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Found 182 results
  1. Content Article
    Fatigue is increasingly considered as one of the most significant hazards to aviation safety and other safety-critical industries. Both the academic community and industry have focused on understanding the phenomenon of fatigue and the factors that contribute to it in order to prevent it, but also to mitigate its possible consequences. As a result, procedures and regulations have been developed for operators to comply with and there is now a requirement for operators to demonstrate that they are actively managing fatigue. The aim of this white paper by Clockwork Research is to provide safety practitioners with a better understanding of the process of investigating fatigue.
  2. Content Article
    These Guidelines for the Provision of Anaesthetic Services (GPAS) support the development and delivery of high quality anaesthetic services. GPAS chapters have previously focused on a particular aspect of clinical service delivery. However, experience has identified a requirement in GPAS to describe what it is about a department of anaesthesia itself, beyond the different aspects of the clinical service delivery, that contribute to a successful department.  The Good Department chapter has been developed to address this requirement, describing current best practice for developing and managing a safe and high quality anaesthesia service in terms of the non-clinical aspects of the service that underpin the clinical provision. The guidance makes recommendations in terms of: leadership, strategy and management workforce education and training clinical governance support services.
  3. Content Article
    The Association of Anaesthetists established a working group to help anaesthetics trainees with safe sleeping patterns. In this blog, Dr Emma Plunkett, consultant anaesthetist and chair of the working group, talks more about new initiatives to fight fatigue and why it’s important to monitor the impact of tiredness in the national training surveys.
  4. Content Article
    This consensus document by The Association of Anaesthetists of Great Britain & Ireland aims to improve patient safety. It is intended to act as a reference document for individuals and departments when considering the effects of hours of work and type of work undertaken in anaesthesia on clinician’s performance and wellbeing.
  5. Content Article
    Anaphylaxis is a severe and often sudden allergic reaction that occurs when someone with allergies is exposed to something they are allergic to (known as an allergen). Anaphylaxis is potentially life-threatening, and always requires an immediate emergency response. Between 10 May 2017 and 10 May 2019, 55 hospital trusts reported 77 incidents relating to allergens in hospital, three of which involved the patient going into anaphylaxis, a severe and potentially life-threatening condition. This e-learning course is for nurses, healthcare assistants, ward managers, staff educators, directors of nursing, dieticians and anyone else involved in patient care on the ward. It has been designed to equip participants with knowledge and understanding about food allergies so that they can ensure the necessary processes are in place to keep inpatients with food allergies safe.
  6. Content Article
    The Community Pharmacy Patient Safety Group conducted this anonymous survey on patient safety culture in Autumn 2021 and invited pharmacy staff from across the UK to participate. The aim of the survey was to understand patient safety practice from the perspective of frontline pharmacy teams. Both the full results and an infographic of key results are available to download.
  7. Content Article
    This visual guide by the UK Health Security Agency shows photographs of different vaccines used in the UK routine immunisation schedule and their packaging. It includes information on trade names and abbreviations, diseases each vaccine protects against and the age at which it should be administered.
  8. Content Article
    The UK Government has announce a statutory public inquiry into the handling of the Covid-19 pandemic - the Hallett inquiry. However, in light of the wide-ranging impact of the pandemic, the inquiry faces a huge task to decide on the highest priority areas for investigation. This long read by Tim Gardner, Senior Policy Fellow at The Health Foundation, aims to examine what the parameters and structure of the UK Covid-19 Inquiry could be, and set out what it might realistically cover.
  9. Content Article
    In this blog, Clare Rayner, an occupational physician, describes how an international collaboration to help understand Long Covid was established by harnessing the power of technology and social media. This collective, between a group of UK doctors experiencing prolonged health problems after Covid-19 infection and a globally renowned rehabilitation clinic at Mount Sinai Hospital in New York, aims to help both patients and healthcare professionals by disseminating learning about Long Covid from both sides of the Atlantic.
  10. Content Article
    This census of the consultant physician workforce in the UK conducted by the Royal College of Physicians shows that the number of doctors needed to meet patient demand continues to significantly outnumber the supply.
  11. Content Article
    This guidance from the General Medical Council sets out the how doctors should raise and act on concerns about patient care, dignity and safety. 
  12. Content Article
    This manifesto was created by the Community Rehabilitation Alliance, a collective of 50 charities, trade unions and professional bodies coming together to call on all political parties to ensure there is equal access to high quality community rehabilitation services for all patients.
  13. Content Article
    This study in the British Journal of Clinical Pharmacology involved searching electronic health records to uncover how many people in prisons have been affected by a potential problem related to their prescribed medication. Researchers looked at published studies and worked with prison healthcare staff to develop and implement prescribing safety indicators (PSIs) for prison electronic health records. The authors found that PSIs provide a significant opportunity to measure and improve medication safety for people in prisons and that more patients were affected by some PSIs than others. The study also investigated how the searches could be used more widely in prisons and interviewed 20 prison health care staff to explore this topic. The staff they spoke to said that it was important to have people who can take on leadership of the searches and to promote team-based responses to them.
  14. Content Article
    Christopher Collinson was admitted to the Medical Assessment Unit at Birmingham Heartlands Hospital with suspected deep vein thrombosis and pulmonary embolism. He was admitted at 1.28pm on 14 June 2021, but was not seen by a Doctor until 9.33pm. He was later prescribed a prophylactic dose of Enoxaparin, rather than the therapeutic dose which the doctor had intended to prescribe. He collapsed at 11.00pm suffering a cardiac arrest and could not be revived. He died at 2.14am on 15 June 2021.
