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Showing results for tags 'protocols and procedures'.
Found 82 results
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Content ArticlePeople with kidney failure or chronic kidney disease, whose kidneys have stopped working properly, may need dialysis. This therapy takes over the normal function of the kidneys and removes waste products and excess fluid from the blood. Many people have regular dialysis in hospital, where fluids are filtered by a machine (haemodialysis). In peritoneal dialysis, often carried out at home, a catheter is inserted in the abdomen and left there permanently. A catheter can be inserted under general anaesthetic by a surgeon, or without a general anaesthetic by a physician using a needle (medical insertion). Medical insertions have become more common in recent years due to a lack of access to surgeons and theatre space; they have the advantage of being possible in people who are not well enough to have a general anaesthetic. However, evidence on the safety and efficacy of medical insertions is lacking. This study assessed the number of safety events following catheter insertions for peritoneal dialysis via the medical and surgical route. Researchers explored the reasons for choosing medical, versus surgical catheter insertions.
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News Article
ICB whistleblowing process ‘not fit for purpose’
Patient Safety Learning posted a news article in News
An integrated care board (ICB) has found its handling of whistleblowing “not fit for purpose”, after a complaint about safety incidents not being properly investigated. A report by North West London ICB, obtained by HSJ, states: “The whistleblowing policy is not fit for purpose and requires immediate updating. The [Freedom to Speak Up] Guardian has been left blank and the policy does not include key components of best practice.” It also found the “whistleblower should have been provided with a substantive response to their concerns within 28 days” but in fact waited 98 working days, “due to delays with starting the whistleblowing component of the grievance”. The ICB reviewed its processes after a complaint from a staff member who raised concerns early last year about “a lack of, or poor, response” to reported patient safety incidents in the system, which are meant to be routinely reviewed by ICBs “prior to closure”. Read full story (paywalled) Source: HSJ, 15 February 2024 -
Content ArticleAppropriate care escalation requires the detection and communication of in-hospital patient deterioration. Although deterioration in the ward environment is common, there continue to be patient deaths where problems escalating care have occurred. Learning from the everyday work of health care professionals (work-as-done) and identifying performance variability may provide a greater understanding of the escalation challenges and how they overcome these. The aims of this study from Ede et al. were to i) develop a representative model detailing escalation of care ii) identify performance variability that may negatively or positively affect this process and iii) examine linkages between steps in the escalation process.
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Content Article
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In a three-part series of blogs for the hub, Norman Macleod explores how systems behave and how the actions of humans and organisations increase risk. In part 1 of this blog series, Norman suggested that measuring safety is problematic because the inherent variability in any system is largely invisible. Unfortunately, what we call safety is largely a function of the risks arising from that variability. In this blog, Norman explores how error might offer a pointer to where we might look. -
Content ArticleThis is the protocol for a Campbell systematic review. The main aim of this systematic review was to identify whether hospital leadership styles predict patient safety as measured through several indicators over time. The second aim was to assess the extent to which the prediction of hospital leadership styles on patient safety indicators varies as a function of the leader's hierarchy level in the organisation.
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Community Post
Better use of data for medication safety in hospitals
Kenny Fraser posted a topic in Medicine management
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NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. I have just published a post about this challenge and Triscribe's solution. I would love to hear any comments or feedback on the topic... How could we use this information better? What are hospitals already doing? Where are the gaps? Thanks- Posted
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Content ArticleOutpatient and daycase hysteroscopy and polypectomy (OPHP) are widely recognised methods for the treatment of endometrial polyps. There have been concerns regarding pain affecting satisfaction and tolerability of the outpatient procedure. Dr Bhawana Purwar and colleagues from the Royal Wolverhampton Hospitals NHS Trust conducted a service evaluation of their outpatient hysteroscopy and polypectomy (OPHP) and compared it with their daycase procedures. They concluded that the OPHP is cost-effective and efficient method with reasonable acceptability. It is well tolerated with remarkable success rates and excellent patient satisfaction. As compared to daycase group, it requires less time for recovery and sooner returns to work.
