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Found 40 results
  1. Content Article
    More information about "Corridor care: are the health and safety risks being addressed?"
    In a blog earlier this year, Patient Safety Learning’s Associate Director Claire Cox looked at how corridor care within the NHS is affecting safety culture and examined its implications for both healthcare professionals and patients. In this new blog, she turns her attention to the associated health and safety risks, questioning whether these are being properly addressed. Claire draws out key areas for consideration and suggests practical measures that can help protect patient safety in such challenging working environments.  In recent years, corridor care has become an unfortunate reality in many NHS hospitals across the UK. With hospitals operating over capacity, patients are often treated in corridors due to a lack of available beds. While this practice may provide temporary relief in overcrowded healthcare settings, it also introduces significant health and safety risks for patients, staff and visitors. What is corridor care? Corridor care is a term used to describe the practice of providing medical attention to patients in hallways or other non-designated clinical areas due to overcrowding or resource shortages. This is typically due to emergency departments being overwhelmed or a shortage of inpatient beds. Corridor care is no longer an exception—it has become the norm in many hospitals. A new report published in January by the Royal College of Nursing illustrated the prevalence of this, sharing the experiences of more than 5,000 nursing staff on corridor care in the UK.[1] [2] In February, the Royal College of Physicians published a snap survey of its members highlighting the prevalence of corridor care, with 78% of respondents having provided care in a temporary environment in the previous month.[3] Key health and safety risks of corridor care When speaking about the impact of corridor care, understandably our initial focus tends to be on its direct impact on the care of the patient and the staff member providing that care. However, a somewhat overlooked aspect of this is how it can impact on the wider health and safety of those working in, or using, healthcare facilities. This can manifest itself in a number of different ways: Infection control risks Corridors lack the necessary infection control measures—for example, hand washing facilities and appropriate waste disposal, including sharps—which increases the risk of hospital-acquired infections, such as MRSA and Clostridium difficile.[4] The inability to maintain appropriate isolation for infectious patients poses a serious public health concern.[5] Delayed emergency response Corridors are not equipped for life-saving interventions in emergencies. Delayed access to equipment, medication and clinical teams in a corridor setting can increase mortality and morbidity.[6] A lack of emergency call bell alarms may incur delays in receiving appropriate emergency help. Swift transfer of unwell patients is often made challenging due to obstacles obstructing a usually clear path. Emergency teams may find it difficult to locate the unwell patient in a corridor as there may be numerous ‘temporary escalation’ areas within the department. Obstruction and fire safety hazards Corridors crowded with trolleys, equipment and patients create obstructions that can impede fire evacuation routes. Fire doors may be left open to accommodate trolleys, compromising compartmentalisation and increasing the spread of fire and smoke. NHS Trusts are legally required under the Regulatory Reform (Fire Safety) Order 2005 to ensure that escape routes remain unobstructed, which is often compromised by corridor care.[7] The London Fire Brigade recently highlighted these issues with their local hospitals, citing concerns about obstruction of fire escape routes, increased fire load in circulation spaces and delayed evacuation times in the event of an emergency.[8] Manual handling and staff safety Healthcare staff face increased manual handling risks while manoeuvring equipment and providing care in narrow corridors. This can lead to musculoskeletal disorders and workplace injuries, further exacerbating staff shortages.[9] The question is, are these risks being addressed? Risk assessments: A key to mitigation While some NHS Trusts have implemented risk assessment templates for corridor care, these are not yet standardised across the system. The Health and Safety Executive (HSE) recommends that risk assessments for corridor care include: infection control protocols fire safety compliance manual handling risk reduction patient privacy and dignity measures emergency response protocols.[9] What about fire safety? Fire safety is one of the most pressing concerns associated with corridor care. Under the Regulatory Reform (Fire Safety) Order 2005, NHS Trusts are required to ensure that: Escape routes remain clear at all times. Adequate fire risk assessments are conducted and updated regularly. Staff are trained in evacuation procedures, especially in high-risk areas like corridors.