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Showing results for tags 'Documentation'.
Found 23 results
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HSE: Health and safety management systems
Patient Safety Learning posted an article in Organisational
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Content ArticleKey messages Document the swallow status of all patients with PD at the point of referral to hospital Screen patients with PD for swallowing difficulties at admission Refer patients with PD who have swallowing difficulties (or who have problems with communication) to speech and language therapy Notify the specialist PD service (hospital and/or community) when a patient with PD is admitted, if there is any indication from the notes, or following discussion with the patient or their relatives/carers, that there has been a deterioration or progression of their clinical state Provide written information at discharge on how to manage swallowing difficulties
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CDIA 2021: Transforming health care
Patient Safety Learning posted a calendar event in Community Calendar
untilBe a part of history and join leading minds to explore clinical documentation's impact on patient safety, financial sustainability, and data integrity, in Australia's inaugural CDI conference. Targeting a broad array of health care stakeholders including CEOs, CFOs, Quality Managers, clinical staff, HIMs, Coders, and Clinical Documentation Specialists in Australia, New Zealand, and the Middle East. The conference will provide invaluable networking opportunities both in person and virtually with industry experts and like-minded individuals. Register -
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RLDatix: Product Highlight Series: Tools for patient safety - PolicyStat
Patient Safety Learning posted a calendar event in Community Calendar
Streamline your policy management workflow in the cloud with PolicyStat. From single hospitals to multi-facility organisations, all your policies and procedures are in one easily accessible library and always kept current. Efficiently organise and govern policies, procedures and related documentation . Stay compliant and audit ready to avoid penalties and drive better outcomes. Optimise policy workflows and change management to improve performance. Align culture, process and people for better document control and regulatory compliance. Register -
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A dropped instrument, washed in theatre and immediately reused: a story from a theatre nurse
Anonymous posted an article in By health and care staff
I was once working in a private operating theatre where, to my horror, the surgeon accidentally dropped an instrument on the floor, picked it up and reused it without it going through a steriliser. In my 30 years of working as a theatre nurse, I had never seen anything like this. I felt sick to my stomach! Is this what happens in private hospitals? I reported it immediately to the senior staff on duty and also the theatre manager. I also sent through a report at the end of the case. Nothing happened, except my shifts were blocked for reporting the incident . I no longer work in that hospital. I feel hurt. My mental health has also suffered as I feel tortured. I question myself. Did I do the right thing by reporting it? Because now I do not have a job and I am using my savings to survive. If I was a permanent member of staff, I would still be working. Is this why staff do not report incidents? For fear of losing their jobs? What about the safety of the patient? I tried calling to speak to anyone who would listen. I did not have any luck – I found all avenues were blocked. There was no Speak Up Guardians in post. I feel I did the right thing by reporting it, but I was not supported by management. Where is the system in private hospitals to protect locum theatre staff? Why is this allowed to go on? In theatres, we are the patient's advocate. We are only there to ensure the patient is safe at all times. Would I do things differently if it happens again, now that I know the consequences? Yes! Absolutely 100%. I will continue to speak up and send through a report. What will you do?- Posted
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Content ArticleFollowing a review of the events that led up to Amy’s death Great Ormond Street Hospital have already made changes to practice: They have improved the way clinical information is shared between different specialist teams, to make sure staff have as comprehensive a picture as possible when making complex decisions about a patient’s treatment. They now use a single log-in electronic patient record system which means staff can quickly access clinical information about a patient and have the right information at the right time, rather than routinely having to use multiple systems. They have improved consultant availability. This means there is more consultant time for each patient being looked after in our paediatric intensive care unit. They have introduced a new process to make sure the care of patients, like Amy, who have both complex spinal and heart conditions is routinely considered by the hospital’s specialist joint cardiology committee.
