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Showing results for tags 'Operating theatre / recovery'.
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News Article
Hospital cancels operations as Covid patient numbers soar
Patient Safety Learning posted a news article in News
A hospital in Yorkshire has said it is cancelling planned surgeries for at least two weeks as the number of coronavirus patients there hits levels not seen since May. Bradford Teaching Hospitals said it was being forced to stop non-urgent surgery and outpatient appointments for two weeks from Tuesday because of the numbers of severely ill COVID-19 patients. In statement the hospital said it had seen a spike in admissions in the last few days with 100 coronavirus patients now on the wards with 30 patients needing oxygen support – the highest number of any hospital in the northeast and Yorkshire region. It also said more patients were needing ventilators to help them breathe in intensive care. The trust is the latest to announce cancellations, joining the University Hospitals of Birmingham, Nottingham University Hospitals and Plymouth Hospitals as well as those in Liverpool and Manchester where hundreds of Covid patients are being looked after. Read full story Source: The Independent, 21 October 2020 -
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Content ArticleBased on an analysis of surgical data received through the Patient Safety Organization, plus detailed research and expert evaluation, this Deep Dive identifies and provides actionable recommendations and tools on six key risk categories of adverse event reports related to operative procedures: complications patient and OR readiness retained surgical instruments contamination equipment failures wrong surgery. There are common themes echoed through each of the six event types examined in this Deep Dive. These include the following: Communication problems are an underlying issue. Problems with communication—whether between the scheduler and the OR team, between clinical staff and the patient, or among the OR team—can lead to adverse events or near misses. Organisations should promote a team approach. Taking a team approach to surgical procedures can help avoid many of the adverse events reported in this Deep Dive. Such an approach is an element of a culture of safety and should be emphasised through team-building exercises. Organisations should focus on addressing preventable events. Some events are not preventable, meaning that no matter how well the team prepares, the event would likely have happened anyway. For example, the patient could have an allergic reaction resulting from an unknown anesthesia allergy, or a rare but known risk of surgery occurring. Focusing on preventable events can help focus the surgical team’s attention, however, thereby reducing the risk of unpreventable events as well. Quality improvement should be emphasized to reduce risk. Clinical staff should apply a quality improvement mentality to any problems that emerge, and focus on actions that can be taken to prevent such problems in the future.
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Content ArticleThis report teases out the ‘ingredients’ for successful team working at system, organisational, team and individual level. In the COVID-era, multidisciplinary perioperative teams can be at the front and centre of supporting staff to deliver the best possible care. Key messages Our review found that multidisciplinary working is worth prioritising. There is evidence that in some cases multidisciplinary working can: speed access to surgery, if that is an appropriate treatment option improve people’s clinical outcomes, such as reducing complications after surgery reduce the cost of surgical care by helping people leave hospital earlier However, these benefits are not always apparent. More work is needed to explore which types of multidisciplinary working are most effective and what infrastructure and resources are needed to strengthen and sustain multidisciplinary care around the time of surgery.