[7] Are Trusts compliant? While most Trusts have fire risk assessments in place, reports from the Care Quality Commission (CQC) indicate that compliance varies across the country. Some hospitals have been flagged for failing to adequately mitigate the fire risks associated with corridor care.[10] What measures can we take to protect patient safety? The below points offer some practical health and safety measures that can be put in place to help reduce risk: Fire risk management: Regular audits to ensure corridors are not overcrowded and escape routes remain clear. Patient identification and monitoring: Implementing digital systems to track patient location and their condition when placed in corridors. Enhanced infection control: Providing hand hygiene stations and maintaining isolation protocols even in corridor settings. Staff training and awareness: Ensuring staff are trained in dynamic risk assessments and evacuation procedures. Establishing escalation protocols: Creating clear guidelines on when to escalate corridor care situations to prevent patient harm. The need for systemic change Corridor care is a symptom of a healthcare system under immense pressure. While temporary risk mitigation measures can improve safety, long-term solutions require increased capacity, better resource allocation and investment in community-based care to prevent unnecessary admissions. If the current trend continues, addressing health and safety risks associated with corridor care must become a top priority to protect both patients and healthcare staff. Call to action Do you work in healthcare or health and safety? Your expertise can make a real difference! Share your corridor care risk assessments with Patient Safety Learning to help identify risks, prevent harm and improve outcomes for patients. Comment below (sign up first for free) or email [email protected]. References Royal College of Nursing. On the frontline of the UK’s corridor care crisis, 16 January 2025. Patient Safety Learning. Response to RCN report: On the frontline of the UK’s corridor care crisis, 17 January 2025. Royal College of Physicians. Doctors confirm ‘corridor care’ crisis as 80% forced to treat patients in unsafe spaces, 26 February 2025. National Institute for Health and Care Excellence (NICE). Infection Prevention and Control Quality Standard, 2014. London: NICE. Public Health England. Guidelines on Infection Prevention and Control, 2019. London: PHE. Royal College of Emergency Medicine (RCEM), 2021. Crowding and its Consequences: Policy Brief. London: RCEM. HM Government, 2005. The Regulatory Reform (Fire Safety) Order 2005. London: The Stationery Office. London Fire Brigade. Letter to Trusts to review your Fire Risk Assessments, 17 February 2025. Health and Safety Executive (HSE). Manual Handling Operations Regulations 1992 (as amended), September 2016. London: HSE. Care Quality Commission (CQC). State of Care Report, September 2021. London: CQC. Related reading on the hub: How corridor care in the NHS is affecting safety culture: A blog by Claire Cox The crisis of corridor care in the NHS: patient safety concerns and incident reporting Response to RCN report: On the frontline of the UK’s corridor care crisis A nurse's response to the NHSE guidance on their principles for providing safe and good quality care in temporary escalation spaces A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift
  2. Content Article
    This letter from the London Fire Brigade draws attention to two key issues that may have implications for fire safety within your hospital, and to request that you review your Fire Risk Assessments accordingly. 1. Corridor use for additional bed capacity Recent news reports and material circulating on social media indicate that some hospitals are increasingly using corridors for additional bed capacity. The use of corridors in this way can present significant challenges to fire safety, including: obstruction of fire escape routes increased fire load in circulation spaces. delayed evacuation times in the event of an emergency. 2. Fire Door Recall – Office for Product Safety and Standards You will be aware that there has been a Product Recall concerning certain hospital fire doors installed across England and Wales, affecting approximately 70 sites, with a significant concentration in London and the Southeast. The manufacturer has identified the affected units and has been in contact with project managers at impacted locations. Where correct fire doors are not used, properly fitted and maintained, and corridors are used to house patients, this can exacerbate the spread of smoke and fire, compromise escape routes, and significantly increasing the risk to life. Given the above risks, we ask that you review your fire risk assessment to ensure that you are compliant with the Regulatory Reform (Fire Safety) Safety and appropriate guidance, to safeguard your patients, staff and visitors in the event of a fire.
  3. Content Article
    Theatres are a high risk area. This poster from the Association for Perioperative Practice and BD illustrates how to plan and practise to manage a surgical fire. Download a pdf of the poster from the attachment below.
