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Showing results for tags 'Health and safety'.
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Further serious patient safety incidents: why are staff still not being listened to when concerns are raised?
Anonymous posted an article in Whistle blowing
Complaints from staff are not being heeded. Why is it that healthcare staff's opinions and pleas for their safety and the safety of patients do not matter? Here are just some examples of where safety has been compromised: Disposable gowns are being reused by keeping them in a room and then reusing after 3 days. There were no fit tests. Staff were informed by management that "one size fits all, no testers or kits available and no other trusts are doing it anyway". Only when the Health and Safety Executive (HSE) announced recently that fit tests were a legal requirement, then fit tests were given. I queried about fit checks only to discover that it was not part of the training and, therefore, staff were wearing masks without seals for three months before fit tests were introduced and even after fit tests! I taught my colleagues how to do fit checks via telephone. There was no processes in place at the hospital to aid staff navigation through the pandemic (no red or green areas, no donning or doffing stations, no system for ordering PPE if it ran out); it was very much carry on as normal. A hospital pathway was made one week ago, unsigned and not referenced by governance, and with no instructions on how to don and doff. Guidelines from the Association for Perioperative Practice (AFPP) and Public Health England (PHE) for induction and extubation are not being followed – only 5 minutes instead of 20 minutes. Guidelines state 5 minutes is only for laminar flow theatres. None of the theatres in this hospital have laminar flow. One of my colleagues said she was not happy to cover an ENT list because she is BAME and at moderate/high risk with underlying conditions. She had not been risk assessed and she felt that someone with lower or no risk could do the list. She was removed from the ENT list, told she would be reprimanded on return to work and asked to write a report on her unwillingness to help in treating patients. The list had delays and she was told if she had done the list it would not have suffered from delays. Just goes to show, management only care about the work and not the staff. It was only after the list, she was then risk assessed. Diathermy smoke evacuation is not being used as recommended. Diathermy is a surgical technique which uses heat from an electric current to cut tissue or seal bleeding vessels. Diathermy emissions can contain numerous toxic gases, particles and vapours and are usually invisible to the naked eye. Inhalation can adversely affect surgeons’ and theatre staff’s respiratory system. If staff get COVID-19 and die, they become a statistic and work goes on as usual. The examples listed above are all safety issues for patients and staff but, like me, my colleagues are being ignored and informed "it's a business!" when these safety concerns are raised at the hospital. The only difference is they are permanent staff and their shifts cannot be blocked whereas I was a locum nurse who found my shifts blocked after I spoke up. Why has it been allowed to carry on? Why is there no Freedom To Speak Up Guardian at the hospital? Why has nothing been done? We can all learn from each other and we all have a voice. Sir Francis said we need to "Speak Up For Change", but management continues to be reactive when we try to be proactive and initiate change. This has to stop! Actions needed We need unannounced inspections from the Care Quality Commission (CQC) and HSE when we make reports to them. Every private hospital must have an infection control team and Freedom To Speak Up Guardian in post. -
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Content ArticleKey benefits of tool Raises the profile of Health & Safety – engages the workforce to talk about health and safety issues. Captures sensitive information – participants respond anonymously. Enables active management of health and safety - allows companies to highlight both areas of concern and good practice. Provides a baseline measure - can help you evaluate whether health and safety initiatives have had the desired effects on performance. Key features Generates paper and HTML versions of the questionnaire. Quick wizard guides the user through easy set up to produce the survey. The survey can be tailored towards the organisation, for example by incorporating the company logo and supporting Management statement and by tailoring terminology within the SCT statements. Allows for up to 9 demographic questions and an additional 6 open questions. The software automatically analyses the data to produce a series of charts and also allows detailed filtering to further interrogate your findings
