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Found 477 results
  1. Content Article
    This investigation explores the patient safety risk of unintended retention of surgical swabs after surgery. Surgical swabs are sterile pieces of gauze which are used to absorb bodily fluids, such as blood, during a surgical procedure. The investigation will: explore the factors associated with unintentional retained surgical swab events identify alternative safety controls to reduce the likelihood of foreign objects being unintentionally retained. The interim report analyses the findings of 31 NHS trust serious incident reports.
  2. News Article
    A hospital that unnecessarily delayed a man’s surgery at the last minute because he had HIV failed in their care, according to England’s Health Ombudsman. The 48-year-old from Walsall, who does not want to be named, had been due to have prostate surgery at Walsall Manor Hospital on 10 March 2020. His surgery was scheduled to be the first of the morning. As he was about to enter the operating room, he was told that due to his HIV status his surgery would now be moved to last on the operating list that afternoon. The hospital claimed that this was due to the level of cleaning and infection control that would need to take place following his surgery to reduce the risk to others. However, the Parliamentary and Health Service Ombudsman (PHSO), found that Walsall Healthcare NHS Trust acted inappropriately and failed the man. This is because the universal precautions that apply to all patients having surgery are enough to protect and prevent infections from spreading among patients and staff. Therefore, no additional cleaning should have been necessary. The policy of placing a patient at the end of an operating list usually relates to patients with a high-risk bacterial infection. It should not be applied to a person who has HIV and is receiving treatment. The Ombudsman also found that although the Trust had made some changes since this happened, they had not done enough to make sure the same mistake did not reoccur. PHSO recommended the Trust apologise to the man and create an action plan to stop this happening again. The Trust has complied with these recommendations. Read full story Source: Parliamentary and Health Service Ombudsman, 1 December 2023
  3. News Article
    Police are investigating 105 cases of alleged medical negligence at the Royal Sussex County Hospital in Brighton amid claims of a cover-up. Specialist officers from the National Crime Agency and Sussex police are looking into cases of harm, which include at least 40 deaths, in the general surgery and neurosurgery departments between 2015 and 2021. An email from Sussex police, released to The Times after a court application, revealed the huge investigation is looking into 84 cases connected to neurology and 21 related to gastroenterology. Most of the families are yet to be told that their case is among them. Officers were called in by the senior coroner after she heard of allegations made by two consultant surgeons at University Hospitals Sussex NHS Foundation Trust, one of the largest NHS organisations with 20,000 staff. The trust has been accused of bullying the whistleblowers and attempting to cover up the circumstances of the deaths. Mansoor Foroughi, a consultant neurosurgeon, was sacked for “acting in bad faith” in December 2021 after raising concerns about 19 deaths and 23 cases of serious patient harm. Another whistleblower, Krishna Singh, a consultant general surgeon, claimed that he lost his post as clinical director because he said the trust promoted insufficiently competent surgeons, introduced an unsafe rota and had cut costs too quickly. Read full story (paywalled) Source: The Times, 27 November 2023
  4. Content Article
    This study in the American Journal of Surgery aimed to understand the impact of operating room temperature and humidity on surgical site infection (SSI). The authors found that large deviations in operating theatre temperature and humidity do not increase the risk of SSI.
  5. Content Article
    The harsh reality of surgery often involves grappling with the distressing and emotionally taxing aspects of human suffering that many people outside of healthcare never witness. When complications occur, surgeons feel the weight of their responsibility and are often alone to ruminate with negative thoughts of self-doubt, sometimes leading to anxiety and depression. This article in The American Journal of Surgery examines existing literature on Second Victim Syndrome (SVS) specifically focusing on prevalence among surgeons and factors related to different responses. The authors identify women and junior surgeons at particularly high risk of SVS and peer support as a preferred method of coping but an overall lack of institutional support highlighting the need for ongoing, open conversations about the topic of surgeon well-being.