  15. Content Article
    Healthcare workers have had the longest and most direct exposure to COVID-19 and consequently may suffer from poor mental health. Quintana-Domeque et al. conducted one of the first repeated multi-country analysis of the mental wellbeing of medical doctors at two timepoints during the COVID-19 pandemic to understand the prevalence of anxiety and depression, as well as associated risk factors. Rates of anxiety and depression were highest in Italy (24.6% and 20.1%, June 2020), second highest in Catalonia (15.9% and 17.4%, June 2020), and lowest in the UK (11.7% and 13.7%, June 2020). Across all countries, higher risk of anxiety and depression symptoms were found among women, individuals below 60 years old, those feeling vulnerable/exposed at work, and those reporting normal/below-normal health.
  16. Content Article
    This report by The Right Reverend James Jones KBE aims to provide an insight into what the bereaved Hillsborough families experienced in the years following the Hillsborough disaster in April 1989. It seeks to place their insight on the official public record in the hope that their suffering and experience will bring about changes to the way in which public institutions treat people who have been bereaved. It records family members' experiences of interacting with the authorities after the disaster and around the different inquests, and highlights 25 points of learning for public institutions.
  17. Content Article
    TCC-CASEMIX has created a unique infrastructure to provide total traceability of medical device performance. This infrastructure is supported by The Association of British HealthTech Industries [ABHI]. We refer to it as an 'Open Registry Infrastructure' for medical devices. It is 'open', because unlike existing clinically focused registries, which are 'closed', we enable wide searches across the registries connected into it. It is 'open' because registries will 'declare the content' (I don't know what I don't know, so how can I search for what I don't know?) Access to this infrastructure is through a Data Access Portal which is being configured for the specific needs of each stakeholder group. We are seeking interest from patient groups who would like to join an Advisory Board to help specify how data should be presented to patients in a way that is relevant and meaningful. Our vision is to link this portal into an enhanced pre-operative assessment process, and to transform patient informed consent. 
  18. Content Article
    This is a presentation given by the Quality and Safety Department at the Sussex Community NHS Foundation Trust to the Patient Safety Management Network on 22 October 2021. It provides an overview of how they have been developing the Trust’s approach to patient safety, focusing on safety culture, learning for improvement and aiming to raise the profile of patient safety within their organisation.
  19. Content Article
    In this blog for The BMJ Opinion, John Middleton argues that the Government must act now, or be faced with much tougher decisions and less popular choices as the winter kicks in. He describes the increasing rates of Covid-19 in the UK and the need for action to avoid a healthcare crisis this winter, highlighting that the NHS and the BMA have both called for urgent action to protect the NHS. He urges the Government to take a multi-faceted approach and use the 'Swiss Cheese' model to combat the spread of coronavirus, rather than focusing on single measures. Living with the virus involves changes to normal life, but they are a small price to pay to save lives, protect people from the long term effects of Covid and prevent the evolution of new virus strains.
  20. Content Article
    Diagnostic error occurs more frequently in the emergency department than in regular in-patient hospital care. This study in BMC Emergency Medicine sought to characterise the nature of reported diagnostic error in hospital emergency departments in England and Wales from 2013 to 2015. The authors identified the priority areas for intervention to reduce the occurrence of diagnostic error. The study found that system modifications are needed to support clinicians in assessing patients and interpreting investigations. Interventions to reduce diagnostic error need to be evaluated in the emergency department setting, and could include standardised checklists, structured reporting and technological investigation improvements.
  21. Content Article
    Variation in healthcare processes is widespread in mental health care and can lead to inefficient processes and unnecessarily long inpatient stays. This study in The British Journal of Healthcare Management aimed to identify sources of variation and introduce a huddle intervention to increase system efficiency on a psychiatric inpatient ward in London. The study found that huddles are a useful way to improve staff communication and increase ward efficiency without taking up a significant amount of clinicians' time.
  22. Content Article
    This blog sets out a timeline of the major landmarks for transvaginal surgical mesh since its first approval in 1996.
  23. Content Article
    The report of the Independent Inquiry into Inequalities in Health chaired by Sir Donald Acheson was published in 1998. The purpose of the inquiry was to inform the development of the government's public health strategy and to contribute to the forthcoming white paper, Our healthier nation. The report made a number of specific recommendations on a range of areas relating to health, environmental and social factors including: introducing health impact assessments for all policies that were likely to have a direct or indirect impact on health and health inequalities. appointing directors of public health in every health authority. placing a partnership duty on the NHS executive and regional government to ensure local partnerships between health and local government.
  24. Content Article
    Too often in healthcare, when effective solutions to prevent avoidable harm are found, there is a lack of means to share these more widely. This gap between learning and implementation means that while we may we know what improves patient safety, this information can often remain siloed in specific organisations and health care systems. This results in patients continuing to experience harm from problems that have already been addressed by others. This article published in the Journal of Patient Safety and Risk Management describes how the charity Patient Safety Learning created the hub, a platform to encourage and support shared learning for patient safety. Designed by and for patient safety professionals, clinicians and patients, the hub offers a powerful combination of tools, resources, stories, ideas, case studies and good practice to anyone who wants to make care safer for patients.
  25. Content Article
    The national Perinatal Mortality Review Tool (PMRT) was developed with clinicians and bereaved parents in 2017 and launched in England, Wales and Scotland in early 2018; it was subsequently adopted in Northern Ireland in autumn 2019. The aim of the PMRT programme is to support standardised perinatal mortality reviews across NHS maternity and neonatal units. Unlike other reviews or investigation processes, the PMRT makes it possible to review every baby death after 22 weeks’ gestation, and not just a subset of deaths. This report presents data from the 3,981 reviews which were completed between March 2020 and February 2021.
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