Search the hub
Showing results for tags 'Surgery - General'.
Found 485 results
-
Content ArticleTraditionally, 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.
-
Content ArticleThe Perioperative Warming Quality Improvement Resource summarises the evidence for temperature monitoring, pre, intra and post-operative warming, plus intravenous and irrigation fluids. See also the Perioperative Warming Decision Guide to help support what pre, intra and post-op actions need to be taken to prevent inadvertant perioperative hypothermia.
-
Content ArticleThe Surgical Skin Preparation Quality Improvement Resource summarises the evidence for patient washing, hair removal, skin disinfection and the use of incise drapes.
-
Content ArticleLearn about the latest scientific evidence around theatre ventilation, movement in and out of theatres and the cleaning processes.
-
Content ArticleA guide about skin preparation and disinfection to help reduce the risk of surgical site infection.
-
Content ArticleThe OneTogether Quality Improvement Resources are intended to provide practical information for implementing best practice for each of the elements of care across the surgical pathway. These resources can be used as stand‑alone documents, but are recommended to be used in conjunction with the OneTogether Assessment Toolkit. The OneTogether Assessment Toolkit is designed to measure adherence to best practice to prevent surgical site infection (SSI). Following completion of the OneTogether Assessment, healthcare professionals will be able to identify areas of low compliance and develop a prioritised action plan for improvement. The Quality Improvement Resources summarise the evidence underpinning recommended practice and provide a competency assessment checklist. The information they contain is drawn from evidence-based guidelines or expert recommendations from professional bodies
-
Content ArticleEducate and inspire your surgical teams to adopt the recommended guidance across the surgical pathway.
-
Content ArticleAdministrative data systems are used to identify hospital-based patient safety events; few studies evaluate their accuracy. McIsaac assessed the accuracy of a new set of patient safety indicators (designed to identify in hospital complications).
-
Content ArticleThis directive alert has been issued on the need to confirm intravenous (IV) lines and cannulae have been effectively flushed or removed at the end of the procedure.
-
Content ArticleEvidence on heterogeneity in outcomes of surgical quality interventions in low-income and middle-income countries is limited. Alidina et al. explored the factors driving performance in the Safe Surgery 2020 intervention in Tanzania’s Lake Zone to distil implementation lessons for low-resource settings. They found that performance experiences of higher and lower performers differed on the following themes: (1) preintervention context, (2) engagement with Safe Surgery 2020 interventions, (3) teamwork and communication orientation, (4) collective learning orientation, (5) role of leadership, and (6) perceived impact of Safe Surgery 2020 and beyond. Higher performers had a culture of teamwork which helped them capitalise on Safe Surgery 2020 to improve surgical ecosystems holistically on safety practices, teamwork and communication. Lower performers prioritised overhauling safety practices and began considering organisational cultural changes much later. Thus, while also improving, lower performers prioritised different goals and trailed higher performers on the change continuum. The authors conclude that future interventions should be tailored to facility context and invest in strengthening teamwork, communication and collective learning and facilitate leadership engagement to build a receptive climate for successful implementation of safe surgery interventions.
-
Content Article
Endometriosis: Laparoscopic surgery for endometriosis
Patient Safety Learning posted an article in Women's health
This leaflet covers laparoscopic surgery for endometriosis. It provides information for women who have been offered or are considering laparoscopic surgery for the treatment of endometriosis. -
Content ArticleAt the age of 15, Helen Haskell's son, Lewis, died due to treatable surgical complications. Following a routine elective surgery, he developed signs of sepsis, a life-threatening response to infection. Like most patients in postsurgical distress, Lewis deteriorated slowly. As he became weaker and weaker over the course of many hours, his bedside caregivers downplayed the significance of his mounting pain and unstable vital signs. Finally, his blood pressure became undetectable and he went into cardiac arrest, from which he could not be saved. His death, like thousands of others, was preventable. In this article, Helen discusses the erosion of patient safety reporting at the United States' CMS. Each year, CMS proposes changes to quality reporting programmes. Longstanding evidence-based patient safety measures, especially those used to detect harm to patients, are gradually being removed. These measures are largely extrapolated from hospital records and do not add to the workload of hospital staff. But they are embarrassing to hospitals, and hospital representatives lobby against them. The trend of downgrading patient safety is concerning.
-
Content ArticleThe purpose of wearing a type II fluid resistant surgical mask (FRSM) during surgical and invasive procedures is to minimise the transmission of pathogens in the nose, mouth and throat of staff to patients. They also protect staff from splash or spray of blood/body fluids onto their respiratory mucosa (nose and mouth). A wide range of FFP3 respirators have been used as protection by staff across healthcare settings during the COVID-19 pandemic, including FFP3 respirators with and without exhalation valves. The exhalation valves do not filter exhaled breath, even when of a ‘shrouded’ type. Current infection control guidance states that: “Valved respirators should not be worn by a healthcare worker/operator when sterility directly over the surgical field is required, eg in theatres/surgical settings or when undertaking a sterile procedure”. Powered hoods (also known as powered air purifying respirators or PAPRs) have been provided as respiratory protective equipment (RPE) for staff unable to achieve a tight fit with an FFP3 respirator(s). The air exiting PAPR hoods is not filtered. Incident reports received since March 2020 identified five incidents describing dripping of condensation from the exhalation valve of an FFP3 respirator, potentially compromising the sterile field; one cerebral abscess involving an oral bacterium linked to the use of a valved FFP3 respirator during brain surgery; and three cases of endocarditis linked to PAPR use during cardiac surgery. These incident reports and feedback from services suggest that the risks of valved respirators and PAPRs for surgical and invasive procedures is not well recognised, and that their use may have become routine in some theatre environments.