  4. Content Article
    Tony Clarke suffered from a chronic inflammatory skin disease, hidradenitis suppurativa. In September 2020, Tony underwent surgery to remove infected tissue on one side of his body. When he entered the operating theatre, Tony’s surgical team first covered part of his body with an alcohol-based solution, to keep the area clean. Then, when the operation began, the surgeons began cutting off the infected tissue using a diathermy pen, a device that targets electrically-induced heat to stop wounds from bleeding. However, shortly into the surgery, disaster struck: heat from the surgical pen had ignited the alcohol on Tony’s body. “But because alcohol burns so hot, no fire was seen,” says Tony, recalling an explanation he later received from the hospital.  “The surgeons were concentrating on the right side of my body. The left side was left burning for about 20 minutes.” For the next four months, Tony travelled back to the hospital every three days, to get his injuries checked and bandages changed. During that time, Tony describes himself as ‘totally disabled.’ In September this year, Tony, as a patient ambassador for prevention of surgical fires, spoke at a conference held in York by the Association for Perioperative Practice (AFPP). There, perioperative practitioners from across the country gathered to listen to Tony’s experience. “I was speaking to lots and lots of different professionals in the medical service and they'd never heard of it [being set on fire during surgery]. It was a rarity for them,” Tony says. Tony’s now working with different health agencies, with the aim of stopping preventable surgical burns entirely.
  5. News Article
    Hospitals across England could see oxygen supplies at worse levels this winter than at the peak of the first coronavirus wave – when some sites were forced to close to new admissions. An alert to NHS hospitals this week warned that because of the rise in admissions of COVID-19 patients, there is a risk of oxygen shortages. Trusts have been ordered to carry out daily checks on the amount of oxygen in the air on wards to reduce the risk of catastrophic fires or explosions. The problem is not because of a lack of oxygen but because pipes delivering the gas to wards will not be able to deliver the volume of gas needed by all patients. This can trigger a cut-off in supply and a catastrophic drop in pressure, meaning patients would be denied the oxygen they need to breathe. Read full story Source: The Independent, 20 November 2020
  6. Content Article
    More information about "Needlestick injuries – making the point for safety"
    An article outlining the significance of needlestick injuries - their risks to healthcare workers, their cost, and the importance of prevention. Needlestick injuries account for 17% of accidents to NHS staff and are the second most common cause of injury, behind moving and handling (nhsemployers.org). The major risk of needlestick injuries is that they can transmit infectious diseases to healthcare workers, especially blood-borne viruses. Many occupational exposure incidents could have been avoided by adopting precautions and by disposing of clinical waste appropriately (nhsemployers.org). Needlestick injuries are wounds caused by needles that accidentally puncture the skin (ccohs.ca). When penetrating the skin, this is called a percutaneous injury, whilst if blood or other body fluid splashes into the eyes, nose, mouth or onto broken skin, the exposure is said to be mucocutaneous (nhsemployers.org). Needlestick injuries can occur at any stage when people use, disassemble or dispose of needles. Causes of needlestick injuries include non-compliance with standard infection control precautions, inadequate disposal of clinical waste, overfull sharps bins, and not using Personal Protective Equipment (resolution.nhs). When needlestick injuries occur in a workplace setting, this is called occupational exposure. If the needle or sharp instrument is contaminated with blood or other body fluid, there is the potential for transmission of infection (nhsemployers.org), which is why needlestick injuries are so dangerous. The major blood-borne pathogens, or blood-borne viruses (BBVs) of concern associated with needlestick injury are hepatitis B, hepatitis C & human immunodeficiency virus (HIV) (nhsemployers.org). However, there are more than 20 diseases that can be transmitted, either transiently or persistently, such as Epstein-Barr virus and malarial parasites. BBVs are carried by some people in their blood and have the potential to cause severe disease (whilst causing few or no symptoms in others); notably, they can spread to others regardless of whether the carrier of the virus is or isn’t symptomatic. BBVs can also be found in bodily fluids other than blood, for example, semen, vaginal secretions and breast milk (hse.gov.uk). Even small amounts of infectious fluid can spread certain diseases effectively (ccohs.ca). Employers have a legal requirement to take steps to prevent healthcare staff being exposed to infectious agents from sharps injuries (resolution.nhs). The Health and Safety (Sharp Instruments in Healthcare) Regulations of 2013 state that all employers are required under existing health and safety law to ensure that the risks of sharps injuries from needles are