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Found 54 results
  1. Content Article
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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
  3. News Article
    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
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    On a ward round in 2005 I was about to send home a man who had been successfully treated for pneumonia with intravenous antibiotics. He asked me what was wrong with his left arm. When I looked he had an obvious infection around the intravenous cannula with signs of the infection spreading up the vein. He had been treated with intravenous antibiotics which had been changed to oral 3 days earlier. At that point the cannula should have been removed. It turned out that the infection was caused by MRSA and he required a further 2 weeks of intravenous antibiotics to eradicate the infection. I p
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    The Care Quality Commission has ordered immediate improvements to a trust after it reported six never events inside eight months. The watchdog has issued a warning notice to Royal Cornwall Hospitals Trust after it carried out an announced inspection which focused on the trust’s surgical care group – where six never events had occurred between February and October last year. In November, HSJ reported that a total of eight never events had been recorded in 2020, with trust chief executive Kate Shields saying it had raised fears the trust had not fully embedded safety improvements initi
  13. Community Post
    Overview Human error (HE) in global medicine kills 2.6 million annually placing patient safety on the G20 Summit (1). Solutions available (a) more staff training dominated by a HE-rate of about one error in 200 tasks and (b) a simple computer system used by high reliability organisations such as Banking with zero HE. With 70% of adverse events occurring on wards, patients should electronically acknowledge each intervention with their wristband-data. Missed interventions now detectable are compellingly alarmed reducing the consequences of HE 10,000 fold. Problem: The Healthcare s
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    The anaesthetist has a primary responsibility to understand the function of the anaesthetic equipment and check it before use. Anaesthetists should not use equipment unless they have been trained in its use and are competent to do so. A self-inflating bag should be immediately available in any location where anaesthesia is given. A two-bag test should be performed after the breathing system, vaporisers and ventilator have been individually checked. A record should be kept with the anaesthetic machine that these checks have been carried out. The ‘first user’ check, after servicing, is especiall
  19. Content Article
    Recently Dr Peter Brennan tweeted a video of a plane landing at Heathrow airport during Storm Dennis. I looked at this with emotion, and with hundreds of in-flight safety information, human factors, communication and interpersonal skills running through my head. I thought of the pilot and his crew, the cabin crew attendants and the passengers, and how scared and worried they would have felt. On a flight, the attendants will take us through the safety procedures before take off. We are all guilty, I am sure, of partly listening because it is routine and we have heard it all before. Then s
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    In this book, Atul Gawande makes a compelling argument for the checklist, which he believes to be the most promising method available in surmounting failure. Whether you're following a recipe, investing millions of dollars in a company or building a skyscraper, the checklist is an essential tool in virtually every area of our lives and Gawande explains how breaking down complex, high pressure tasks into small steps can radically improve everything from airline safety to heart surgery survival rates.
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    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
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