  6. Content Article
    Yvette Greenway-Mansfield experienced complications relating to the vaginal mesh that was used to treat a uterine prolapse. Those complications were not listed on the consent form she signed. Fortunately, she kept her copy and was able to prove this. Yvette has recently been awarded £1 million because it was found that her form had been doctored after she had signed it.   Her successful medical negligence claim was also based on the fact that alternative treatment options were not considered when they should have been. These alternatives came with fewer risks, and it was agreed that they would actually have been more suitable in her case.  In this blog, I reflect on the levels of harm caused to the patient and how digital consent forms could help protect others. 
  7. News Article
    The NHS should better track patients with the greatest clinical need so they can move to the front of the queue for treatment, a former government waiting list tsar has said. Anthony “Mac” McKeever told HSJ the health service could improve how it works through its elective backlog by using a system introduced during the covid pandemic to prioritise the most pressing cases. He said a “large chunk” of cases were still not given a code to say how long they are considered to be able to wait for surgery, which is at the heart of this process. Mr McKeever retired as Mid and South Essex Integrated Care Board chief executive this month following nearly five decades in the health service, including as a trust leader. Although Mr McKeever said he only knew the regional situation for the East of England, he would be “very surprised” if the national picture was any different. Waiting list expert Rob Findlay agreed this was a reasonable assumption. Read full story (paywalled) Source: HSJ, 17 November 2023
  8. Content Article
    Potentially serious complications occurred in 1 in 18 procedures under the care of an anaesthetist in UK hospitals, according to a national audit by the Royal College of Anaesthetists (RCA). Risks were found to be highest in babies, males, patients with frailty, people with comorbidities, and patients with obesity. Risks were also associated with the urgency and extent of surgery and procedures taking place at night and/or at weekends.  The survey, published in Anaesthesia, was the RCA's seventh national audit project (NAP7) and included more than 20,000 procedures at over 350 hospital sites. NAPs study rare but potentially serious complications related to anaesthesia, and are intended to drive improvements in practice. Each focuses on a different topic and NAP7 examined perioperative cardiac arrest.  Dr Andrew Kane, consultant in anaesthesia at James Cook University Hospital in Middlesbrough and a fellow at the RCA's Health Services Research Centre in London, said the new data presented "the first estimates for the rates of potentially serious complications and critical incidents observed during modern anaesthetic practice". The data confirmed that individual complications are uncommon during elective practice, but highlight the relatively higher rate of complications in emergency settings.
  9. News Article
    NHS staff are carrying out the equivalent of one 'never-event' every day, figures show. This is despite the Government ordering a crackdown on the mistakes, which cost hospitals an estimated £800million in compensation each year. Experts today demanded further action on 'unacceptable' levels of never-events, blaming inadequate staffing levels and a lack of investment in the NHS. A MailOnline audit of a decade's worth of NHS data found a colossal 4,328 never-events have occurred in England since 2013. This equates to roughly eight a week. Shocking incidents uncovered include women getting parts of their reproductive anatomy cut out instead of an appendix, men getting unwanted circumcisions and laser procedures to the wrong eye. The Royal College of Surgeons said the level of never-events was 'unacceptable' and blamed NHS staffing levels for increasing the risk to patients. "Surgeons will be working hard to do their best for patients, but they do so in difficult circumstances," a spokesperson said. "The NHS is overstretched, with staff shortages, a workforce suffering from burn-out and pressure to get record waiting times down. "This increases the risk of mistakes happening." Read full story Source: MailOnline, 10 October 2023
  10. Content Article
    This report published by the National Confidential Enquiry into Patient Outcome and Death, is a review of the care provided to patients aged 16 and over with a diagnosis of, and who underwent surgery for, Crohn’s disease. In summary, the report says that surgery for patients with drug resistant Crohn’s disease surgery should be considered earlier in the treatment pathway for patients, instead of surgery being perceived as a failure of medical care. Once a decision to perform surgery has been made it should be undertaken within a month to prevent patients on elective waiting lists deteriorating and requiring emergency surgery. Furthermore, closer working between all members of the multidisciplinary team would benefit patients, to reduce delays as well as providing all the holistic care that patients with Crohn’s disease need. Read the full list of recommendations and the report via the link below.