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ThinkSAFE: Information checklists – Admission & discharge
Claire Cox posted an article in Keeping patients safe
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‘Total IT failure’ at four hospitals sparks safety concerns
Patient Safety Learning posted a news article in News
Four hospitals in Greater Manchester are struggling with a near ‘total IT failure’ which has forced staff in all key services to use handwritten lists and notes. The problems have affected multiple IT systems across Royal Oldham, Fairfield General, Rochdale Infirmary and North Manchester General hospitals. Staff at the sites are running theatre and emergency departments using handwritten patient lists and notes, while bloods and scan results are also being written by hand. Patient histories are largely unavailable. HSJ spoke to staff who said there are major concerns over patient safety, as the lack of digital systems increases the risk of errors, and also slows down multiple processes. They described the problems as a “total IT failure”. Chris Brookes, deputy CEO and chief medical officer, said: “Patient safety and maintaining essential services remains our priority. We are doing everything we can to fix the IT issues and to limit disruption to patients and our services." Read full story (paywalled) Source: HSJ, 25 May 2022 -
Content ArticleThe report highlights the following key findings: The maternity service was offering care to women whose pregnancies represented a high risk, but did not have the necessary systems or staff with the appropriate skills in place to manage such cases. There was a lack of input from consultants at crucial times, and there was an over reliance on junior staff to manage complex and difficult cases with little guidance or support. Consultant obstetricians did not routinely carry out ward rounds when they were responsible for overseeing care in the labour ward and the teamwork between midwives and obstetricians was not as effective as it should have been. Therefore, there was no adequate mechanism in place for staff to discuss concerns that they may have had about the women. There was an excessive reliance on the use of locum and agency staff, who did not always receive the necessary guidance or support. Deficiencies in the management structures also contributed to the poor quality of care the women received, for example midwives were expected to manage a busy delivery suite that was reliant on agency and locum staff, with at times, little professional or managerial support. Around the time of the first deaths the midwives received little professional support from the supervisors of midwives. In the majority of cases the women attended their hospital and GP antenatal appointments and sought help when they felt unwell. Yet despite this, in a number of the cases, clinical staff failed to recognise and respond to the severity of the condition of the women, thereby reducing the chances of survival of the women. In some of the cases there were minor deficiencies in care which, in isolation, may not have had such a dramatic impact, but when occurring together had serious consequences for the health of the women concerned. The anaesthetic staff involved in the care of the women responded well, often in difficult circumstances. The haematology department responded efficiently in providing the necessary, and at times large, volumes of blood and blood products. In two of the cases there was an absence of documentation for surgical procedures that were carried out by the obstetric staff and in one case there was an absence of contemporaneous documentation. Related reading An independent review of serious untoward incidents and clinical governance systems within maternity services at Northwick Park Hospital (16 September 2008)
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PRSB to develop a new nursing standard
Patient Safety Learning posted a news article in News
Nurses are a crucial part of care across a wide range of sectors, with patients and other professionals often reliant on their expertise. That’s why the Professional Records Standard Body (PRSB) has been asked to develop a new nursing standard by NHSx for use across all the different health and social care settings. The standard aims to improve quality and safety of care in key nurse-led areas, including care planning. It will reflect best practice and standardise documentation across different nursing settings, to free nurses and give them more time to care. For example, it will standardise information that a district nurse in a care home setting can access and share in the same way as a mental health or hospital nurse, with a focus on the person’s overall wellbeing. Read full story Source: PRSB, 30 March 2021 -
News ArticleComplaints about NHS care cannot always be investigated properly because of medical records going missing, the public services watchdog has said. Ombudsman Nick Bennett said many people were left "suspicious" and thought there was a "darker motivation". One woman whose notes went missing said she no longer trusted what doctors said and had lost faith in NHS transparency. The Welsh NHS Confederation said staff were "committed to the highest standards of care". In a report called Justice Mislaid: Lost Records and Lost Opportunities, Mr Bennett found 70% of 17 cases he looked at in Welsh NHS hospitals and care settings could not be properly investigated because of lost documents. Read full story Source: BBC News, 10 March
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Pager systems used in healthcare could be exposing patient data across Canada
Patient Safety Learning posted a news article in News
Paging systems used across B.C could be exposing sensitive health data of patients, and the privacy researcher who first discovered the data breach believes it’s likely happening across the country. “I wouldn’t be surprised to find this everywhere in Canada,” said privacy researcher Sarah Jamie Lewis, in an interview with CTVNews.ca in Vancouver. Lewis first discovered and reported the breach to Vancouver Coastal Health in November 2018. Now, internal emails released this month through a Freedom of Information request show that the vulnerability is not limited to Vancouver. Read full story Source: CTV News, 13 December 2019 -
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Accident and emergency grab sheet
Claire Cox posted an article in Learning disabilities
