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Found 52 results
  1. Content Article
    Let’s imagine that you’re in your early 70s and you have a few chronic health problems. Your mobility has been getting worse due to arthritis in your hip. You’ve tried pain killers, had some physiotherapy and now use a stick but the pain and restriction in your function is getting you down. Your GP refers you to your local hospital to see an orthopaedic surgeon to discuss surgery. How do you know if having surgery is the right decision for you? On the face of it the decision may seem easy; have the surgery to cure the problem. Indeed many, or even most of us, would choose this option to be rid of the pain. What, however, about the short- and long-term risks of surgery? We know that with increasing age, and in particular with increasing number of chronic health problems, the medical risks associated with surgery increase. That is to say, the surgical procedure, the hip replacement itself, may go smoothly but the overall process of surgery, anaesthesia and hospitalisation may make existing medical problems worse or create new ones. This is a situation that hundreds of older people face each week in the UK, and as the population ages and advances in medicine and surgery increase, will become even more common. However, quantifying these risks has been a major challenge for researchers to date. The Optimising Shared Decision Making In high RIsk Surgery (OSIRIS) research programme is funded by the National Institute of Health Research (NIHR). We’re focussing on the group of older patients who often have significant chronic health issues and are at greater risk of complications around and after surgery. We’re asking some big questions about how these patients and their doctors currently make decisions about major surgery and how we could improve that process. We are also looking at the data on over 5 million patients to truly understand what happens to older patients in the year after surgery. This will then allow us to develop a tool to forecast and present risks associated with surgery. This will be tested in a trial across UK hospitals, to see if it improves the decisions people make. Presenting a more detailed risk forecast to patients will help them to understand how the choice about surgery may specifically impact them and their lives and so support genuine shared decision-making. Surgery improves the lives of millions of people a year around the world, but it is not without risks and patients and doctors need to be more aware of these and be able to discuss them openly. The outputs of the OSIRIS research programme will help increase that awareness and allow people to make informed decisions where all the risks can be weighed up against all the benefits. Shared decision making and informed consent are hot topics right now in the health care professions and in the media. We’re 2 years into our 6-year research programme and we already know so much more about the decision-making process and how we might improve this. Ultimately, doctors need access to better, more individualised information and patients need to be presented this information in a way that is clear and comprehensible. We are very hopeful that OSIRIS will provide a model to empower patients to make a major decision that is right for them. Watch this space! You can find out more about the research by visiting the OSIRIS Programme website or following @osirisprogramme on Twitter. If you'd like to share your thoughts on any of the issues raised in the blog or another patient safety topic, please get in touch with Patient Safety Learning by emailing content@pslhub.org or leave a comment below.
  2. Content Article
    Key findings Fear of catching and becoming seriously ill with COVID-19 outweighed concerns about respondents’ existing health conditions. Around 1 in 3 people said they had delayed healthcare and this was broadly consistent across all conditions. This rose to 2 in 5 for people with diabetes, lung disease and mental health conditions. People had switched to home therapy, delayed starting new treatments, avoided routine medication monitoring or self- managed. Some felt their health had deteriorated while they waited for the pandemic to abate.
  3. News Article
    High-risk women at a maternity unit were not monitored closely enough and there was a "lack of learning" from a mother's death, inspectors found. A Care Qualtiy Commission (CQC) report rated the unit at Basildon University Hospital as inadequate with "failings" found in six other serious cases. Inspectors carried out unannounced checks in June after a whistleblower voiced fears about patient safety. The unit was criticised following the deaths of baby Ennis Pecaku in September 2018 and mother Gabriela Pintilie, 36, in February 2019. The CQC previously carried out an inspection of the department the month Mrs Pintilie died and said the unit, which had once been rated outstanding, required improvement. Inspectors returned for the surprise "focused" inspection after being contacted by an anonymous whistleblower. The report found babies were born in a poor condition and then transferred for cooling therapy, which can be offered for newborn babies with brain injury caused by oxygen shortage during birth. During their visit, inspectors found: High-risk women giving birth in a low-risk area. Not enough staff with the right skills and experience. "Dysfunctional" working between midwives, doctors and consultants, which had an impact on the "increased number of safety incidents reported". Concerns over foetal heart monitoring. Women being referred to by room numbers instead of their names. A "lack of response by consultants to emergencies" resulting in delays The CQC also referred to issues relating to the death of Mrs Pintilie, who was not named in the report, and said five serious incidents "identified the same failings of care". Read full story Source: BBC News, 18 August 2020 "This demonstrated there had been a lack of learning from previous incidents and actions put in place were not embedded."