  11. Content Article
    The Safe & Sound podcast by the Royal College of Surgeons in Ireland explores the world of human factors in healthcare and patient safety. Each episode, we will try to untangle different aspects of this complicated web of human factors in healthcare, through interviews with some extraordinary guests and faculty in Ireland, and across the world.
  12. News Article
    Former BBC Technology correspondent Rory Cellan-Jones, now a writer and podcaster, has Parkinson's disease. Two weeks ago, after fracturing his elbow in a nasty fall, he found out just how difficult it can be to get answers from the NHS. "Getting information about one's treatment seems like an obstacle race where the system is always one step ahead. But communication between medical staff within and between hospitals also appears hopelessly inadequate, with the gulf between doctors and nurses particularly acute. "I also sense that, in some cases, new computer systems are slowing not speeding information through the system. On Saturday morning, as we waited in the surgical assessment unit, four nurses gathered around a computer screen while a fifth explained to them all the steps needed to check-in a patient and get them into a bed. It took about 20 minutes and appeared to be akin to mastering some complex video game beset with bear traps." Rory's latest experience as a customer of the health service has left him convinced that more money and more staff won't solve its problems without some fundamental changes in the way it communicates. Read full story Source: BBC News, 29 October 2023
  13. Content Article
    The risks in perioperative care are well known. However, for patients having surgery in some African countries, the dangers are far more apparent. Staff are few and far between and many have not been able to access rationale for their practice or receive adequate training over the years. Friends of African Nursing (FoAN) is a small UK-based charity that has been providing education in several African countries to address this issue. More than 3,000 nurses and other healthcare workers have been trained face to face—and many more on-line—in patient safety, staff safety and infection prevention. FoAN's Chair of Trustees Kate Woodhead describes the challenges facing nurses working in perioperative care in many African countries.
  14. Content Article
    The number of older people having surgery is increasing. However, older patients are more likely to have complications after surgery than younger patients as they often have multiple health conditions and age-related problems such as frailty and a decline in mental ability. These factors increase the risk of surgery and can hinder recovery. Surgical pre-assessment usually focuses on the patient’s physical fitness for surgery, not the broader range of health-related factors that are important to consider in older patients. The Perioperative care for Older People undergoing Surgery (POPS) model was developed to provide a holistic assessment of an older person’s medical, physiological and functional condition prior to surgery. The assessment is then used to inform interventions that can reduce the risk of complications. The POPS model is increasingly being implemented across the English and Welsh NHS, but there are often challenges in introducing these new ways of providing care that need to be better understood. This independent study, led by THIS Institute Fellow Professor Justin Waring, outlines the key activities and strategies that are needed for the POPS model to be successfully implemented and become part of routine practice in a hospital.
  15. Content Article
    In this webinar, Chloe from the Getting It Right First Time (GIRFT) programme and Raj, a patient who had had surgery at a surgical hub an hour and half away from his home, talk about a project to improve the elective surgical hub programme based on patients' experiences and feedback. They were joined by the Patients Association project manager, Hannah.  Elective hubs are surgical centres on existing hospital sites, separated from emergency services, which means the facilities can be kept free for patients waiting for planned operations, reducing the risk of short-notice cancellations. Raj speaks candidly of his experiences in the early days of the project, and Chloe explains how patient experiences have enabled the NHS to improve the service. 
  16. News Article
    The mother of a four-year-old boy with complex needs said she fears he could die waiting for life-changing surgery. Collette Mullan made the claim to BBC Spotlight as it examined the scale of hospital waiting lists. Northern Ireland has the worst waiting times in the UK, with more than half a million cases queued for an outpatient or inpatient appointment. The Department of Health has described current waiting lists as "entirely unacceptable". Óisín, from County Londonderry, has a number of health conditions including cerebral palsy, and is currently waiting for two procedures. He is fed with a tube that carries his food through his nose into his stomach, but since it was inserted six months ago, his mum Collette said he has struggled to breathe. Óisín is now waiting to have the nasogastric tube removed and replaced by a different feeding system which goes directly to his stomach. Collette said she was told it could be a three-year wait for the procedure. She is concerned that Óisín's cerebral palsy puts him at a greater risk of complications, saying she had been warned there was a danger he could aspirate. "He could die. Anything going into his lung really, it could be very dangerous," she said. Read full story Source: BBC News, 3 October 2023
  17. Content Article
    Watch this World Patient Safety Day webinar with Nigel Roberts on enhancing patient safety and surgical outcomes with the surgical safety checklist.