adequately assessed, and that appropriate preventative and control measures are put in place (hse.gov.uk), such as correct disposal of used sharps and effective workforce training. Needlestick injuries generate significant direct and indirect costs. Between 2012 and 2017, successful claims cost the NHS over £4 million (resolution.nhs). It has been shown that economic efforts directed at preventing occupational exposures and infections, including the provision of safety-engineered devices, may be offset by the savings from a lower incidence of needlestick injuries (Mannocci, 2016). Such devices include needle-free connectors that provide injection ports which can be accessed without needles. For instance, in Belgium, the investment and use of safety-engineered sharp devices has greatly reduced the incidence of needlestick injuries and the costs associated with their management (Hanmore, 2013). Needlestick injuries are a well-known risk in the health and social care sector. Because of their potential for disease transmission, such injuries can cause worry and stress to the many thousands who receive them. Most needlestick injuries can, however, be prevented, and there are legal requirements on employers to take necessary steps to prevent healthcare staff being exposed to the transmission of diseases via this safety issue. References Canadian Centre for Occupational Health and Safety (2021). ‘Needlestick and Sharps Injuries’. [online] Available at: https://www.ccohs.ca/oshanswers/diseases/needlestick_injuries.html Hanmore, E. (2013). ‘Economic benefits of safety-engineered sharp devices in Belgium - a budget impact model’. BMC Health Serv Res. [online] Available at: https://pubmed.ncbi.nlm.nih.gov/24274747 Health and Safety Executive (2001). ‘Blood-borne viruses in the workplace’. [online] Available at: https://www.hse.gov.uk/pubns/indg342.pdf Health and Safety Executive (2013). ‘Health and Safety (Sharp Instruments in Healthcare) Regulations 2013’. [online] Available at: https://www.hse.gov.uk/pubns/hsis7.htm Health and Safety Executive (2020). ‘Sharps injuries’. [online] Available at: https://www.hse.gov.uk/healthservices/needlesticks/index.htm Mannocci, A. et al. (2016). ‘How Much do Needlestick Injuries Cost? A Systematic Review of the Economic Evaluations of Needlestick and Sharps Injuries Among Healthcare Personnel’. Infection Control and Hospital Epidemiology, 37(6). [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4890345 NHS Employers (2011). ‘Needlestick injury’. [online] Available at: https://www.nhsemployers.org/-/media/Employers/Documents/Retain-and-improve/Health-and-wellbeing/Needlestick-Injury-22-02-2011.pdf?la=en&hash=44A54B023D6C14CE21C749A226435581BD8F4FE8 NHS Resolution (2017). ‘Did you know? Preventing needlestick injury’. [online] Available at: https://resolution.nhs.uk/wp-content/uploads/2017/05/NHS-Resolution-Preventing-needlestick-injuries-leaflet-final.pdf
  7. News Article
    Frontline NHS staff are at risk of dying from Covid-19 after the protective gear requirements for health workers treating those infected were downgraded last week, doctors and nurses have warned. Hospital staff caring for the growing number of those seriously ill with the disease also fear that they could pass the infection on to other patients after catching it at work because of poor protection. Doctors who are dealing most closely with Covid-19 patients – A&E medics, anaesthetists and specialists in acute medicine and intensive care – are most worried. A doctor in an infectious diseases ward of a major UK hospital, who is treating patients with Covid-19, said: “I am terrified. I am seriously considering whether I can keep working as a doctor.” Read full story Source: The Guardian, 16 March 2020
  8. News Article
    Two out of five GPs have still not received any personal protective equipment (PPE) against coronavirus, a Pulse survey suggests. The poll of over 400 GPs saw 41% of respondents say they have not received any PPE, while a further 32% said they had not received enough. Just 15% of GPs said they have sufficient PPE, with the remainder unsure. This comes despite NHS England promising last week that it would ship PPE free of charge to practices. The Welsh Government made the same announcement this week, while in Scotland health boards should be distributing PPE. A GP who has received no proper equipment, Dr Kate Digby, in Cirencester, said she feels "woefully underprepared". She told Pulse: "I'm becoming increasingly concerned at the lack of resources being provided for frontline primary care". Read full story Source: Pulse, 2 March 2020
  9. News Article
    A baby with a serious heart condition has died after she received an infection from mould in a Seattle hospital's operating room, her mother says. Elizabeth Hutt was born with a heart condition that she battled for the entirety of her six-month-long life. The young child underwent three open heart surgeries, and after the third one is when it's believed she contracted an Aspergillus mould infection in the hospital's operating room. The mould in the hospital's operating rooms was first detected in November, around the same time as the child's third surgery. It was later determined the infection was contracted from the mould discovered in three of the 14 operating rooms at the hospital in November. The mould came from the hospital's air-handling units in the operating rooms, and 14 patients have developed infections from the mould since 2001, the hospital revealed. Seven of those 14 children have since died from their infections. Elizabeth's parents have joined a class action suit against Seattle Children's Hospital in January, which alleges facility managers knew about the mould since 2005 and failed to fix the problem. Read full story Source: The Independent, 14 February 2020
