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News Article
Record number of 'foreign objects' left inside patients after surgical blunders
Patient Safety Learning posted a news article in News
A record number of "foreign objects" have been left inside patients' bodies after surgery, new data reveals. Incidents analysed by the PA news agency showed it happened a total of 291 times in 2021/22. Swabs and gauzes used during surgery or a procedure are one of the most common items left inside a patient, but surgical tools such as scalpels and drill bits have been found in some rare cases. A woman from east London described how she "lost hope" after part of a surgical blade was left inside her following an operation to remove her ovaries in 2016. The 49-year-old, who sp- Posted
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Content Article
Delphi study participants Participants were from the seven regions identified by NHS England. The study revisited several questions from round one to gather further knowledge and understanding of the responses received. The debrief was not undertaken due to all team members not being present, staff wanting to go home, current culture and list overruns. Key initial findings of Delphi study round two The second round facilitated a broader engagement in the literature, as well highlighting a number of reasons why full compliance has not yet been universally achieved. The Delphi study- Posted
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Postoperative patients were sampled from surgical wards at two large London teaching hospitals. Patients were shown two professionally produced videos, one demonstrating use of the WHO surgical safety checklist, and one demonstrating the equivalent periods of their operation before its introduction. Patients’ views of the checklist, its use in practice, and their involvement in safety improvement more generally were captured using a bespoke 19-item questionnaire. In total, 141 patients participated. Patients were positive towards the checklist, strongly agreeing that it would impact posit- Posted
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The World Health Organization (WHO) introduced the surgical safety checklist in 2009 after a successful trial in eight pilot countries; the term ‘Never Event’ has been in existence since 2001.[1] NHS England defines a Never Event as; “Serious incidents that are entirely preventable because guidance of safety recommendations providing strong systematic barriers are available at a national level and should have been implemented by all healthcare providers.” The current list of Never Events still only classes three reportable intra-operative ‘Never Events’: wrong site surgery, wrong imp- Posted
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News Article
Hardeep Singh, an informatics leader, patient safety advocate and innovator, and friend of the Jewish Healthcare Foundation (JHF), has been awarded the Individual Achievement Award in the 20th John M. Eisenberg Patient Safety and Quality Awards for demonstrating exceptional leadership and scholarship in patient safety and healthcare quality through his substantive lifetime body of work. The Joint Commission and National Quality Forum present Eisenberg Awards annually to recognise major achievements to improve patient safety and healthcare quality. Dr Singh, chief of the Health Policy- Posted
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How to use the checklist Identify a senior leader (e.g., chief quality officer, chief patient safety officer, chief medical officer, or other clinician with oversight of quality) in the organisation who can serve as the champion for learning and exploration of diagnostic excellence. Establish a multidisciplinary team of individuals from various clinical and non-clinical disciplines, including quality and safety, patient representatives, medical educators, and trainees. This team should meet regularly to review and analyse the current state of diagnostic safety and work toward impl -
Content Article
Human factors - Safer surgery checklist (June 2022)
Patient-Safety-Learning posted an article in Surgery
The article is found on pages 10-12 of the digital edition of the journal.- Posted
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ADRe is designed for use by nursing staff (NVQ level 3-5 or above), the professionals closest to patients. By using ADRe complex information on drugs is combined into a checklist providing advice on common problems. This helps nurses recognise and act on adverse drug reaction, including pain, dental pain, aggression, peptic ulcers, and sedation. In doing so, it greatly enhances the administration of medicines, and by capturing this individualised picture of the patients’ health and well-being prompts prescribers to refine dosages. ADRe is very simple to use: Nurses use the Profile- Posted
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News Article
Father calls for overhaul of 'flawed' suicide assessments
Patient Safety Learning posted a news article in News
A father whose son took his own life in July 2020 is calling for an "urgent overhaul" of the way some counsellors and therapists assess suicide risk. His son Tom had died a day after being judged "low risk", in a final counselling session, Philip Pirie said. A group of charities has written to the health secretary, saying the use of a checklist-type questionnaire to predict suicide risk is "fundamentally flawed". The government says it is now drawing up a new suicide-prevention strategy. According to the latest official data, 6,211 people in the UK killed themselves in 2020- Posted
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The campaign poster can be downloaded below and can be printed and displayed at bedsides and on notice boards.- Posted
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Patients must be warned of breast implant risks, FDA says
Patient Safety Learning posted a news article in News
A decade after scientists identified a link between certain implants and cancer, the US Food and Drug Administration has ordered “black box” warnings and a new checklist of risks for patients to review. Federal regulators have placed so-called black box warnings on breast implant packaging and told manufacturers to sell the devices only to health providers who review the potential risks with patients before surgery. Both the warnings and a new checklist that advises patients of the risks and side effects state that breast implants have been linked to a cancer of the immune system and- Posted
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What are the safety challenges of intubation? Intubation is a highly committing procedure. After we induce anaesthesia, our patient stops breathing, and we must rapidly secure the airway and establish ventilation in order to maintain oxygen levels. If oxygen levels drop major organs are rapidly unable to function, in particular the heart, which will stop within minutes. Particularly for our critically ill patients, forward planning and communication are crucial. Anaesthetic drugs and mechanical ventilation are life-saving, but do come at an immediate cost to the overall stability o- Posted
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Annual checks can lengthen life
Patient Safety Learning posted a news article in News
A group set-up following the Winterbourne View scandal is urging more people with learning disabilities to attend their annual health check-up. Healthwatch South Gloucestershire said regular health checks could prevent people from dying unnecessarily. It formed after BBC Panorama exposed abuse of patients at Winterbourne View hospital 10 years ago. Only about 36% of people with learning difficulties are believed to have an annual GP health check-up. The Local Democracy Reporting Service (LDRS). said the lack of regular, medical observations contributed to them having a life expe- Posted
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