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News ArticleThe surgeon at the centre of a body parts scandal operated on patients who were dangerously sedated so that their procedures could be carried out simultaneously, according to a leaked investigation seen by The Independent. Renowned hip surgeon Derek McMinn and two anaesthetists at Edgbaston Hospital, Birmingham, were accused of putting “income before patient safety” in the internal investigation for BMI Healthcare, which runs the hospital. It comes after a separate review found that McMinn had hoarded more than 5,000 bone samples from his patients without a licence or proper permission to do so over a period of 25 years, breaching legal and ethical guidelines. Police are investigating a possible breach of the Human Tissue Act. According to the report on sedation by an expert from another hospital, the two anaesthetists, Imran Ahmed and Gauhar Sharih, sedated patients for so long that their blood pressure fell to dangerous levels in order to allow McMinn to carry out near-simultaneous surgery. It found this meant long delays in the operations starting, with one sedated patient being subjected to prolonged anaesthesia for longer than one hour and 40 minutes – recommended best practice is 30 minutes. Another patient was apparently "abandoned" for an hour and 26 minutes after their surgery was only partially completed while McMinn began operating on another patient. The report’s author, expert anaesthetist Dr Dhushyanthan Kumar of Coventry’s University Hospital, said this was unsafe practice by all three doctors and urged BMI Healthcare to carry out a review of patients to see if any had suffered lasting brain damage. Both anaesthetists work for the NHS – Ahmed at Dudley Group of Hospitals, Sharih at University Hospitals Birmingham – without restrictions on their ability to practise. Read full story Source: The Independent, 30 September 2020
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News ArticleFor more than two decades, Derek McMinn harvested the bones of his patients, according to a leaked report – but it was not until last year that anyone challenged the renowned surgeon. The full scale of his alleged collection was apparently kept from the care regulator until just days ago, and thousands of those who went under his knife for hip and knee treatment still have no idea that their joints may have been collected in a pot in the operating theatre, and stored in the 67-year-old’s office or home. Clinicians and managers at the BMI Edgbaston Hospital, where McMinn carried out the majority of his operations, actively took part in the collection of bones and – even after alarms were raised – the hospital did not immediately act to stop the tissue being taken away, according to a leaked internal report seen by The Independent. An investigation found operating theatre staff at the private hospital left dozens of pots containing joints removed from patients femurs during hip surgery in a storage area, in some cases for months. According to the report, there had been warnings about their responsibilities under the Human Tissue Act when an earlier audit between 2010 and 2015 identified the storage of femoral heads, the joints removed in the procedure. The internal report said there was no evidence McMinn had carried out any research or had been approved for any research work – required by the Human Tissue Authority to legally store samples. It said one member of staff told investigators the samples were being collected for research on McMinn’s retirement. Although the Care Quality Commission knew about claims that a small number of bones being kept by McMinn, it is understood that the regulator received a copy of the BMI Healthcare investigation report only last Friday, after The Independent had made initial inquiries about the case. That report suggests a minimum of 5,224 samples had been taken by McMinn. The regulator confirmed to The Independent it had not been aware of the extent of McMinn’s supposed actions. An insider at BMI Healthcare accused the company of “covering up”, adding: “Quite senior staff at the hospital went along with it and just handed the pots over to his staff when they came to collect them.” Read full story Source: The Independent, 30 September 2020
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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. -
News Article
Hospital chiefs keen to restart operations as covid peak passes
Patient Safety Learning posted a news article in News
Several acute trust chief executives have told HSJ they are keen to resume more planned operations, as the peak of new coronavirus cases has passed and many hospital beds remain empty. Some trust leaders said they believed routine elective surgery could be restarted as early as next week. There is also tension between NHS hospitals — some of which are keen to resume their own planned care, especially the more urgent operations — and a desire to use private hospitals, which have been booked out by NHS England. The government said yesterday the number of people in hospitals with COVID-19 has fallen by 10% over the last week. Around 42% of acute beds are now unoccupied, according to figures seen by HSJ. The peak of new infection cases in hospitals was at about 3,000 on 1 April — the number is now about half that figure. However, there will be fears nationally about the NHS seeking to return to normal and being caught out by ongoing COVID-19 pressures, or by a second peak of infections. Read full story Source: HSJ, 24 April 2020 -
News Article
NHS trusts suspend life-saving organ transplants
Patient Safety Learning posted a news article in News
