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Found 50 results
  1. Community Post
    Subject: Looking for Clinical Champions (Patient Safety Managers, Risk Managers, Nurses, Frontline clinical staff) to join AI startup Hello colleagues, I am Yesh. I am the founder and CEO of Scalpel. <www.scalpel.ai> We are on a mission to make surgery safer and more efficient with ZERO preventable incidents across the globe. We are building an AI (artificially intelligent) assistant for surgical teams so that they can perform safer and more efficient operations. (I know AI is vaguely used everywhere these days, to be very specific, we use a sensor fusion approach and deplo
  2. Content Article
    'To support all prescribers in prescribing safely and effectively, a single prescribing competency framework was originally published by the National Prescribing Centre/National Institute for Health and Care Excellence (NICE) in 2012. NICE and Health Education England approached the Royal Pharmaceutical Society (RPS) to manage the update of the framework on behalf of all the prescribing professions in the UK. A Competency Framework for all Prescribers was first published by the RPS in July 2016. Going forward, the RPS will continue to maintain and publish this framework in collabora
  3. Content Article
    Human factors that could reduce the risk of wrong tooth extraction: Lower team authority gradients - anyone can speak up if concerned irrespective of grade or positionImprove situational awareness - ask the team to confirm the tooth (teeth) to be extractedAvoid miscommunication error: if there is potentially conflicting information (often in relation to molar teeth), seek advice from the prescribing practitioner or another colleague if possibleCheck and double-check radiographs, consent, and clinical examination findingsIf in doubt, do NOT proceed.
  4. News Article
    NHS trusts are to be told to remove devices linked to more than 120 never events caused by ‘unconscious errors’. A national patient safety alert is being drafted by NHS England which urges trusts to remove all air flowmeters from wall medical gas outlets. It is likely to be published next month. The alert comes after 121 never events in the last three years involved staff members accidentally connecting patients to air instead of oxygen. This number is close to 10% of all never events recorded during that period. These types of never events have been recorded by 57 NHS organisat
  5. Content Article
    Key points include: Misplacement and use of nasogastric feeding tubes leads to ongoing avoidable complications and deaths classified as Never Events despite multiple NHS Alerts since 2005. The most common cause relates to use of X-rays to confirm intragastric placement, followed by poor adherence to guidance on use of gastric aspirate pH, although the vast majority of nasogastric feeding tubes in the UK are passed safely and have their position confirmed using pH checks without issue. The root cause of these problems is a failure by Hospital Trusts and Health Boards to implement gu
  6. Event
    until
    This Q Community session: Introduces the concepts and origins of ‘never events’ and ‘zero harm’ as safety interventions. Explores and debates the usefulness of ‘never event’ and ‘zero harm’ initiatives as effective safety management strategies in healthcare. Reflects on and considers alternative approaches to managing risks of serious harm to as low as reasonably practicable. Further information Register
  7. Content Article
    Case submission When submitting a case, the following information is required. Title (please provide an appropriate title for the case). Patient Description (describe the patient [as much as you would in a case summary] at the time of the event of interest) Nature of Error (the nature of the error and any relevant events or contributing factors) Impacts/Effects (describe the impact of the error on the patient and state whether the patient was harmed or required increased level of care, even if only temporarily) How Error was Recognised (if not noted above, de
  8. News Article
    A trust which had four ‘never events’ where patients were connected to air rather than an oxygen supply could have avoided them if it had been more proactive when a national patient safety alert was sent out several years earlier, a report has found. In one case, a baby being investigated for sepsis had oxygen saturation levels of just 75% before the mistake was realised. In another, a woman with COPD and pneumonia had oxygen saturation at 80% when she was connected to the air outlet. Calderdale and Huddersfield Foundation Trust asked the Royal College of Physicians to carry out an i
  9. News Article
    The Care Quality Commission has ordered immediate improvements to a trust after it reported six never events inside eight months. The watchdog has issued a warning notice to Royal Cornwall Hospitals Trust after it carried out an announced inspection which focused on the trust’s surgical care group – where six never events had occurred between February and October last year. In November, HSJ reported that a total of eight never events had been recorded in 2020, with trust chief executive Kate Shields saying it had raised fears the trust had not fully embedded safety improvements initi
  10. News Article
    Clinicians within a major teaching hospital’s cancer services have raised multiple concerns over patient safety, which they believe have resulted from badly planned service changes in response to the covid crisis. HSJ has spoken to several staff members who have worked in the haematology speciality at University Hospitals Birmingham Foundation Trust since last June, when the services underwent significant changes to free up capacity for coronavirus patients. This involved most haematology services at Heartlands Hospital in east Birmingham moving to the trust’s main Queen Elizabeth Ho
  11. 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
  12. News Article
    An acute trust’s record of eight never events in the last six months has raised concerns that quality standards have slipped since it was taken out of special measures. The never events occurred at Royal Cornwall Hospitals Trust. They included three wrong site surgeries within the same speciality and an extremely rare incident in which a 30cm (15 inch) wire was left in a cardiology patient. Kate Shields, chief executive of the trust, said the incidents have led to a “great deal of soul searching”. Prior to the incidents the trust had gone 13 months without recording a never even
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