  18. Event
    until
    CORESS invites you to join their free educational webinar and hear from four speakers as they talk about their area of expertise in relation to patient safety. Programme overview: 14:00 - Introduction to CORESS and Welcome - Professor Frank Smith, Professor of Vascular Surgery & Surgical Education, University of Bristol and North Bristol NHS Trust and CORESS Past-Programme Director 14:03 - Symposium Programme Overview - Miss Harriet Corbett FRCS Paed Consultant Paediatric Urologist, Alder Hey Children’s Foundation NHS Trust, British Association of Paediatric Urologists and CORESS Programme Director 14:05 - SPOT Programme: The National inpatient PEWS Chart - Professor Damien Roland, Consultant in Paediatric Emergency Medicine, Head of Service Children's Emergency Department, University Hospitals of Leicester NHS Trust 14:30 - Championing Patient Safety with Evidence Based Medicine - Robotically Assisted Surgery - Dr John Burke, Chief Medical Officer, AXA Health 14:55 - What’s new at HSIB - Saskia Fursland, National Investigator, HSIB 15:20 - Patient Safety in a Medico-legal Context - Dr Michael Devlin, LLM, MBA, FRCP, FRCGP, FFFLM , Head of Professional Standards and Liaison, MDU 15:45 - Symposium Summary and Close - Harriet Corbett, CORESS Programme Director Intended Audience: This session is for Consultant Surgeons, medics, students with a surgical healthcare background and those in healthcare and insurance sectors with an interest in surgical improvement and patient safety. Register
  19. Content Article
    A series of podcasts from Molnlycke UK, with host Steve Feast, discussing topics such as sustainability, patient safety and more.
  20. News Article
    In 2018 the British Association of Aesthetic Plastic Surgeons (www.baaps.org.uk) dissuaded all its members from performing Brazilian Buttock Lift (BBL) surgery, until more data could be collated. The decision was taken due to the high death rate associated with the procedure. Now, following an extensive four-year review of clinical data, new technology and techniques, BAAPS has published its Gluteal Fat Grafting (GFG) guidelines. Gluteal fat grafting is currently the procedure with the biggest growth rate in plastic surgery worldwide, with an increase of around 20% year-on-year). It has become the most popular means of buttock volume augmentation, overtaking gluteal augmentation with implants. In 2020, The Aesthetic Society statistics recorded 40,320 buttock augmentation procedures, which included both fat grafting and buttock implants. In 2015, there were reports of intraoperative mortality related to pulmonary fat emboli associated with BBL surgery and in 2018 with growing concern about the high mortality rate associated with this procedure BAAPS recommended it was not performed by its members. The development of the present guidelines and recommendations has been stimulated by the evidence that has emerged since 2018, based on scientific review and analysis. BAAPS guidelines now recommend that Gluteal Fat Grafting is safe to perform under two key conditions: Injection into the subcutaneous plane only - there is a plethora of evidence to suggest this significantly reduces mortality related to the procedure perhaps this needs to be changed to – the evidence shows that the only deaths from the procedure have been when fat has been injected into the deeper muscle layer. Intraoperative ultrasound must be used during the placement of fat in the gluteal area to ensure that the cannula remains in the subcutaneous plane – this is the only way that surgeons can be confident they are not in the muscle layer. Read full story Source: BAAPS, 17 October 2022
  21. News Article
    UK plastic surgeons have released new guidelines to try to make Brazilian Butt Lift (BBL) procedures safer for people who desire a bigger bottom. Some women have died from the operation, which involves sucking out fat from elsewhere - such as the belly - and injecting it into butt cheeks. The British Association of Plastic Surgeons (BAAPS) says the injections should not go very deep to help avoid complications such as dangerous clots. According to the NHS, it has the highest death rate of all cosmetic procedures, and the risk of death from BBL surgery is at least 10 times higher than many other procedures. A major concern is that the injected fat can cause a blockage in a blood vessel in the lungs - called a pulmonary embolism - which can be fatal. This happened to Leah Cambridge, a beautician and mother of three from Leeds. She suffered a massive pulmonary embolism during the operation at a private hospital in Turkey in 2018, a coroner found. BAAPS president Marc Pacifico told the BBC: "Unfortunately we don't know how many people have been going for these risky BBL procedures. We have been recommending against it for a number of years after seeing quite a frightening death rate associated with it. But people have been going abroad to get it done." "Make sure you ask if the surgeon will be using ultrasound for gluteal fat grafting. We are recommending that surgeons should only perform this with real time ultrasound guidance as the only way to ensure the procedure is performed superficially and safely." Read full story Source: BBC News, 10 October 2022
