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Found 99 results
  1. Content Article
    This improvement initiative featured in the Journal of Patient Safety aimed to examine whether the independent double check (IDC) during administration of high alert medications resulted in improved patient safety when compared with a single check process. The authors found that IDC had no impact on reported medication events compared with single checking.
  2. Content Article
    Nurses play a significant role during transitions of care, such as discharge from inpatient care to the home. Findings from this systematic review of 15 studies confirm the role of nurses in ensuring high-quality care and patient safety in pediatric inpatient care. The review identified five essential elements that could be used in a checklist to ensure safe discharge to home – emergency management, physiological needs, medical device and medications management, and short-term and long-term management.
  3. Content Article
    Patient harm, patient safety and their governance have been ongoing concerns for policymakers, care providers and the public. In response to high rates of adverse events/medical errors, the World Health Organization (WHO) advocated the use of surgical safety checklists (SSC) to improve safety in surgical care. Canadian health authorities subsequently made SSC use a mandatory organisational practice, with public reporting of safety indicators for compliance tied to pre-existing legislation and to reimbursements for surgical procedures. Perceived as the antidote for socio-technical issues in operating rooms (ORs), much of the SSC-related research has focused on assessing clinical and economic effectiveness, worker perceptions, attitudes and barriers to implementation. Suboptimal outcomes are attributed to implementations that ignored contexts. Using ethnographic data from a study of SSC at an urban teaching hospital (C&C), a critical lens and the concepts of ritual and ceremony, this paper examinse how it is used, and theorise the nature and implications of that use. Two rituals, one improvised and one scripted, comprised C&C’s SSC ceremony. Improvised performances produced dislocations that were ameliorated by scripted verification practices. This ceremony produced causally opaque links to patient safety goals and reproduced OR/medical culture. We discuss the theoretical contributions of the study and the implications for patient safety.
  4. Content Article
    Doctors At Work is a series of video podcasts hosted by Dr Mat Daniel. In this episode, Dr Gordon Caldwell shares his experiences of managing and preventing adverse events. He stresses the importance of creating a culture that encourages everyone to speak up. His top tips for preventing errors is to create systems, checklists and routines that ensure a focus on all aspects of care not just the obvious and urgent.
  5. Content Article
    This tool is based on the Surgical Safety Checklist developed by the World Health Organization (WHO) in 2009. It should be used at three key transitions in care: Before anaesthesia is given Immediately prior to incision Before the patient is taken out of the operating room The checklist is not intended to be comprehensive, and additions and modifications to fit local practice are encouraged.
  6. Content Article
    In a report published in 2000 by the UK's Chief Medical Officer, it was estimated that 400 people in the UK die or are seriously injured each year in adverse events involving medical devices, and that harm to patients arising from medical errors occurs in around 10% of admissions—or at a rate in excess of 850 000 per year. The cost to the NHS in additional hospital stays alone is estimated at around £2 billion a year. This article examines system safety in healthcare and suggests a 20-item checklist for assessing institutional resilience (CAIR).
  7. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Gordon talks to us about how bureaucracy in the health service can compromise patient safety, the vital importance of agreed quality standards and what hillwalking has taught him about healthcare safety.
  8. Content Article
    Commercial aviation practices, including the role of the pilot monitoring, the sterile flight deck rule, and computerised checklists, have direct applicability to anaesthesia care. Checklists are commonly used in the operating room, especially the World Health Organization surgical safety checklist. However, the use of aviation-style computerised checklists offers additional benefits. In this editorial, Jelacic et al. discuss how these commercial aviation practices may be applied in the operating room.
  9. Content Article
    Watch this World Patient Safety Day webinar with Nigel Roberts on enhancing patient safety and surgical outcomes with the surgical safety checklist.
  10. Content Article
    Dr Kristin Harris, Research Fellow in the Department of Anaesthesia and Critical Care at Haukeland University Hospital, Bergen, Norway, discusses why patient safety patient involvement personally matters to her and talks about the tool she's currently working on, which are safety checklists specific to surgical patients.
  11. Content Article
    This checklist has been developed by the Alzheimer’s Society to allow patients to check symptoms that could be a possible sign of dementia. Endorsed by the Royal College of General Practitioners (RCGP), it is a simple tool to help patients and their families clearly communicate their symptoms and concerns to a GP or other healthcare professional. It is not a diagnostic tool, but aims to provide a basis for helpful conversations.
  12. Content Article
    Most healthcare organisations (HCOs) find diagnostic errors hard to address. Singh et al. developed a checklist (the Safer Dx Checklist) of 10 high-priority safety practices HCOs can use to conduct a proactive risk assessment to address diagnostic error.
