switchboard. Mr Guillaume was admitted to the unit on 19 June 2023, but sadly died on 20 June 2023 due to a further sudden deterioration in his condition.
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- Coroner
- Coroner reports
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Content Article
Latest issue of the Operating Theatre Journal
Patient Safety Learning posted an article in Surgery
A monthly journal for all operating theatre staff covering surgical and anaesthesia news.- Posted
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- Operating theatre / recovery
- Research
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(and 14 more)
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- Operating theatre / recovery
- Research
- Surgery - General
- Surgery - Cardiothoracic
- Surgery - ENT
- Surgery - Neurosurgery
- Surgery - Vascular
- Surgery - Urology
- Surgery - Trauma and orthopaedic
- Surgery - Paediatric
- Surgery - Oral and maxillofacial
- Surgery - Ear nose & throat
- Surgery - Obs & Gynae
- Surgeon
- Anaesthesia
- Anaesthetist
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Content ArticleAortic valve replacement (AVR) is a life-saving procedure for symptomatic severe aortic stenosis (AS), which relieves symptoms, increases life expectancy and improves quality of life. Little is known about the rate of AVR provision by gender, race or social deprivation level in the NHS across England. However, a large analysis examining AVR on the health service in England – the first of its kind – reveals striking inequalities in its provision. Women, black and Asian people, and those living in the poorest parts of the country are much less likely to receive the life-saving procedure, the study shows. “In this large, national dataset, female gender, black or south Asian ethnicities and high deprivation were associated with significantly reduced odds of receiving AVR in England,” the authors wrote. Dr Clare Appleby, a consultant cardiologist at the Liverpool Heart and Chest hospital NHS foundation trust and an author of the study, said public health initiatives to understand and tackle these inequalities should be prioritised. “Severe symptomatic aortic stenosis is a serious disease that causes mortality and reduces quality of life for patients,” she said. “Left untreated it has a worse prognosis than many common metastatic cancers, with average survival being 50% at two years, and around 20% at five years.” Further research and public health initiatives to understand and address inequalities in the timely provision of AVR are important and should be prioritised in England.
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- Health inequalities
- Social determinants of health
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Content ArticlePatients are facing increased delays at almost every stage of their NHS treatment, as the health system struggles to find the resources to deal with demand. The latest data shows waiting lists across England have surpassed record highs every month for two years running, one of many major challenges currently facing the NHS. But what impact does this have on ordinary people trying to access the NHS in 2022? Through a combination of interviews with health professionals and analysis of official data, the Guardian has plotted the journeys of four fictional patients through their NHS journey and how waiting times have changed at each stage of their treatment and recovery.
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- Organisation / service factors
- Patient
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Content ArticleThe Resilient Surgeon is a podcast by The Society of Thoracic Surgeons in the US. In this episode, Dr Michael Maddaus interviews Dr Amy Edmondson, a scholar of leadership, teamwork and organisational learning. Dr Edmondson defines psychological safety as a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns or mistakes. It makes a team a safe place for interpersonal risk-taking. In this podcast, she explains how psychological safety is the key to unlocking high quality conversations that result in improved team outcomes.
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- Just Culture
- Speaking up
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Event
Future surgery 2022
Patient Safety Learning posted an event in Community Calendar
Future Surgery, brings together surgeons, anaesthetists and the whole perioperative team. Designed specifically to meet the training needs, promote networking and develop a stronger voice for all surgical professionals and their multidisciplinary teams in perioperative care. Our CPD accredited speaker programme explores disruptive technology, connectivity, human factors, training and research to support the transformation of the profession and the improved care and safety of patients. Future Surgery is the biggest gathering of surgical and operating theatre teams with over 110 expert speakers – in keynote sessions, panel discussions and workshop sessions, covering all that is new in the field of surgery. Register- Posted
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- Surgery - General
- Surgery - ENT
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News Article
Almost 100,000 facing excessive wait for serious cardiac care in England
Patient Safety Learning posted a news article in News
Almost 100,000 people with serious heart problems, including some “living on borrowed time”, are enduring long waits for potentially life-saving NHS care because hospitals are so busy. Some of them are in such poor health they will have a heart attack and die as a consequence of facing such “dangerous” long delays, the British Heart Foundation has warned. The number of patients in England being forced to wait more than the supposed maximum 18 weeks for cardiac treatment has trebled since Covid-19 struck, from 32,186 in February 2020 to an unprecedented 96,321, a BHF analysis of published NHS England data shows. They are waiting for procedures such as having a stent or balloon inserted to reopen a blocked artery, a pacemaker or implantable defibrillator fitted, or open heart surgery, including bypasses or valve replacement operations. Others urgently need to have an echocardiogram, CT or MRI scan to help doctors decide on treatment. Dr Sonya Babu-Narayan, a consultant cardiologist who is also the BHF’s associate medical director, said: “Cardiac care can’t wait. Without timely treatment, heart patients may be living on borrowed time.” “Tens of thousands of people feel in limbo, waiting many months or even years for cardiac surgery, invasive heart procedures or important diagnostic tests. During this time they could quite quickly become much sicker, and tragically some could even die before they can receive the heart care they so desperately need,” she added. Read full story Source: The Guardian, 16 June 2022- Posted