  22. News Article
    A woman who died during an operation for a buttock enlargement in Turkey was not given enough information to make a safe decision about the procedure, a coroner has concluded. Melissa Kerr, 31, from Gorleston, Norfolk, died at the private Medicana Haznedar Hospital in Istanbul, in 2019. Ms Kerr had gone abroad to have what is commonly referred to as a Brazilian butt-lift or BBL, the Norwich inquest heard. The inquest was told Brazilian butt-lift operations carried the highest risk of all cosmetic surgery procedures. The UK has an agreed moratorium on carrying out such operations due to the dangers involved, expert witness and plastic surgeon Simon Withey said in a report for the inquest. Mr Withey said if the risk of the procedure had been explained to Ms Kerr before she had financially committed to the procedure she would not "in all probability" have gone through with it. Coroner Jaqueline Lake said she would be writing a report for the health secretary to try and prevent further deaths from this "risky" procedure. She said she was "concerned patients are not being made aware of the risks or the mortality rate associated with such surgery". She added, while the UK government had no control over what happens in other countries, "the danger to citizens who continue to travel abroad for such procedures continues... and I'm of the view future deaths can be prevented by way of better information". Read full story Source: BBC News, 12 September 2023
  23. Content Article
    Demand for surgical and non-surgical cosmetic treatments has spiralled in the past ten years among men and women, especially young women in the 18-34 age group, thanks to social media, reality TV and celebrity endorsements. A corresponding increase in ‘botched’ procedures is putting pressure on the NHS to solve problems created by unregistered, unqualified practitioners.  Official advice is to check your practitioner is qualified and has appropriate insurance. This makes sense but it’s not always easy to know where to look. That’s why the Professional Standards Authority have done the hard work for you. The Check a Practitioner service exists for situations like these. You can check if a practitioner is regulated by law or belongs to a reputable Accredited Register.
  24. Event
    until
    This webinar looks at a project by the Patients' Association and the Getting It Right First Time (GIRFT) programme that focuses on elective surgical hubs. These are surgical centres on existing hospital sites, separated from emergency services, which means the facilities can be kept free for patients waiting for planned operations, reducing the risk of short-notice cancellations. They can help reduce waiting times for some patients. They tend to specialise in uncomplicated surgical procedures, with particular emphasis on ophthalmology, general surgery, trauma and orthopaedics, gynaecology, ear nose and throat and urology. Speakers: Chloe Scruton, Senior Implementation Manager, GIRFT Hannah Verghese, Project Manager, the Patients Association Raj Patel, patient Shivani Shah, Head of Programmes (event chair) They will be joined by one of the patients who was part of the project. Register for the webinar
  25. News Article
    A woman who suffered chronic abdominal pain for 18 months after undergoing a caesarean section was found to have a surgical instrument the size of a dinner plate inside her abdomen. The Alexis retractor, or AWR, was left inside the New Zealand mother after her baby was delivered at Auckland City Hospital in 2020. Following initial investigations into the case, Te Whatu Ora Auckland, formerly Auckland District Health Board, claimed it had not failed to exercise reasonable skill and care towards the patient, who was in her 20s. But on Monday, New Zealand’s Health and Disability Commissioner, Morag McDowell, found Te Whatu Ora Auckland in breach of the code of patient rights. Read full story Source: Guardian, 4 September 2023
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