  10. Content Article
    A National Patient Safety Alert has been issued on the elimination of bottles of liquefied phenol 80%. The alert has been issued by the NHS England and NHS Improvement National Patient Safety Team, British Orthopaedic Society, The Association of Coloproctology Great Britain and Ireland, and Royal College of Podiatry. Following incidents where bottles of liquefied phenol 80% were either confused with other medication or caused burns when spilt, this alert asks providers to eliminate its use and to follow professional guidance to use safer alternatives. Phenol, a caustic compound used for its antimicrobial, anaesthetic, and antipruritic properties, is highly toxic and corrosive. Liquefied phenol 80% can cause burns, severe tissue injury and is rapidly and well absorbed causing systemic toxicity. It is most commonly used in podiatry and orthopaedic foot surgery for destroying the nail matrix. Actions to be completed as soon as possible and no later than 25 Feb 2022: Identify where liquefied phenol 80% is used and update procedures/guidelines to substitute use for a safer, suitable alternative. Ensure clinical areas have stock of agreed safer alternatives and then remove bottles of liquefied phenol 80% from clinical areas, and update stock lists. Amend electronic prescribing systems to ensure liquefied phenol 80% cannot be prescribed. Amend current purchasing systems, and introduce ongoing controls on purchasing, to ensure liquefied phenol 80% cannot be purchased inadvertently via the pharmacy department or any alternative purchasing route.
  11. News Article
    A woman has died after being set on fire during surgery in Romania, the country’s health ministry has said, in a case that has cast a spotlight on the ailing Romanian health system. The patient, who had pancreatic cancer, died on Sunday after suffering burns to 40% of her body when surgeons used an electric scalpel despite her being treated with an alcohol-based disinfectant. Contact with the flammable disinfectant caused combustion and the patient “ignited like a torch”, Emanuel Ungureanu, a Romanian politician, said. A nurse threw a bucket of water on the 66-year-old woman to prevent the fire from spreading. The health ministry said it would investigate the “unfortunate incident”, which took place on 22 December. “The surgeons should have been aware that it is prohibited to use an alcohol-based disinfectant during surgical procedures performed with an electric scalpel,” the Deputy Minister, Horatiu Moldovan, said. Read full story Source: The Guardian, 30 December 2019 the hub has a number of posts on preventing surgical fires: Surgical fires: nightmarish “never events” persist MHRA. Paraffin-based skin emollients on dressings or clothing: fire risk (18 April 2016) National Patient Safety Agency: Fire hazard with paraffin-based skin products (Nov 2007) How I raised awareness of fires in the operating theatre
  12. Content Article
    Today was the Parliamentary launch event of the Surgical Fires Expert Working Group’s report, 'A case for the prevention and management of surgical fires in the UK', which focuses on the prevention of surgical fires in the NHS This report contains important information on surgical fires and their prevention, to be submitted to the Centre for Perioperative Care (CPOC), in order to make the case for its inclusion on their agenda. In the perioperative setting, a fire may cause injury to both the patient and healthcare professionals. Injuries caused by a surgical fire most commonly occur on the head, face, neck and upper chest. The prevention of surgical fires, which can occur on or in a patient while in the operating theatre, is an urgent and serious patient safety issue in UK hospitals.  A Short Life Working Group (SLWG) for the prevention of surgical fires was established in May 2019, following an initial discussion in December 2018 on the issue of surgical fires in the UK. The group of experts from healthcare organisations and bodies across the UK convened four times in 2019 with the aim of compiling this document, in order to recommend surgical fires for a Never Event classification. The group conducted a literature review of best practice and evidence, in the UK and internationally, which informed the development of a number of considerations that could address the issue of surgical fires. This report contains information surrounding the scale of the problem of surgical fires in the UK, in addition to reported experiences of these incidences by both healthcare professionals and patients. It also includes prevention and management materials, and mandatory training that should be consistently delivered to hospital staff, and concludes with recommendations moving forward, in order to ensure the prevention of surgical fires in UK hospitals.