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Fault warning for Emerade 500 adrenaline pens
Patient Safety Learning posted a news article in News
People carrying Emerade 500 microgram adrenaline auto-injector pens should return them and get hold of a prescription for a different brand. A fault has been detected in the pens, meaning the dose of adrenaline may not be delivered when needed for people with severe allergies. The official advice comes from the Medicines and Healthcare products Regulatory Agency (MHRA). Alternative brands - EpiPen and Jext - are available up to 300 micrograms. "Action has been taken to protect patients, following detection of a fault in one component of the Emerade adrenaline auto-injector pens," an MHRA spokesperson said. "Patients should return all Emerade 500 microgram pens to their local pharmacy once they have a new prescription and have been supplied with pens of an alternative brand." If an Emerade pen does need to be used before a patient can get hold an alternative pen, the advice is that it should be pressed very firmly against the thigh. If this does not work, the patient should immediately use their second pen. Read full story Source: BBC News, 19 May 2020 -
Content ArticleActions for healthcare professionals All healthcare professionals in primary, secondary or specialist healthcare services who prescribe, supply or administer adrenaline auto-injectors, or who advise patients and their carers, should ensure that they: identify patients who have been supplied with Emerade 500 micrograms auto-injectors and ensure they are reviewed to determine whether their adrenaline auto-injector prescription is still appropriate and in line with existing guidance immediately inform patients and carers to request a new prescription to replace each Emerade 500 microgram auto-injector with one new 300 microgram adrenaline pen in an alternative brand. Healthcare professionals should be aware that the licensed dosing recommendations for each brand of pen are not identical. inform patients to return Emerade 500 microgram auto-injectors to the pharmacy, when they have obtained a total of two adrenaline 300 microgram auto-injectors in a different brand; although pens should be returned to a pharmacy once a replacement is obtained, this should not require someone who is self-isolating to leave their home during COVID-19. Pharmacies that receive Emerade 500 microgram auto-injectors from patients should quarantine the pens and return them to the supplier using the supplier’s approved process. Inform patients: that they should always carry two in-date auto-injectors with them at all times in case they need to administer a second dose of adrenaline before the arrival of the emergency services that they need to receive training, so they are confident in being able to use any new devices so that they know the signs of anaphylaxis and the actions they should immediately take and are aware that this recall also applies to Emerade 500 microgram auto-injectors that are in emergency anaphylaxis kits held by healthcare professionals, such as dental surgery kits etc. adrenaline ampoules, as opposed to auto-injectors, should be stocked when renewing the adrenaline in anaphylaxis kits (ensuring dosing charts, needles and syringes are included) are aware that this recall also applies to Emerade 500 microgram auto-injectors that are currently held by schools. Prescribers should issue no more than two adrenaline auto-injectors per patient (of any brand or strength) unless: schools require separate pens to be kept on the school premises (e.g. in a medical room) in which case prescribers may need to consider issuing more than two but no more than four pens per child (of any brand or strength). for the rare scenario where patients might need more than two adrenaline pens prescribed (for example, a prior severe reaction resistant to treatment with adrenaline), where the prescriber may issue additional pens. General Practitioners (GPs) should send the letter “Advice for patients who have been prescribed an Emerade 500 microgram auto-injector” on page 6 of the alert, to all patients and carers, as appropriate, who have been prescribed Emerade 500 micrograms auto-injectors.