Major transplant centres have stopped performing many of their procedures due to the coronavirus pandemic, while the national coordinating body says a complete cessation “may only be days away”. Read full story (paywalled) Source: HSJ, 2 April 2020 -
News ArticleNHS hospitals have been told to cancel operations in an effort to free up 30,000 beds to create space for an expected surge in coronavirus patients. In a letter to NHS bosses today, NHS England said hospitals should look to cancel all non-urgent surgeries for at least three months starting from 15 April. Hospitals were given discretion to begin winding down activity immediately to help train staff and begin work setting up makeshift intensive care wards. Any cancer operations and patients needing emergency treatment will not be affected. The letter from NHS England Chief Executive Simon Stevens said: “The operational aim is to expand critical care capacity to the maximum; free up 30,000 (or more) of the English NHS’s 100,000 general and acute beds." In the meantime hospitals were told to do as much elective surgery, such as hip operations and knee replacements, as possible and to use private sector hospitals which it said could free up 12 to 15,000 beds across England. Sir Simon also said patients who did not need to be in hospital should be discharged as quickly as possible adding: “Community health providers must take immediate full responsibility for urgent discharge of all eligible patients identified by acute providers on a discharge list. For those needing social care, emergency legislation before Parliament this week will ensure that eligibility assessments do not delay discharge. Read full story Source: The Independent, 17 March 2020
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Content Article
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. -
News Article
NHS prepares to cancel elective ops in readiness for covid-19 surge
Patient Safety Learning posted a news article in News
System leaders are telling hospitals to prepare for a potential suspension of all non-emergency elective procedures which could last for months, as they get ready for a surge in coronavirus patients. Senior sources told HSJ NHS England had asked trusts to risk stratify elective patients in readiness for having to suspend non-emergency work to free up capacity. HSJ understands trusts have been told to firm up their plans for how they would incrementally reduce and potentially suspend non-emergency operations, while also protecting “life saving” procedures such as cancer treatment. An announcement is expected soon, with patients affected given at least 48 hours notice. It has not been decided how long it might last for, as the duration of any surge in cases and acute demand is unknown. But HSJ has been told it could stretch out for several months, with three or four months discussed, which would potentially mean tens of or even hundreds of thousands of cancelled operations. Read full story (paywalled) Source: HSJ, 12 March 2020 -
Content ArticleMy health has always been a ‘challenge’ as they say. I had a stoma in 1988, when I was 28 years old, for bowel disease. They were never sure if it was Crohn's disease or ulcerative colitis, but I was more than happy to kiss my rotten colon goodbye. It restored my bowel health and I carried on working and living my life with my husband and child. Two years after the ileostomy, I had further abdominal problems and a MRI suggested ovarian cancer. I had an emergency laparotomy which revealed severe endometriosis which had obliterated my whole pelvis and infiltrated my internal organs. The gynaecologist closed me up and said nothing could be done as my pelvis was ‘frozen’ and I would have to be treated medically. The condition plagued me for the next 20 years; I developed cysts in the pelvis which were drained repeatedly. My health was at times poor but I still managed to work and live my life. In 2010, my gynaecologist retired and I was referred to a new team. They were based 80 miles from where I lived, which was a nuisance but I felt it was worth the journey to have the best. They were adamant I needed a hysterectomy – they were not happy with the recent imaging and felt one of the cysts looked suspect. I spent years putting this off as I was very fearful. I had been told it could be very easy to make things much worse. In 2012 my mum had a massive brain haemorrhage and I became her carer, but by 2014 they were still saying I needed the surgery to find out what the suspect mass actually was so, reluctantly, I agreed. January 2015 The hysterectomy went ahead at a private hospital. I was in BUPA, my mother was brain damaged and I was her carer, I needed this op out of the way so I could go back to caring for her. I awoke from the surgery to be told it had been very difficult – I felt totally wiped out. Two days after the operation, there was no improvement. I was encouraged to get up from the bed; I could barely move but I managed a few steps when I felt something running down my legs forming a green puddle on the floor. My bowel had perforated and the contents were flooding out of my vagina. My consultant was away and I was transferred late at night to the local NHS hospital. That was a nightmare in itself as they at first wouldn’t accept me. I lay there in A&E with warm liquid pumping out of me with every spasm of my bowel. I was convinced it was blood and I tried not to think of my loved ones whom I thought I’d never see again. My poor husband looked on helplessly; he spent a freezing night in the car as he wanted to be near me. I spent 3 months in hospital being fed through my central vein. I was told I may never eat or drink