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Showing results for tags 'protocols and procedures'.
Found 83 results
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Content ArticleMedicines reconciliation and medication reviews play an integral part in medicine optimisation. Medicines reconciliation is the process of accurately listing a person’s medicines. This could be when they're admitted into a service or when their treatment changes. It involves recording a current list of medicines, including over-the-counter and complementary medicines. Then, the list is compared with the medicines the person is actually using. It involves recognising and resolving any discrepancies and documenting any changes. The medicines reconciliation process will vary depending on the care setting that the person has moved into (or from). Trained and competent staff should carry out the medicines reconciliation. They should consult with a health professional. Ideally, this should be the person’s GP, nurse or pharmacist.
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Letter from America: a Fall tradition to learn from
lzipperer posted an article in Letter from America
‘Letter from America’ is a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. The series will cover successes large and small. I share them here to generate conversations through the hub, over a coffee and in staff rooms to transfer these innovations to the frontline of UK care delivery. -
Content ArticleWhen patients are harmed as a result of the care they receive through Alberta Health Services (AHS), the organisation has a responsibility to understand how the harm happened and, where appropriate, respond to improve the healthcare system. This handbook has been developed to assist and support AHS staff and medical staff to retrospectively review clinical adverse events, hazards and close calls using Systems Analysis Methodologies (SAM). It is not an administrative review of individual healthcare provider performance. Using these methodologies, the complex interactions of all the components within the health system are considered, not the individual contributions of healthcare providers that have or may have led to harm. This creates opportunities to identify vulnerabilities in structures, processes and practices that can be improved and ultimately make care safer.
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Content ArticleOperating theatre fires remain an uncommon but real safety risk for patients undergoing nearly all types of procedures, and despite ongoing safety initiatives, occur more commonly than wrong-site surgeries. One of the most compelling cases for safety improvement in the surgical setting is within this area. Combining the simple steps of operating theatre team education; improving lines of communication between surgeons, anaesthetists, and operating theatre nurses or practitioners; and the deliberate separation of the elements of the fire triangle can almost completely eliminate the incidence of surgical fires. In this brief review, Cowles Jr and Culp Jr hope that readers will be able to reduce the risk of surgical fires effectively by the application of the safety principles described.
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Safer outcomes for people with psychosis
Dorit posted an article in By patients and public
Dorit describes the assessment and subsequent death of her much loved daughter-in-law who died during a psychotic episode having been discharged the previous evening. Her story raises a number of questions: How should families be included in making judgements and assessments about the patient and their well-being? What support do they need to care for a very distressed loved one? Why aren't written care and contingency plans provided to the patient and their family? What more needs to be done to ensure standard practices are in place to protect patients with psychosis? -
Content ArticleIn 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.
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Content ArticleThe National Institute for Healthcare Research (NIHR) are the nation's largest funder of health and care research and provide the people, facilities and technology that enables research to thrive. Working in partnership with the NHS, universities, local government, other research funders, patients and the public, they deliver and enable world-class research that transforms people's lives, promotes economic growth and advances science.
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Content ArticleThe Canterbury Renal Unit is situated at Kent and Canterbury Hospital and provides renal services for the East Kent, Medway and Maidstone areas. There are currently 680 transplant patients currently being followed up. There have been a number of immunosuppression related prescribing errors in the surrounding hospitals. Indeed, one such error occurred in the renal unit itself, when a transplant patient had prednisolone inadvertently withheld resulting in rejection of the kidney. Thus, a group of 12 transplant patients attended a co-production group to discuss the problems and potential solutions.
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Content ArticleEach quarter, the Patient Safety Movement Foundation hosts a free webinar on a variety of central patient safety topics aligned with their Actionable Patient Safety Solutions (APSS). This session addressed airway safety. It's focus was on how existing, high-impact solutions can be planned to reduce unplanned extubation. The presentation was given by Dr. Art Kanowitz.