  13. News Article
    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. It is the most common cause of death in 20-34-year-olds. And of the 17 people each day, on average, who kill themselves, five are in touch with mental health services and four of those five are assessed as "low" or "no risk", campaigners say. Tom Pirie, a young teacher from Fulham, west London, had been receiving help for mental-health issues. He had repeatedly told counsellors about his suicidal thoughts - but the day before he had killed himself, a psychotherapist had judged him low risk, his father said. Tom's assessment had been based on "inadequate" questionnaires widely used despite guidelines saying they should not be to predict suicidal behaviour, Philip said. The checklists, which differ depending on the clinicians and NHS trusts involved, typically ask patients questions about their mental health, such as "Do you have suicidal thoughts?" or "Do you have suicidal intentions?" At the end of the session, a score can be generated - placing the individual at low, medium or high risk of suicide, or rating the danger on a scale between 1 and 10. Read full story Source: BBC News, 20 April 2022
  14. 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, Quality & Informatics Program in the Center for Innovations in Quality, Effectiveness and Safety at Michael E. DeBakey VA Medical Center and professor at Baylor College of Medicine, was recognised for his pioneering career in diagnostic and health IT safety and his commitment to translating his research into pragmatic tools, strategies, and innovations for improving patient safety. His commitment to improving patient safety began while pursuing his Master of Public Health at the Medical College of Wisconsin in 2002 when he first learned the field of patient safety existed. That commitment was galvanised early in his medical career, as he found himself treating patients who had been misdiagnosed, received unsafe care, or experienced poor outcomes. The breadth and depth of Dr Singh's research work is remarkable, but what is most notable is the extent to which he has succeeded in translating it into pragmatic strategies and innovations for improving patient safety. Dr. Singh emphasised that while the Eisenberg Award recognizes an individual for their achievements, his work in patient safety has been successful because of its multi-disciplinary and collaborative approach with psychologists, human factors engineers, social scientists, informaticians, patients, and more. That work has led to the development of several tools to improve patient safety, including The Safer Dx Checklist, which helps organizations perform proactive self-assessment on where they stand in terms of diagnostic safety. "As an immigrant and an international medical graduate, I have had a lifelong dream to make an impact on health care. I saw every scientific project as an opportunity to change health care. So, I made a personal commitment that my research must use a pragmatic, real-world improvement lens and challenge the status quo in quality and safety," Dr. Singh said. Read full story Source: Jewish Healthcare Foundation News, 31 August 2022
  15. News Article
    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 spoke to PA on condition of anonymity, said: "When I woke up, I felt something in my belly. "The knife they used to cut me broke, and they left a part in my belly." She added: "I was weak, I lost so much blood, I was in pain, all I could do was cry." The object was left inside her for five days, leading to an additional two-week hospital stay. Commenting on the analysis, Rachel Power, chief executive of the Patients Association, said: "Never events are called that because they are serious incidents that are entirely preventable because the hospital or clinic has systems in place to prevent them happening. "When they occur, the serious physical and psychological effects they cause can stay with a patient for the rest of their lives, and that should never happen to anyone who seeks treatment from the NHS. "While we fully appreciate the crisis facing the NHS, never events simply should not occur if the preventative measures are implemented." Read full story Source: Sky News, 4 January 2022
  16. Content Article
    In this BMJ opinion piece, Scarlett McNally discusses the revised National Safety Standards for Invasive Procedures (NatSSIP2). The original NatSSIPs were designed to prevent “never events”—yet more than 300 occurrences of wrong site surgery, retained objects after procedure, or wrong implant insertion still occur yearly in the UK.  NatSSIP2 brings in safety science and human factors, with expectations for organisations including standardisation, harmonisation, training, and audit. "The biggest danger is if the new standards sit on the shelf. With their benefits for patient safety and teamworking, we must accept the repetitive elements and consistently apply these new standards, every time, in every department", writes Scarlett.
  17. Content Article
    These prompt cards were developed by a team at University Hospitals Sussex NHS Foundation Trust to assist emergency department teams in dealing with: medical emergencies trauma transfers and briefings anaesthetics and resuscitation procedures medications clinical scores.
  18. Content Article
    It is difficult to monitor compliance to surgical checklists, which is associated with improved patient outcomes. This research study in The Annals of Surgery reported for the first time on the use of the Operating Room Black Box (ORBB) to track checklist compliance, engagement, and quality. The authors took a retrospective review of prospectively collected ORBB data and measures of checklist compliance, engagement and quality were assessed. ORBB provides the unprecedented ability to assess not only compliance with surgical safety checklists but also engagement and quality. This technology allows the assessment of compliance in near real time and to accurately address safety threats that may arise from noncompliance.