-
Content ArticleHaugen et al. studied the impact of the Norwegian National Patient Safety Campaign and Program on Surgical Safety Checklist (SSC) implementation and on safety culture. They found that the National Patient Safety Program, fostering engagement from trust boards, hospital managers and frontline operating theatre personnel enabled effective implementation of the SSC. As part of a wider strategic safety initiative, implementation of SSC coincided with an improved safety culture.
-
Content ArticleCOVID-19 continues to have a severe effect on planned surgery in the UK, and dealing with the resulting backlog is a critical concern for the NHS. In this BMJ Editorial, Andrew Carr and colleagues look at why the waiting times have increased so much and what can be done.
-
Content ArticleRecently, NHS England and NHS Improvement published planning guidance for the year ahead, outlining six priorities for the NHS as it emerges from the pandemic. The guidance strikes a balance between prioritising covid response and recovery efforts and advancing the broader service transformation objectives of the NHS Long Term Plan. With NHS surgical waiting lists now standing at a record 4.6 million, it is not surprising that accelerating the restoration of elective care is one of the priorities. The elective backlog challenge is not a new one for the NHS, but addressing it has acquired a new urgency and scope. Clearing the backlog sustainably and equitably will require the NHS, as the guidance states, “to do things differently.” In this BMJ article, Jugdeep Dhesi and Lisa Plotkin what they think "doing things differently" must include.
-
Content Article"The biggest struggle I had to overcome was the lack of confidence caused by microaggressions over time", says Samantha Tross, the first Black female orthopaedic surgeon in Britain. In the latest episode of the Royal College of Surgeons of England Health inequalities podcast series, Samantha considers how diverse leadership can be better developed and supported within surgery, with a focus on widening opportunities and creating a more positive training environment.
-
Content ArticleAs part of a Patient Safety in Surgery Webinar Series held by Massachusetts General Hospital’s COMPASS (Center for Outcomes and Patient Safety in Surgery), Vivian Lee, president of Verily Health Platforms, shares strategies for leading quality improvement and change to work toward a healthcare system that provides better care, more efficiently and at a lower cost.
-
Content Article
.png.3b6ddec516a2937d79f769afd2d589d3.png)
In this blog, retired Occupational Health Doctor, Clare Rayner draws on personal experience to illustrate the impact delayed surgery can have on a patient. Clare’s insights as a physician, patient and relative lead several questions around risk management for patients as the NHS deals with the pressures of the surgical backlog.- Posted
- 1 comment
-
1
-
- (and 2 more)
-
Content Article
(1).png.8600f2a6a31dcb9f907971b22af17703.png)
One in 20 patients who undergo a surgical procedure contract an infection afterwards, in the part of the body where the surgery took place. 60% of these are preventable. We’re looking for patients to help raise awareness of the damaging impact these infections can have on people, and guide improvements. Have you ever contracted an infection after surgery? How did it affect you? Would you be happy to share your experience? -
Content ArticleThis study examined the impact of the Norwegian National Patient Safety Campaign and Program on Surgical Safety Checklist (SSC) implementation and on safety culture, with a secondary objective looking at the associations between SSC fidelity and safety culture.
-
Content ArticleThis research was conducted with the aim to reduce the number of poor outcomes for surgical patients with a National Early Warning Score (NEWS) score ≥7 in the author's institution by 50%. Results found that the introduction of the surgical safety huddle supported by the deteriorating patient response team reduced the number of cardiac arrests and poor outcomes in a surgical inpatient cohort.
-
Content ArticleThe Healthcare Safety Investigation Branch (HSIB) identified a patient safety risk involving the timely detection and treatment of non-malignant spinal compression (cauda equina syndrome). Cauda equina syndrome (CES) is a rare and severe type of spinal stenosis, causing all the nerves in the lower back to become suddenly and severely compressed. If CES is not diagnosed and treated in a timely way it can lead to permanent incontinence, sexual dysfunction and even paralysis. The investigation was launched after HSIB identified an event where a patient had several GP and hospital presentations before CES was diagnosed.
-
Content ArticleMany surgeons prefer to perform total knee replacement surgery with the aid of a tourniquet. A tourniquet is an occlusive device that restricts distal blood flow to help create a bloodless field during the procedure. This article considers the results of a review that compared knee replacement with use of a tourniquet versus without use of a tourniquet and non‐randomised studies with more than 1000 participants. It highlights the risks of complications such as blood clots and infections associated with this, and indicates that changing surgical practice to avoid using tourniquets could avoid nearly 2,000 serious complications in the UK each year.
-
Content ArticleThis paper describes the case of a patient who had undergone a Ripstein procedure to address rectal prolapse 6 years before admission to the researchers clinic due to pain and discomfort over a period of 2 years. The researchers document the complications of the mesh implantation for rectal prolapse repair and presents the case of the unusual complication and reviews the relevant literature.
.png.3b6ddec516a2937d79f769afd2d589d3.png)
(1).png.8600f2a6a31dcb9f907971b22af17703.png)