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Content ArticleThis document outlines the standard operating procedure (SOP) adopted by University Hospitals Bristol NHS Foundation Trust, relating to parental involvement in escalation of clinical care for acutely ill children. It aims to clarify the process of empowering parents to escalate concerns if they are worried about the clinical condition and care being delivered to their child, or themselves if they are a patient. It also aims to ensure accurate and appropriate information is provided to parents on admission (elective and acute) regarding how they should escalate concerns about the care their child is receiving.
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Content ArticleThe variety of alarms from all types of medical devices has increased from 6 to 40 in the last three decades, with today’s most critically ill patients experiencing as many as 45 alarms per hour. Alarm fatigue has been identified as a critical safety issue for clinical staff that can lead to potentially dangerous delays or non-response to actionable alarms, resulting in serious patient injury and death. To date, most research on medical device alarms has focused on the nonactionable alarms of physiological monitoring devices. While there have been some reports in the literature related to drug library alerts during the infusion pump programming sequence, research related to the types and frequencies of actionable infusion pump alarms remains largely unexplored.
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News Article
Woman stored baby’s remains in fridge after London hospital refused them
Patient Safety Learning posted a news article in News
A London hospital has launched an investigation after a woman whose baby died in the womb had to deliver her son at home due to lack of beds and keep his remains in her fridge when A&E staff said they could not store them safely. Laura Brody and her partner, Lawrence, said they were “tipped into hell” after being sent home by university hospital Lewisham to await a bed when told their baby no longer had a heartbeat but no beds were immediately available to give birth, the BBC reported. Two days later, after waking up in severe pain, Brody, who was four months into her pregnancy, gave birth in agony on the toilet in their bathroom. “And it was then,” she told the broadcaster, “I saw it was a boy”. The couple, who wanted investigative tests to be carried out at a later time, dialled 999 but were told it was not an emergency. They wrapped their baby’s remains in a wet cloth, placed him in a Tupperware box, and went to A&E where they were told to wait in the general waiting room, they said. She was eventually taken into a bay and told she would require surgery to remove the placenta. But, with the waiting room hot and stuffy and staff refusing to store the remains or even look inside the Tupperware box, they decided as it got to midnight they had no option but for her partner to take their baby’s remains home. Brody said the whole experience “felt so grotesque”. “When things go wrong with pregnancy there are not the systems in place to help you, even with all the staff and their experts – and they are working really hard – the process is so flawed that it just felt like we had been tipped into hell,” she told Radio 4’s Today programme. The case is said to have raised wider concerns among campaigners who argue that miscarriage care needs to be properly prioritised within hospitals including A&E. Read full story Source: The Guardian, 30 May 2022 -
News Article
Hundreds of organisations breached patient data rules, reveals BMJ
Patient Safety Learning posted a news article in News
Hundreds of organisations, including drug companies, private healthcare providers and universities, have breached patient data sharing agreements but not had their access to patient data withdrawn, a report reveals. “High risk” breaches were revealed to have occurred at healthcare groups, pharmaceutical giants and educational institutions including Virgin Care, GlaxoSmithKline (GSK) and Imperial College London, during audits by NHS Digital, according to an investigation by the BMJ. This means these organisations were handling information outside the remit agreed in data contracts and may be failing to protect confidentiality, the journal said. In one instance, local NHS commissioners allowed sensitive, identifiable patient data to be released to Virgin Care without permission from NHS Digital. When auditors tried to get access to Virgin Care to check their compliance, they were denied access for several weeks and the company refused to delete the patient data, the BMJ reported. Records about mental health, including children and young people, those with learning disabilities, diagnostic imaging and other confidential patient data was being processed outside the scope of objectives agreed with NHS Digital, at an address that had not been agreed, and without a data sharing contract. A spokesperson for Virgin Care said it had “robust data protection in place”. “It is outrageous that private companies and university research teams are failing to comply,” said Kingsley Manning, the former chair of NHS Digital. “How is it that these organisations can be so lax with data?” Read full story Source: The Guardian, 11 May 2022 -
Content Article
Patient Safety Journal
Claire Cox posted an article in Suggest a useful website