  19. Content Article
    This paper asked healthcare workers who are considered to be theatre safety experts—theatre managers, matrons and clinical educators—to take part in the second round of a Delphi study. These individuals work at the coalface in operating theatres and deliver the surgical safety checklist daily. It addresses information raised as part of a Delphi study of NHS hospital operating theatres in England. The aim of the second Delphi study round was to establish the views of theatre users on the theatre checklist and local safety standards for invasive procedures. Likert scale responses and a combination of closed and open-ended questions solicited specific information about current practice and researched literature that generated ideas and allowed participants freedom in their responses of how the World Health Organisation’s (WHO's) Surgical Safety Checklist (SSC) is currently being used in the peri-operative setting as part of a strategy to reduce surgical ‘never events’. The paper is part of a literature review undertaken by the author towards a Doctor of Philosophy (PhD). Read the findings of round one of the Delphi study
  20. Content Article
    Standard operating procedures (SOPs) should improve safety in the operating theatre, but controlled studies evaluating the effect of staff-led implementation are needed. Morgan et al. evaluated three team process measures (compliance with WHO surgical safety checklist, non-technical skills and technical performance) and three clinical outcome measures (length of hospital stay, complications and readmissions) before and after a 3-month staff-led development of SOPs.  They found that SOPs when developed and introduced by frontline staff do not necessarily improve operative processes or outcomes. The inherent tension in improvement work between giving staff ownership of improvement and maintaining control of direction needs to be managed, to ensure staff are engaged but invest energy in appropriate change.
  21. Content Article
    Traditional approaches to patient safety and handoffs need redesigning to acknowledge the different constraints, goals, and requirements necessary for each individual patient. There is no “one size fits all” approach to patient safety, handoffs or a perfect checklist. Despite the inherit complexity present in healthcare systems, we tend to reduce our thinking about handoffs into simple solutions of checklists and cognitive aids. In studies of these tools, their association with patient outcomes is unclear with mixed results in large studies. Incorporating general resilience engineering principles of visibility, understanding, anticipation, and learning provides new opportunities for increased patient safety. This involves situating the handoff in the context of the system - understanding the process of summarising pre-handoff and of developing understanding post-handoff, tracing flows of information and patients, and considering the role of feedback and control loops in the system. Direct observations, analysis of multiple outcomes, focus on patient evolving specific exceptions, reducing the number of handoffs, taking time for two-way discussions, and user-centred design and redesign may promote acceptability and sustainability of a new view of handoffs for improved patient safety.
  22. Content Article
    This NatSSIPs 8 flow chart illustrates the sequential standards in the National Safety Standards for Invasive Procedures 2 combined with the World Health Organization (WHO) surgical safety checklist.
  23. Content Article
    The purpose of this assessment is to ensure that all Theatre Practitioners are fully compliant with current Trust Policy with regard to swabs, instruments, sharps and disposables items. All Theatre staff must be assessed and deemed competent.
  24. Content Article
    The Centre for Perioperative Care (CPOC) has published new safety standards (NatSSIPs2) to enable all hospitals in the UK to improve patient safety by applying a consistent and proportionate set of safety checks for all invasive procedures. Listen to the podcast from the Royal College of Anaesthetists on the new standards.
  25. News Article
    Early warning scores are used in the NHS to identify patients in acute care whose health is deteriorating, but medics say it could actually be putting people in danger. The rollout of an early warning system used in hospitals to identify patients at the greatest risk of dying is based on flawed evidence, according to a study published in the BMJ which suggests that much of the research supporting the rollout of NEWS was biased and overly reliant on scores that could put patients at greater risk.. Medical researchers said problems with NHS England's National Early Warning Scores (NEWS) system had emerged "frequently" in reports on avoidable deaths. The system sees each patient given an overall score based on a number of vital signs such as heart rate, oxygen levels, blood pressure and level of consciousness. Doctors and nurses can then prioritise patients with the most urgent NEWS scores. But some professionals have argued that the system has reduced nursing duties to a checklist of tasks rather than a process of providing overall clinical assessment. Professor Alison Leary, a fellow of the Royal College of Nursing and chair of healthcare and workforce modelling at London South Bank University, told The Independent: “In our analysis of prevention of future death reports from coroners, early warning scores and misunderstanding around their use feature frequently". “It's clear that some organisations use scoring systems and a more tick box approach to care as they lack the right amount of appropriately skilled staff, mostly registered nurses.” “Early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care,” the authors of the research conclude. “Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice.” Read full story Source: The Independent, 21 May 2020
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