again and my whole life just fell apart. It was explained the suspect mass was in fact a twisted mess of bowel, adhesions and goodness knows what possibly caused by the repeated aspirations I’d had for the endometriosis. I was told because of the perforation I now had a fistula which is essentially a connection between my small bowel and my skin. Despite my numerous surgical experiences, I had never heard of such a thing but Dr Google soon educated me and it did not make good reading. I became seriously depressed, wanting my life to end. I was discharged in the spring of 2015 to a totally different world. I could by now eat small amounts but the holes appearing on my abdominal wall were evidence the fistula had not healed. I was too afraid to move as any activity meant I’d have ominous discharges from various orifices. I totally lost confidence in myself, the doctors and the world in general… I became a recluse. Life with a fistula was difficult. Apart from the constant dressings required to contain the output, I was in permanent pain and suffered frequent infections. Considering I had gone into hospital reasonably well and come out like this was almost too much to bear. I tried to access mental health support but I was put on a waiting list whilst my mental state got progressively worse. I was told I would have to wait for two years for the fistula to be repaired. It was a long wait, my daughter had a baby so that kept me going and I looked forward to being free of this demon within. I missed the old capable me so much. March 2017 The repair op took place this time in the NHS hospital, albeit as a private patient again. I couldn’t wait any longer and so once again made use of my medical insurance. Again I had serious complications. The days that followed the surgery were horrific, I truly wanted to die. My gut had stopped working, a condition called ileus. Bile was building up in the stomach so I had a nasogastric tube inserted; the thirst was causing me to have hallucinations. I tried to impress upon everyone how ill I was feeling, but I didn’t feel believed; they told me I was anxious and all my problems were normal post op things. My husband called as usual to visit, getting more worried as each day was passing. I had spiked a temperature of 39.6⁰C. I cried into his chest as I tried to sit up to relieve the horrific symptoms I was experiencing. Next minute I had no breath, I was suffocating. My husband called for help and, even at that point, I was told I was having a panic attack until the nurse saw my oxygen levels – they were 71% which was dangerously low. I was having a stage 1 respiratory arrest, and I was rushed to ICU and spent days fighting for my life. A three month hospital stay followed and this further catastrophe had resulted in a fistula worse than the one I went in with. I now had to wear three stoma bags, two of which leaked constantly. I felt a mutilated mess. Again, I left hospital a broken shell, with no support apart from my family who were also finding it hard to accept what had happened to me. Life now... It’s now 3 years since the failed repair and I have never recovered. It actually made things much worse. As well as the fistulae and three stoma bags, I now have bladder problems as part of my bladder was excised during the last op and gallbladder disease thanks to the parenteral nutrition. The inflammation in my body has led to autoimmune diseases, such as scleritis, which is an agonising and destructive eye condition. The whole awful experience has left me a broken, psychological wreck. I finally accessed mental health support at the end of 2019 and have been diagnosed with post traumatic stress disorder (PTSD), anxiety and depression. Life is difficult. In my mind there are so many unresolved issues which have plunged me into a deep pit of depression I can’t get out of. The therapy I now receive is ‘systemic’ so basically addresses how my husband and I are responding to the trauma, rather than the trauma itself. The initial trauma of my surgery going so wrong has now been followed by a second trauma of lack of support, feelings of worthlessness and the consequences of having a complex condition whilst living in rural west Wales where my local hospital can’t treat me. How I wish I’d said NO to that fateful hysterectomy! But we don’t do we. The surgeons are the experts, they lead and we follow, that’s how it works. Lamb to the slaughter springs to mind. That is probably unfair, my surgical luck was bound to run out one day, but I am angry at losing one of life’s most important gifts – good health. To make matters worse I’ve discovered that the suspect mass that they told me had to come out, had actually been identified 30 years previously. It was a harmless benign fibroma. That makes things harder to bear as I realise I probably never even needed the surgery. I didn’t complain or even ask many questions as I was too ill, traumatised and exhausted. My mother ended up in a home, my marriage is understandably struggling, my husband and I no longer work. I had nothing left to challenge anyone. My psychologist says I need answers to help me move on but I’m now told it’s too late. I have to go back to that hospital because I am now so complex my local hospitals won’t treat me. It’s a 3 hour round trip to a place that absolutely terrifies me. An enterocutaneous fistula is a very rare complication of surgery. But as I told my Consultant, it’s only rare until it happens to you. Then statistics become irrelevant. They seem to overlook the fact that there is a person behind that tiny statistic, who has to somehow learn to live again with all the fallout of that disastrous surgical experience.