The latest issue of the Patient Safety Journal is now out. US patient safety journal brought to you by the Patient Safety Authority, an independent agency of the Commonwealth of Pennsylvania. Each issue publishes original, peer-reviewed research and data analyses and also gives patients a voice. It's mission is to give clinicians, administrators and patients the information they need to prevent harm and improve safety. -
Content Article
NHS England: Our National Patient Safety Alerts
Patient-Safety-Learning posted an article in NHS England
This webpage provides links to all recent NHS England national Patient Safety Alerts and sets out the criteria for issuing a Patient Safety Alert. -
Content ArticleNHS healthcare providers are under constant pressure to make costs savings. There does not appear to be a way to account for the costs of errors, harms and inefficiencies in patient care. If we could account for these costs, then medium to long term plans could be created in order to reduce the costs lost in the consequences of errors, harm and delayed or low-quality care of patients. If we get ‘Care Correct First Time’ then these wasted costs will fall, which could well achieve the 5% savings target within 5 years. Dr Gordon Caldwell proposes a conceptual framework, which would account for these costs wasted on the consequences of error, harm or delays caused by opportunity costs in the inefficient way that frontline staff have to provide patient care.
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Content ArticleDouble-checking the administration of medications has been standard practice in paediatric hospitals around the world for decades, but there is little evidence of its effectiveness in reducing errors or harm. This study in BMJ Quality & Safety measures the association between double-checking and the occurrence and potential severity of medication administration errors. The authors found that: most nurses complied with mandated double-checking, but the process was rarely independent when not carried out independently, double-checking resulted in little difference to the occurrence and severity of errors compared with single-checking where double-checking was not mandated, but was performed, errors were less likely to occur and were less serious. They raise a question about whether the current approach to double-checking is a good use of time and resources, given the limited impact it has on medication administration errors.
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Content ArticleThe aim of the study was to create a core outcome set (COS), an agreed set of outcomes that could be measured, and report in all studies an evaluation of the introduction and evaluation of novel surgical techniques. The authors used data from several different sources such as innovation-specific literature, policy/regulatory body documents, and surgeon interviews. The results included 7,972 verbatim outcomes that were identified which were categorized into 32 domains. The researchers conclude the COS could be used to help encourage safer surgical innovation.
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Content ArticleThe use of graded exercise therapy and cognitive behavioural therapy for myalgic encephalomyelitis/chronic fatigue syndrome has attracted considerable controversy. This controversy relates not only to the disputed evidence for treatment efficacy but also to widespread reports from patients that graded exercise therapy, in particular, has caused them harm. The authors of this study surveyed the NHS–affiliated myalgic encephalomyelitis/chronic fatigue syndrome specialist clinics in England to assess how harms following treatment are detected and to examine how patients are warned about the potential for harms. The study found that clinics were highly inconsistent in their approaches to the issue of treatment-related harm. They placed little or no focus on the potential for treatment-related harm in their written information for patients and for staff. Furthermore, no clinic reported any cases of treatment-related harm, despite acknowledging that many patients dropped out of treatment. The authors recommend that clinics develop standardised protocols for anticipating, recording, and remedying harms, and that these protocols allow for therapies to be discontinued immediately whenever harm is identified.
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Content ArticleThis document describes how the Surveillance of Surgical Site Infection: Surgical Site Infection Surveillance Service aims to better patient care by asking hospitals to use data obtained from surveillance and compare rates of surgical site infections over time and against a benchmark rate. The aim is also to encourage the use of this information to help guide clinical practice.
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Content ArticleMeasuring a patient’s height is a routine part of a healthcare encounter. But once completed, how often is this information used? For most of us who fall within 95% of the mean population height, this metric is rarely discussed, but what happens when it is overlooked? And what about those on the outer tails of the bell curve of population distribution? Almost 1 million (909,222) adults in the United States are at least 6'4", more than the entire population of South Dakota (884,659). Conversely, an estimated 30,000 Americans have a form of dwarfism, typically defined as an adult height no taller than 4'10". However, despite this prevalence, the healthcare system struggles to provide consistent, adequate care for patients with extreme heights.
