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Showing results for tags 'Health hazards'.
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News ArticleHospitals 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
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Patient Safety Authority: Surgical fires
Patient Safety Learning posted an article in Surgery
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. -
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Prevention of and response to surgical fires (1 August 2019)
Patient Safety Learning posted an article in Surgery
Key points Communication between members of the surgical team is an integral component of the prevention of surgical fires. Open delivery of 100% oxygen should be avoided if at all possible for surgery above the xiphoid process. Surgeons usually control the ignition sources, such as electrosurgical units and lasers. Operating theatre nurses or practitioners usually control the fuel sources, such as alcohol-based preparations and surgical drapes. The use of an ignition source in close proximity of an oxidiser-enriched environment creates a high risk for surgical fires. -
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Surgical fires, a clear and present danger (April 2010)
Patient Safety Learning posted an article in Surgery
The authors found that fire occurs when the three elements of the fire triad, fuel, oxidiser and ignition, coincide. Surgical fires are unusual in the absence of an oxygen-enriched atmosphere. The ignition source is most commonly diathermy but lasers carry a relatively greater risk. The majority of fires occur during head and neck surgery. This is due to the presence of oxygen and the extensive use of lasers. The risk of fire can be reduced with an awareness of the risk and good communication. Surgery will always carry a risk of fire. Reducing this risk requires a concerted effort from all team members. -
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Hazardous Hospitals: research project
PatientSafetyLearning Team posted an article in Research
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Content ArticleHazardous 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.
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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.
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Content ArticleResources: driver diagrams (tree diagrams) the health and wellbeing framework and diagnostic tool workforce stress and the supportive organisation — a framework for improvement.
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Woman dies after being set on fire during surgery in Romania
Patient Safety Learning posted a news article in News
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 -
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'Not fit for purpose': UK medics condemn Covid-19 protection
Patient Safety Learning posted a news article in News
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 -
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Electrosurgery. Managing the risk (September 2004)
Patient Safety Learning posted an article in Surgery
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Content ArticleThis action plan includes details of the event, notable practice, improvements to be made and the learning found.
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News ArticleA 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
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Brighton Anaesthesia FFP3 Donning & Doffing
Claire Cox posted an article in Good practice and useful resources
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How I raised awareness of fires in the operating theatre
Kathy Nabbie posted an article in Surgery
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- Posted
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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. -
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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Majority of GPs do not have sufficient coronavirus protective equipment
Patient Safety Learning posted a news article in News
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