  4. Content Article
    Between April 2008 to March 2017, procedure data from the UK NHS confirmed that 100,516 patients had a mid-urethral tape procedure, while only 1195 patients had a non-tape SUI procedure. Although the 2013 national guideline from The National Institute for Health and Care Excellence (NICE) recommended that tape and non-tape SUI procedures be offered equally, 84 mesh tape procedures were performed for every 1 non-tape procedure over the 10-year period. Hundreds of patients recently engaged in litigation on the basis of lack of informed consent, particularly in offering alternatives to the mesh tape option. Little is known, however, about how patients choose among different treatment options for SUI and there are no validated patient decision aids (PDAs) in this context. PDAs have been shown to increase patient knowledge, clarity about their own values and accuracy of risk perceptions regarding various management options. Women considering SUI surgery require up-to-date information on all common and available surgical procedures as well as support in their decision-making, tailored to their values and needs. Agur et al. on behalf of the NHS Ayrshire & Arran Continence Multidisciplinary Team designed and developed a novel SUI surgery patient decision aid (SUI-PDA) to help women in making a choice of treatment based on their own individual values. This study reports the development and validation of SUI-PDA as well as the initial evaluation of its usefulness in clinical practice for women considering SUI surgery.
  5. Content Article
    This document outlines ten key guidance points that designers of procedures should address at all stages of its development, implementation and review: 1. What is a work procedure? 2. Ensure a procedure is needed 3. Involve the whole team 4. Identify the hazards 5. Capture work-as-done 6. Make it easy to follow 7. Test it out 8. Train people 9. Put it into practice 10. Keep it under review. An explanation of the discipline of Human Factors and Ergonomics (HFE) and the sub-discipline of human-centred design are also provided.
  6. Content Article
    During my many years of working in operating theatres, I observed that hydrogen peroxide was adopted by surgeons as a ritual for washing out wounds and deep cavities. An entire bottle of 200 ml hydrogen peroxide was mixed with 200 ml of normal saline. It seems this ritual was passed down from consultant to trainee and it then became a habit. In a recent post on the hub, I mentioned that women in 1920 were given Lysol as a disinfectant to preserve their feminity and maritial bliss! Lysol contains hydrogen peroxide, so women were daily irrigating their vaginas with a harmful solution of fizz, unaware of the hazards. I believe it is still being used to colour hair, remove blood stains, as a mouthwash gargle and also to whiten teeth. Then suddenly a breakthrough! In 2014, in my email inbox, a yellow sticker warning appeared from the Medicines and Healthcare products Regulatory Agency (MHRA) regarding the use of hydrogen peroxide in deep cavities. So why did the MHRA ban the use of hydrogen peroxide in deep cavities? Hydrogen peroxide is contraindicated for use in closed body cavities or on deep or large wounds due to the risk of gas embolism. Hydrogen peroxide breaks down rapidly to water and oxygen on contact with tissues. If this reaction occurs in an enclosed space, the large amount of oxygen produced can cause gas embolism.[1] There has been several case reports that have been published from around the world of life threatening or fatal gas embolism with use of hydrogen peroxide in surgery, of which five were from the UK. Most of the global reports describe cardiorespiratory collapse occurring within seconds to minutes of instillation of hydrogen peroxide as wound irrigation or when used to soak swabs for wound packing. This was sometimes accompanied by features associated with excess gas generation such as surgical emphysema, pneumocephalus, aspiration of gas from central venous lines, or the presence of gas bubbles on transoesophageal echocardiography. Non-fatal events were sometimes associated with permanent neurological damage such as neuro-vegetative state and hypoxic encephalopathy.[1] As the Practice Development Lead for the theatre department where I worked it was my role to pass on and act on the information received from the MHRA, so I discussed it with my very supportive theatre manager and then escalated to the theatre staff. But some consultants still ask for it today; it is always refused. So why do consultants request it when they are aware of the hazards? One theatre never event describes a syringe of hydrogen peroxide given to a consultant and injected into a joint instead of the required local anaesthetic![2] The patient survived but required care in the intensive care unit. As a scrub nurse practitioner this scares me. What about you? Would you now research this yellow sticker alert further, implement best practice and speak up, or would you just keep quiet and go "with the flow?" We all make mistakes, but learning from our errors will always be the ultimate key to improvement in healthcare and best practice and safety for our patients. References 1. Medicines and Healthcare products Regulatory Agency. Hydrogen peroxide: reminder of risk of gas embolism when used in surgery. 19 December 2014. 2. Chung J and Jeong M. Oxygen embolism caused by accidental subcutaneous injection of hydrogen peroxide during orthopedic surgery. A case report. Medicine (Baltimore) 2017; 96(43): e8342.