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Content Article
10,000 feet - Patient Safety in the operating theatre
Claire Cox posted an article in Process improvement
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Content ArticleFrom the 5365 operations, 188 adverse events were recorded. Of these, 106 adverse events (56.4%) were due to human error, of which cognitive error accounted for 99 of 192 human performance deficiencies (51.6%). These data provide a framework and impetus for new quality improvement initiatives incorporating cognitive training to mitigate human error in surgery.
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Remove central lines supine - animation (2017)
Claire Cox posted an article in Implementation of improvements
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News Article
Hywel Dda cancels operations after 'critical pressures'
Patient Safety Learning posted a news article in News
A health board has cancelled planned operations at four of its hospitals "in the interest of patient safety". Hywel Dda University Health Board made the decision after "an extraordinary weekend" of "critical pressures". On Monday, inpatient operations were cancelled at Bronglais, Glangwili, Prince Philip and Withybush hospitals in mid and west Wales. The health board said it had contacted the patients affected and outpatient appointments continued as normal. No decisions have been taken yet to cancel more non-emergency operations on Tuesday, it added. Dr Philip Kloer, the health board's medical director, said the weekend saw hospitals "at a level of escalation not seen before". "It is in the interest of patient safety that we have postponed planned operations today," he added. Plaid Cymru's shadow minister for health, Helen Mary Jones, said the decision to cancel operations was "deeply concerning". She said that patients in Wales "deserve so much better". Read full story Source: BBC News, 6 January 2020 -
News Article
Woman awarded £8m after doctors left sponge inside her during surgery
Patient Safety Learning posted a news article in News
A woman has been awarded $10.5 million (£8m) in damages after medical staff left a sponge inside her body. The sponge – which measured 18-by-18 inches and was left behind during surgery – was inside the woman's body for years before she realised. It had been left in her body after she underwent heart surgery at a Kentucky hospital in 2011. The bypass surgery is said to have gone wrong, leaving a mess – and as nurses rushed to deal with the problems, the sponge was left inside her body. It was not discovered for four years, until she had a CT scan in 2015. In the meantime, the sponge had moved around the woman's body, shifting around her intestines and causing pain as it did so. She had her leg amputated and was left with gastrointestinal issues after the sponge eroded into her intestine. The patient's lawyers said the case should be a reminder to hospitals to ensure that objects such as needles and other sharp objects, as well as sponges, are removed from patients after surgery. Read full story Source: The Independent, 1 January 2020 -
News Article
Health strike: Action could delay cancer diagnoses
Patient Safety Learning posted a news article in News
Patients are facing a week of disruption, with more than 10,000 outpatient appointments and surgeries cancelled in Belfast. Some people referred by their GPs on suspicion of cancer could have their diagnosis delayed, the head of the Belfast Trust has said. The trust apologised, blaming industrial action on pay and staffing. Martin Dillon said outpatient cancellations "could potentially lead to a delay in treatment" for cancer. The Department of Health said the serious disruption to services was "extremely distressing". Read full story Source: BBC News, 2 Decmeber 2019