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Content Article
Preventing COVID-19 infections in care homes
Patient Safety Learning posted an article in Guidance
Government guidance on the changes to care home visits. -
News ArticleThe unlawful or inappropriate use of “do not attempt cardiopulmonary resuscitation” (DNACPR) orders by some clinicians risks undermining the care of terminally ill patients, almost 40 leading doctors, nurses and charities have warned. During the coronavirus pandemic repeated examples of unlawful decisions have emerged including widespread blanket orders on care home residents and patients with learning disabilities. Now the charity Compassion in Dying along with Marie Curie, Hospice UK and Sue Ryder, as well as more than 30 GPs, nurses and doctors, are warning more must be done to listen to patients and their families. In a joint statement, signed by more than 30 clinicians, they warn: “There have been examples of poor practice in relation to DNACPR decision-making during the pandemic, and the distressing impact this has had on patients and families cannot be underestimated. It is essential to thoroughly understand and learn from these cases to ensure that they do not happen again." “We are aware that the benefits of DNACPR decisions can be easily undone if they are not accompanied by honest, open and sensitive communication with a person’s healthcare team. To ensure that everybody who encounters a DNACPR discussion has a positive experience, we need to do more to listen to individuals and their families; their wishes must be sought and documented, their questions answered and their feelings acknowledged. “A DNACPR decision must always involve the person, or those close to them, and should be part of a wider conversation about what matters to that individual.” Read full story Source: The Independent, 8 March 2021
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Content ArticlePatient Safety Movement Foundation is joined in this video by Kourtney Wilson, Clinical Practice Consultant, Regional Patient Care Services, Maternal Child Health-Obstetrical Concentration, Kaiser Permanente, to discuss the need for standardised massive transfusion protocols in the context of postpartum haemorrhage (PPH) and the common barriers hospitals face in effectively establishing these protocols.
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Content Article
ECRI: Wrong-site surgery (14 December 2020)
Patient Safety Learning posted an article in Surgery
Wrong-site surgery is a broad, generic term that encompasses all surgical procedures performed on the wrong patient, the wrong body part, or the wrong side of the body; it can also describe performing the wrong procedure on, or performing on the wrong part of, a correctly identified anatomic site. This guidance from ECRI reviews the various types of wrong-site surgery; discusses the incidence, risk factors, and causes of wrong-site surgery; examines barriers to effective risk reduction; highlights Joint Commission’s elements of performance for the Universal Protocol and other accreditation and regulatory issues; and offers guidance for implementing strategies to prevent the occurrence of wrong-site surgery -
Content Article
Mölnlycke: SSI Risk Reduction Partnership
Patient Safety Learning posted an article in Surgery
Surgical Site Infections (SSIs) are a problem of increasing concern with major implications for both patients and the NHS. Between 2014 – 2019 SSIs, as a percentage of all healthcare associated infections, jumped from 16% 1 to 20%. It is a growing problem, in need of a solution. Mölnlycke has developed the Risk Reduction Partnership is a new initiative that has been specifically designed to combat the problem and potentially help reduce its incidence and impact. -
Content ArticleHealth information technology (HIT) provides many benefits, but also facilitates certain types of errors, such as wrong-patient errors in which one patient is mistaken for another. These errors can have serious patient safety consequences and there has been significant effort to mitigate the risk of these errors through national patient safety goals, in-depth research, and the development of safety toolkits. Nonetheless, these errors persist. Kim et al. analysed 1,189 patient safety event reports using a safety science and resilience engineering approach, which focuses on identifying processes to discover errors before they reach the patient so these processes can be expanded.They analysed the general care processes in which wrong-patient errors occurred, the clinical process step during which the error occurred and was discovered, and whether the error reached the patient. For those errors that reached the patient, they analysed the impact on the patient, and for those that did not reach the patient, they analysed how the error was caught.
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