  7. Content Article
    ECRI’s list of patient safety concerns for 2020: 1. Missed and delayed diagnoses—Diagnostic errors are very common. Missed and delayed diagnoses can result in patient suffering, adverse outcomes, and death. 2. Maternal health across the continuum—Approximately 700 women die from childbirth-related complications each year in the U.S. More than half of these deaths are preventable. 3. Early recognition of behavioural health needs—Stigmatisation, fear, and inadequate resources can lead to negative outcomes when working with behavioural health patients. 4. Responding to and learning from device problems—Incidents involving medical devices or equipment can occur in any setting where they might be found, including ageing services, physician and dental practices, and ambulatory surgery. 5. Device cleaning, disinfection, and sterilisation—Sterile processing failures can lead to surgical site infections, which have a 3% mortality rate and an associated annual cost of $3.3 billion. 6. Standardising safety across the system—Policies and education must align across care settings to ensure patient safety. 7. Patient matching in the EHR—Organisations should consistently use standard patient identifier conventions, attributes, and formats in all patient encounters. 8. Antimicrobial stewardship—Over prescribing of antibiotics throughout all care settings contributes to antimicrobial resistance. 9. Overrides of Automated Dispensing Cabinets (ADC)—Overrides to remove medications before pharmacist review and approval lead to dangerous and deadly consequences for patients. 10. Fragmentation across care settings—Communication breakdowns result in readmissions, missed diagnoses, medication errors, delayed treatment, duplicative testing and procedures, and dissatisfaction.
  8. Content Article
    Implications While this study shows that those referring patients to ICU could benefit from greater support, the decision support tool trialled in this study would need some adaptation to fit the time-pressured realities of the users. The process did seem to help clinicians articulate and communicate their reasoning for admission. Perhaps, as the authors say, if the tool were to be integrated into existing systems the perceived additional workload may be diminished. Another not insignificant finding is that although clinicians stated they valued patient’s wishes, in some cases there was a lack of patient and family involvement.
  9. News Article
    Hundreds of people with haemophilia in England and Wales could have avoided infection from HIV and hepatitis if officials had accepted help from Scotland, newly released documents suggest. A letter dated January 1990 said Scotland’s blood transfusion service could have supplied the NHS in England and Wales with the blood product factor VIII, but officials rejected the offer repeatedly. Large volumes of factor VIII were imported from the US instead, but it was far more contaminated with the HIV and hepatitis C viruses because US supplies often came from infected prison inmates, sex workers and drug addicts who were paid to give blood but not screened. The death of scores of people with haemophilia and blood transfusion patients and the infection of thousands of others across the UK in the contaminated blood scandal has been described as the worst health disaster to hit the NHS. The latest document was released under the Freedom of Information Act to campaigner Jason Evans, whose father died in 1993 having contracted hepatitis and HIV. In it, Prof John Cash, a former director of the Scottish Blood Transfusion Service, said the decision not to use Scotland's spare capacity to produce Factor VIII for England was "a grave error of judgement". Read full story Source: The Guardian, 3 January 2020
  10. Content Article
    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.
  11. 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 suddenly we are in the midst of a violent storm and we need to utilise that information! We ardently listen to the attendants instructions and pray for the captain to land the plane safely, which he does with great skill! I now want to link this scenario to the care of our patients in the operating theatre. They are also on a journey to a destination of a safe recovery and they depend on the consultants and the team to get them there safely. Despite being routine, we need to do all the safety checks for each patient and follow the WHO Surgical Safety Checklist as it is written: ask all the questions, involve all members of the surgical team, even do the fire risk assessment score if it is implemented in your theatre. The pilot of that flight during Storm Dennis certainly did not think he was on a routine flight. He had a huge responsibility for the lives of his crew and many passengers! We can only operate on one patient at a time. Always remember, even though the operation may be routine for us, it may be the first time for the patient – so let's make it a safe journey for each patient. Do it right all the time!
  12. Content Article
    This issue of Hindsight includes articles on: Malicious compliance by Sidney Dekker Can we ever imagine how work is done? by Erik Hollnagel Safety is in the eye of the beholder by Florence-Marie Jegoux, Ludovic Mieusset and Sébastien Follet I wouldn't have done what they did by Martin Bromiley
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