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- Medicine - Cardiology
- Surgery - Cardiothoracic
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News Article
Scandal-hit heart surgery unit warned for third time over ‘toxic’ culture
Patient Safety Learning posted a news article in News
Junior doctors have been prevented from returning to scandal hit heart surgery unit previously criticised over “toxic” culture, The Independent has learned. A coroner defended cardiac surgery at St George’s University Hospital, criticising an NHS-commissioned review into 67 deaths that warned of poor care. However, The Independent has learned the unit received a critical report from Health Education England (HEE), the body responsible for healthcare training, just last year. The NHS authority was so concerned about culture problems and “inappropriate behaviour” within the unit that it took away the junior doctors working there. This is the third time HEE has intervened since 2018, when the unit was criticised in an independent review for having a “toxic” culture. In a statement, Professor Geeta Menon, postgraduate dean for South London at Health Education England, said: “HEE carried out a review of cardiac surgery at St George’s University Hospital in July 2021 and concluded that further improvements were required to create a suitable learning environment for doctors in training. "Unfounded’ NHS criticism and investigation caused unnecessary deaths at London heart surgery unit “We continue to work closely with the trust to implement our requirements and recommendations and will reassess their progress this summer. HEE is committed to ensuring high quality patient care and the best possible learning environment for postgraduate doctors at St George’s.” The Independent understands that a report issued in December, following the HEE visit, identified problems of “inappropriate behaviour”, poor team working from consultants and raised concerns the culture problems previously identified at the unit persisted. Read full story Source: The Independent, 14 May 2022- Posted
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- Surgery - Cardiothoracic
- Organisational culture
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Content ArticleThis briefing examines the results of a US study which showed that 80% of patients that have an infection from a cardiac implant are not treated according to clinical practice guidelines, increasing their chances of death from infection. When patients with implantable cardiac devices have an infection, current guidelines state that these devices should be removed, however, this did not happen for the majority of the 1,065,549 Medicare patients included in the study that had a cardiac implant infection between 2006 and 2019.
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- Medical device
- Heart disease
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News Article
Bullying among top surgeons sparks two national investigations
Patient Safety Learning posted a news article in News
‘Horrifying and upsetting’ reports of bullying in prestigious heart units are being probed by national officials and professional leaders, HSJ can reveal. Health Education England told HSJ it was “undertaking a national thematic review of training in cardiothoracic surgery”, while the Society for Cardiothoracic Surgery separately revealed it was investigating concerns about “bullying, harassment and undermining behaviour” in the specialty following high-profile recent cases in Newcastle and Wales. Society president consultant surgeon Simon Kendall, who is based at James Cook University Hospital in Middlesbrough, told HSJ he has been made aware of wider problems beyond those identified in the North East and Wales. Mr Kendall revealed allegations reported to the society have included people being shouted at in public, problems resulting from a “legacy culture of sarcasm and public humiliation”, and more personal disputes between individuals. The consultant surgeon told HSJ: “The job is hard enough for all of us, without picking on each other and making it worse." He added: “It’s the extended team that is affected by these behaviours and it will have an impact on patient safety and patient care. Read full story (paywalled) Source: HSJ, 1 April 2022- Posted
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- Bullying
- Staff factors
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Content Article
CORESS reports
Patient Safety Learning posted an article in Surgery
CORESS is an independent charity, which aims to promote safety in surgical practice in the NHS and the private sector. CORESS receives confidential incident reports from surgeons and theatre staff. These reports are analysed by the Advisory Board, who make comments and extract lessons to be learned. Aiming to educate, and avoid blame, CORESS calls on surgeons to recognise a near miss or adverse event, react by taking action to stop it happening and then report the incident to CORESS so that the lessons can be published. Every month CORESS highlight's one of the cases reported for you to consider the issues raised and read the experts comments.- Posted
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- Surgery - General
- Patient safety incident
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Content ArticleThe aim of this study, published in BMJ Quality and Safety, was to assess the role of intraoperative non-routine events and team performance on paediatric cardiac surgery outcomes. It focuses on improving methods for studying teamwork.