  13. Content Article
    Fires on the operating field are rare events that should never happen, but do. They are dangerous not only to the patient but to the operating room (OR) team members as well. Surgical fires remain a significant enough risk to justify use of a Fire Risk Assessment Score and adherence to the recommendations of the American Society of Anesthesiologists Task Force on Operating Room Fires and those of the Anesthesia Patient Safety Foundation. Here, the Pennsylvania Patient Safety Authority shares key data and statistics, educational tools, multimedia and related links on surgical fires. In 2012, the Pennsylvania Patient Safety Authority published an analysis of surgical fires reported through its database for the primary purpose of determining whether surgical fires continued to be a problem. In 2018, the Authority published an update, including analysis of events reported from 1 July 2011 through to 30 June 2016. The model suggests a 71% decrease in the patient risk of surgical fires from 2005 to 2016. The analysts noted that in 2005, there was about one surgical fire per month in Pennsylvania, and, if the downward trend continues, the rate will be only one surgical fire per year in 2032.
  14. Content Article
    Simon Whitely in this video responds to some of the comments received on his last video, where he talk about a high-level HCS Model of the Healthcare System and how interactions with the general public are key for patient safety. He also talks about the challenges between managing safety and the potential impacts upon the overall economy.
  15. Content Article
    This blog from the PatientSafe Network discusses cognitive dissonance. Cognitive dissonance — the pain of accepting ego-dystonic facts — mitigates against an open, rational aggressive cycle of process improvement. Unfortunately the hierarchical structures in healthcare mean we are likely to suffer from this. Those further up, best positioned to bring about positive change, are the most likely to suffer cognitive dissonance.
  16. Content Article
    Hazardous Hospitals aims to elicit a wide range of viewpoints and experiences about the historical development of safety in NHS hospitals. They are interested to hear from anyone with direct experience of encountering health and safety risks in hospitals, promoting safety, or exposing shortcomings in healthcare quality. Follow the link below to find out more and how to participate.
  17. Content Article
    Hazardous Hospitals is a Wellcome Trust Research Fellowship, exploring the history of safety in the British National Health Service. Hazardous Hospitals: Cultures of Safety in NHS General Hospitals, c.1960-Present is a three-year research project at the University of Warwick, funded by the Wellcome Trust. It is being conducted by Dr Christopher Sirrs. The publication of the Francis Report into healthcare failures at Mid Staffordshire NHS Foundation Trust in 2013 dramatically refocused public and political attention on issues of ‘safety’ in the National Health Service. ‘Safety’ has increasingly occupied the attention of policy makers in recent decades, with hospital managers establishing various systems and processes to protect patients and staff from harm. These include learning and reporting systems, policies about patient consultation, and campaigns for preventing harms such as falls and healthcare-associated infections. However, little is understood about how and why these ideas and practices around ‘safety’ in the NHS evolved. This three-year project explores the history of safety in the NHS, highlighting how hospitals have promoted ‘safety cultures’: ideas, values and behaviours which support safety. Drawing upon a rich seam of archival material, as well as a distinctive methodology, it makes timely contribution to historical understandings of the NHS. The project asks the following key questions: 1. What defines the ‘safety culture’ of NHS hospitals? How can these ‘safety cultures’ vary? 2. How was safety in hospitals assessed, and in what ways did it come to the attention of NHS managers and policymakers after 1960? 3. How did NHS managers promote safety among their staff? 4. What role did groups such as patient organisations, safety campaigners and the press play in depicting, challenging and promoting reform of hospital ‘safety cultures’? The project will directly engage individuals and organisations involved in promoting or campaigning for safety in the NHS. Interviews will also be conducted with a wide range of individuals. If you are interested in participating in the project, please see the ‘Participate‘ page for more information. You can follow the project via @hazardhospitals or, for more information follow the link below.