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Misuse of hydrogen peroxide in a theatre environment
Kathy Nabbie posted an article in Good practice
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. -
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Dying doctor warns of asbestos ‘hidden epidemic’ caused by NHS failures
Patient Safety Learning posted a news article in News
A doctor and mother of two with just months left to live has warned of a “hidden epidemic” of asbestos-related cancers among NHS staff and patients because hospitals have failed to properly handle the toxic material. Kate Richmond, 44, has spoken out to raise awareness after she won a legal case against the NHS for negligently exposing her to asbestos while she was working as a medical student and junior doctor. An investigation by The Independent has learnt there have been 13 prosecutions linked to NHS breaches of regulations for the handling of asbestos since 2010, while 381 compensation claims have been made by NHS staff for work-related diseases, including exposure to asbestos, since 2013, costing the health service more than £26m. According to data from the Health and Safety Executive, between 2011 and 2017, a total of 128 people working in health and social care roles died from mesothelioma, the same asbestos-related cancer which is killing Kate Richmond. She described how maintenance staff removed asbestos ceiling tiles with no protective measures, allowing dust and debris to fall on to wards where patients were in their beds and staff were working. Managers at the Walsgrave Hospital in Coventry failed to heed warnings by workers that they were putting people at risk. Read full story Source: The Independent, 9 February 2020 -
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Managing healthcare fire safety (updated April 2013)
PatientSafetyLearning Team posted an article in Processes
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Medical negligence: Diathermy burns
Patient Safety Learning posted an article in Legal matters
In this article, Glynns Solicitors gives advice on what to do if you have suffered a diathermy burn during surgery. -
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American Association of Nurse Anesthetists: Surgical fires
Patient Safety Learning posted an article in Surgery
The AANA has provided a set of resources, including videos, posters, tools and news items, to increase knowledge about and take steps to mitigate the risk of surgical fires. -
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Electrosurgery. Managing the risk (September 2004)
Patient Safety Learning posted an article in Surgery
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Content ArticleThis document is accompanied by: general advice and advice for hospital inpatients supporting information for healthcare staff including background and findings posters in English and Welsh Health and Safety Laboratory report FS/06/12 ‘Fire hazards associated with contamination of dressings and clothing by paraffin based ointments’ examples of products containing paraffin warning / hazard stickers for products a patient safety video leaflets in English and Welsh. Although the deadline for actions has passed, this guidance remains best practice. It should be followed to prevent future patient safety incidents.
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Surgical fires: nightmarish “never events” persist
Patient Safety Learning posted an article in Surgery
For fires to occur, heat, fuel and oxygen must be present. Oxygen was a factor in half of the surgical fire cases reviewed, usually when the concentration of oxygen being delivered for ventilation wasn’t reduced sufficiently during electro- or laser surgery on the head, neck or upper chest. Most of the burns that weren’t caused by fire involved heat from equipment. These cases included surgeons using the wrong device or settings, as well as issues with the maintenance, malfunction or positioning of devices. Cases involving fuel were usually caused by the unsafe use of alcohol-based antiseptics, including allowing it to pool under patients, using the wrong concentration, or failing to let it dry before placing drapes. To reduce the risk of fires and burns, CMPA recommends that surgical teams “identify, separate and manage the elements of the fire triangle” before procedures. This involves ensuring that “ignition sources should not come into contact with fuels, and oxygen should be reduced to the minimum required concentration.” The association also recommends that surgical teams ensure that antiseptic has time to dry and doesn’t pool, follow device instructions, and run simulations to practice responding to fires. -
News ArticleHealth products powered by artificial intelligence, or AI, are streaming into our lives, from virtual doctor apps to wearable sensors and drugstore chatbots. IBM boasted that its AI could “outthink cancer.” Others say computer systems that read X-rays will make radiologists obsolete. Yet many health industry experts fear AI-based products won’t be able to match the hype. Many doctors and consumer advocates fear that the tech industry, which lives by the mantra “fail fast and fix it later,” is putting patients at risk and that regulators aren’t doing enough to keep consumers safe. Early experiments in AI provide reason for caution, said Mildred Cho, a professor of pediatrics at Stanford’s Center for Biomedical Ethics. Systems developed in one hospital often flop when deployed in a different facility, Cho said. Software used in the care of millions of Americans has been shown to discriminate against minorities. And AI systems sometimes learn to make predictions based on factors that have less to do with disease than the brand of MRI machine used, the time a blood test is taken or whether a patient was visited by a chaplain. In one case, AI software incorrectly concluded that people with pneumonia were less likely to die if they had asthma an error that could have led doctors to deprive asthma patients of the extra care they need. “It’s only a matter of time before something like this leads to a serious health problem,” said Steven Nissen, chairman of cardiology at the Cleveland Clinic. Read full story Source: Scientific American, 24 December 2019
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Content ArticleReminder: Advise patients not to: smoke; use naked flames (or be near people who are smoking or using naked flames); or go near anything that may cause a fire while emollients are in contact with their medical dressings or clothing. Change patient clothing and bedding regularly—preferably daily—because emollients soak into fabric and can become a fire hazard. Incidents should be reported.