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- Surgery - Cardiothoracic
- Teamwork
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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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- Surgery - Paediatric
- Surgery - Cardiothoracic
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Content Article
The Untold Heartbreak
Patient-Safety-Learning posted an article in Heart conditions
Covid-19 has had a lasting impact on cardiovascular care since the outbreak began. The British Heart Foundation has predicted that the number of people in England waiting for care and diagnosis could more than double within two years, peaking at around 550, 385 in January 2024 if the NHS doesn't get the funding it needs. In order to provide a stronger and more resilient health system that supports healthcare staff, a cardiovascular strategy for England to support recovery from the Covid-19 pandemic is needed.- Posted
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- Surgery - Cardiothoracic
- Pandemic
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(and 1 more)
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News Article
Heart surgery waits in England may rise by 40%, warns charity
Patient-Safety-Learning posted a news article in News
According to the British Heart Foundation, it may take up to five years for cardiac services to return to pre-Covid levels. This warning comes after it was revealed nearly 14 million people could be on NHS waiting lists in England by next autumn. "Tragically, we have already seen thousands of extra deaths from heart and circulatory diseases during the pandemic, and delays to care have likely contributed to this terrible toll. At this critical moment, the government must act now to avoid more lives lost to treatable heart conditions. Addressing the growing heart care backlog is only the start," says Prof Samani, medical director at the British Heart Foundation. Read full story. Source: BBC News, 9 August 2021- Posted
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- Surgery - Cardiothoracic
- Long waiting list
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Content ArticleThis report summarises some of the key findings from the full 2020 National Cardiac Audit Programme (NCAP). It provides useful background information and highlights what you can do to help improve cardiac health for you and your friends and family. It includes answers to some frequently asked questions and links to where to go for more information or support.
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- Patient
- Medicine - Cardiology
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Content ArticleGetting 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.
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Content ArticleSince 2015 Quomodus has developed the digital course 'Diathermy – a practical guide to electrosurgery' for surgeons and other professional users of electrosurgery. The 30-minute course covers the history of electrosurgery, indication and proper use, adverse effects and complications associated with the use of diathermy. The course has been tested and quality assured by health professionals in Scandinavia. The course is flexible, user friendly and applies to all models of diathermy equipment currently on the market.
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- Training
- Innovation
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Content ArticleThe surge in the need for invasive ventilation during the covid pandemic has required the provision of intensive care beds in London to be reallocated. NHS England have proposed the formation of a Pan‐London Emergency Cardiac surgery (PLECS) service to provide urgent and emergency cardiac surgery for the whole of London. In this initial report, the Department of Cardiac Surgery, St Bartholomew's Hospital, outline their experience of setting up and delivering a pan‐regional service for the delivery of urgent and emergency cardiac surgery with a focus on maintaining a COVID‐free in‐hospital environment. In doing so, they hope that other regions can use this as a starting point in developing their own region‐specific pathways if the spread of coronavirus necessitates similar measures be put in place across the United Kingdom
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EventuntilJoin BD this live educational event designed to promote discussions on the following topics: An overview of the latest evidence-based prevention measures of HAI (SSI). Essential bundles of an effective infection prevention and control program management in cardiac surgery. Review of the sustainable change in practice within operating room. The event is designed for cardiac surgeons, infection control and nurses who are interested in learning more about new techniques and methodologies to minimise some of the most challenging post-operative complications, with an opportunity to debate and share opinions with peers through live discussions with internationally renowned faculty. Register
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- Medicine - Cardiology
- Post-op period
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Content Article
Surgeons' News (Royal College of Surgeons of Edinburgh)
Patient Safety Learning posted an article in Surgery
Surgeons' News is a magazine for surgical, dental and allied healthcare professionals. Published quarterly by the Royal College of Surgeons of Edinburgh, it features comment and opinion from leading professionals, plus reviews and reports on subjects relevant to all career levels.- Posted
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- Surgery - General
- Surgery - Urology
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Content ArticleIn this review, Jane Carthey and colleagues discuss human factors research in cardiac surgery and other medical domains. The authors describe a systems approach to understanding human factors in cardiac surgery and summarise the lessons that have been learned about critical incident and near-miss reporting in other high technology industries that are pertinent to this field.
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- Human factors
- System safety
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Content Article
Patient Safety Movement: Story of Pat Denton
Patient Safety Learning posted an article in By patients and public
The story of Pat Denton who died from a surgery site infection after surgery. -
Content ArticleThe president of the Vascular Society of Great Britain and Ireland, Chris Imray, has issued a letter to Vascular Society members on the COVID-19 virus and vascular surgery, offering “general principles” on vascular patients and COVID-19, elective surgery and outpatients, urgent vascular surgery, trainees, other specialities, the appropriate use of scarce resources, documentation, personal safety, mental health and burnout, research, clinical training/education, and audit. Imray stresses that “local decision making is key.
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- Virus
- Medicine - Cardiology
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