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Content ArticleThis note provides guidance to those who may be approached to give evidence as a witness if you were involved in providing care and treatment to a claimant on behalf of a Trust.
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Content ArticleThis guidance by NHS Resolution, aims to provide advice for commissioners seeking to ensure that providers with which they are proposing to contract have in place adequate indemnity arrangements. Commissioners need to understand and take account of the differences in cover for clinical negligence risks purchased by healthcare organisations. Commissioners have an important role to play in ensuring that providers possess adequate indemnity. Crucially, they need to understand that in certain circumstances they will have to take over directly the liabilities of providers.
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Content ArticleThis short video describes how the staff at NHS Imperial College Healthcare are at the heart of patient safety and showcases some of the achievements of their teams in improving patient safety.
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NHS Improvement: Elective care pathway analyser (updated 10 April 2019)
Claire Cox posted an article in Processes
NHS Improvement has devised an elective care pathway analyser tool which will support critical review of any clinical pathway (including administrative and process steps) across all types of elective pathway, including referral to treatment (RTT), diagnostics and cancer, and help identify high impact interventions. -
Content ArticleMany types of audits are commonly used in hospital care to promote quality improvements. However, the evidence on the effectiveness of audits is mixed. The objectives of this review from Gans et al. is (1) to understand how and why audits might, or might not, work in terms of delivering the intended outcome of improved quality of hospital care and (2) to examine under what circumstances audits could potentially be effective.
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Content ArticleThe South West Patient Safety Collaborative has introduced a validated assessment tool for safety culture in England, using a survey called SCORE (safety, communication, operational risk, resilience and reliability, and engagement). As part of the ‘Safer Culture, Better Care’ programme, this anonymous survey gives individuals and teams a fresh perspective on their current patient safety culture. Over 10,000 staff in 122 teams have taken part in the programme, leading to improved patient safety and new ways of working.
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Content ArticleThis quick guide from the NHS explains what to expect if you need to stay in hospital for a period of time.
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Content ArticleNational safety standards for invasive procedures (NatSSIPs), published by NHS England in 2015, recommend the creation and implementation of local safety standards for all invasive procedures. This includes procedures undertaken outside a hospital environment, such as surgical procedures undertaken by dentists. In order to implement a local safety standard for invasive procedures (LocSSIP) for oral surgery procedures at a large London teaching hospital, a clean sheet redesign of our service was carried out based on a bottom up model of transformation, using a 'diagnose, design and implement' strategy. In an article published in the British Dental Journal, three lead consultants in oral surgery based at Kings College, London, discuss creating local safety standards for invasive procedures.
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Content ArticlePublished in HSJ, Annie Laverty, Chief Experience Officer, Northumbria Healthcare Foundation Trust, speaks to Jeremy Taylor, former CEO of patient group National Voices, on the work her and the trust has done on patient experience, her motivation and the impact it has had.
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Content ArticleThe Tavistock and Portman NHS Foundation Trust has produced this policy to aid patient safety and risk managers to investigate serious incidents with in their Trust.
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Content ArticleRichard 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.
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Content ArticleThis review by Van Velthoven et al, published in BMJ Open, provides a systematic overview of standards for the development of health apps based on those for software of medical devices and clinical information systems.
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Patient safety and quality - NHS Leeds Clinical Commissioning Group
Claire Cox posted an article in CCGs
This web page describes how NHS Leeds monitors safety and quality. -
Content ArticleChapter 28 of this book covers The Impact of Facility Design on Patient Safety.
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Content ArticleNHS Improvement have published a number of case studies on appropriate use of clinical risk assessment tools, developing new evidence-based alerting systems and developing personalised risk management plans for people who use services, to manage risks positively.
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Content ArticleThis decision tree, used at the Brighton and Sussex University Hospitals NHS Trust, was developed as a ‘quick reference’ aid for nurses setting up non-invasive ventilation (NIV). It highlights key settings and signposts users to the full trust policy for more detailed explanation. It is adapted from the British Thoracic Society guidelines for acute NIV.