  18. Content Article
    This poster from the National Association of Theatre Nurses (ATN) aims to give an overview of electrosurgery in the perioperative setting. It identifies and defines some of the common forms of electrosurgery used in perioperative practice and identifies some of the hazards that can be associated with these products.
  19. Content Article
    Following a reported death, the National Patient Safety Agency (NPSA) commissioned the Health and Safety Executive to undertake fire hazard testing with white soft paraffin on a variety of bandages, dressings and clothing. The results showed the ability to reproduce the fire hazard in a controlled environment. This risk was not previously well recognised.  This 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.
  20. Content Article
    Patient safety groups consider surgical fires “never events,” incidents that can be avoided entirely with organisational checks and balances. Yet, the Canadian Medical Protective Association (CMPA) has handled dozens of lawsuits and regulatory complaints involving surgical burns in recent years. According to a review of 54 cases of perioperative burns between 2012 and 2016, almost a third involved surgical fires, while the rest involved burns from surgical equipment and chemicals used in surgery. Many patients were left scarred, disfigured and psychologically traumatised. Fifteen percent were severely harmed, with airway damage or full-thickness burns destroying the sensory nerves and all layers of the skin. 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.
  21. Content Article
    For over three decades, patients, consultants and perioperative staff have been exposed to diathermy tissue smoke in all operating hospital theatres. This smoke is called plaque and, when inhaled, is the same as smoking cigarettes. Research shows that inhalation of smoke from one gram of cauterised tissue is equal to smoking six cigarettes. This smoke is also cancerous and can mutate to other organs of the body just like cigarettes. Read my personal view of the harmful effects of diathermy smoke published in the Journal of Perioperative Practice, and also  watch the short video kindly made for me by Knowlex UK.
  22. Content Article
    Smoking or a naked flame could cause patients’ dressings or clothing to catch fire when being treated with paraffin-based emollient that is in contact with the dressing or clothing. The Medicines and Healthcare products Regulatory Agency (MHRA) provided this update for healthcare professionals. Reminder: 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.
  23. Content Article
    In January 2017, I read an article in Outpatient Surgery involving an elderly patient in the US who suffered multiple burns following the use of chlorohexidine bottled alcoholic prep. The Oregon woman filed a million-dollar lawsuit against the Oregon Outpatient Surgery Center in Tigard, Ore., saying she suffered severe burns when her face caught on fire during an electrocautery procedure. Having read this tragic story and escalated it to my theatre manager and colleagues, I decided to design and evaluate a FRAS (Fire Risk Assessment Score) and use it as part of the WHO Surgical Checklist at "time out" to raise awareness of fires in operating theatres. Here is the FRAS tool I implemented: Fire risk assessment tool.pdf Other useful resources I found: Scoring_Fire_Risk-2.pdf Surgical Site Fire Triangle.pdf Surgical_Fire_Poster (1).pdf Video: Fire hazard demo by Zaamin Hussain and Mike Reed Demonstration: "Burning Bruce" drives home the reality of surgical fires - article in Outpatient Surgery
  24. Content Article
    Coronavirus disease 2019 (COVID-19), caused by the COVID-19 virus, was first detected in Wuhan, China, in December 2019. On 30 January 2020, the WHO Director-General declared that the current outbreak constituted a public health emergency of international concern.  This document summarises WHO’s recommendations for the rational use of personal protective equipment (PPE) in healthcare and community settings, as well as during the handling of cargo; in this context, PPE includes gloves, medical masks, goggles or a face shield, and gowns, as well as for specific procedures, respirators (i.e., N95 or FFP2 standard or equivalent) and aprons. This document is intended for those who are involved in distributing and managing PPE, as well as public health authorities and individuals in healthcare and community settings, and it aims to provide information about when PPE use is most appropriate. 
  25. Content Article
    Brighton and Sussex University Hospitals Trusts Anaesthetic Department has produced this video demonstrating how to 'don' (put on) and 'doff' (take off) PPE pre- and post-intubation of a high risk/infected patient with COVID-19.

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