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Showing results for tags 'Operating theatre / recovery'.
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Content ArticleThis Maternity and Newborn Safety Investigation (MNSI) safety spotlight shares what they found regarding nitrous oxide decommissioning and offers prompts to help providers keep staff informed and equipment checks consistent.
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Content ArticleDespite improving patient safety in some perioperative settings, some checklists are not living up to their potential and complaints of “checklist fatigue” and outright rejection of checklists are growing. Problems reported often concern human factors: poor design, inadequate introduction and training, duplication with other safety checks, poor integration with existing workflow, and cultural barriers. Each medical setting—such as an operating room or a critical care unit—and different clinical needs—such as a shift handover or critical event response—require a different checklist design. One size will not fit all, and checklists must be built around the structure of medical teams and the flow of their work in those settings. Useful guidance can be found in the literature; however, to date, no integrated and comprehensive framework exists to guide development and design of checklists to be effective and harmonious with the flow of medical and perioperative tasks. Burian and colleagues propose such a framework organised around the 5 stages of the checklist life cycle: (1) conception, (2) determination of content and design, (3) testing and validation, (4) induction, training, and implementation, and (5) ongoing evaluation, revision, and possible retirement. They illustrate one way in which the design of checklists can better match user needs in specific perioperative settings (in this case, the operating room during critical events). Medical checklists will only live up to their potential to improve the quality of patient care if their development is improved and their designs are tailored to the specific needs of the users and the environments in which they are used.
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Content ArticleThis National Patient Safety Alert, issued by the NHS England National Patient Safety Team and endorsed by the Royal College of Obstetricians & Gynaecologists, Royal College of Midwives and Royal College of Anaesthetists, instructs all relevant NHS funded maternity care providers to cease pre-preparing oxytocin infusions at ward level in all clinical areas. All actions should be completed by 31 March 2025. Midwives need to complete several tasks immediately and simultaneously following birth to ensure the safety of both the mother and baby. To support this, postpartum oxytocin infusions have been prepared in advance of being required. If a pre-prepared oxytocin infusion is unintentionally given before the baby is born, for example if it is confused with standard fluids or the intrapartum and postpartum infusions are confused, the woman’s contractions will increase in frequency and strength. This can lower the baby’s oxygen levels and alter their heart rate, increasing the risk of placental abruption (where the placenta prematurely separates from the uterus and deprives the baby of oxygen). A review of the National Reporting and Learning Systems over a 5 year period identified 25 incidents. Actions required: Review and update local clinical procedures (or equivalent documents) to ensure: Oxytocin infusions for any indication are not pre-prepared at ward level in any clinical area (including delivery suites and theatres). Post-partum haemorrhage (PPH) kits/ trolleys are immediately available in all clinical areas/theatres where it may be required. Where a woman is identified to be at high risk of PPH: (a) the PPH kit/trolley should be brought into the labour/delivery room/theatre during the second stage of labour, (b) the postpartum oxytocin infusion should be prepared at the time of birth and not before, (c) a second midwife should be available to support the administration of the postpartum oxytocin infusion. Roles and responsibilities of staff groups in the labour setting, including theatres, are clearly defined in terms of prescribing, preparation, administration and disposal of oxytocin infusions. Including: intrapartum oxytocin infusions, postpartum oxytocin infusions and unused, pre-prepared oxytocin. infusions.
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Engagement with patient & public networks
Patient Safety Learning posted an event in Community Calendar
untilThe Centre for Perioperative Care (CPOC) progresses a number of innovative and exciting collaborations with its patient facing partners since its origin in 2019. This webinar is designed to bring together lay and patient representation from both its Board and Advisory Group partners, as well as patient organisations and charities. The aim is to understand better the needs of patient and public engagement from a perioperative perspective. The webinar will include presentations from speakers investigating the Psychological and Behavioural science backgrounds of patients’ needs and wants, as well as patientvoices@RCOA. There will be an opportunity to develop these ideas in breakout groups to produce a consensus statement which CPOC will use to further develop the patient facing perioperative strategy. Considering the increasing waiting times that patients are having to process, while seeing their conditions potentially deteriorate, this is an opportunity to bring like-minded voices together to benefit patient outcomes within the UK. Further information -
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National NatSSIPs Network
Patient Safety Learning posted an event in Community Calendar
untilNHS England is currently seeking views on whether the existing Never Events Framework remains an effective mechanism to drive patient safety improvement. Never Events are defined as patient safety incidents that are ‘wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers’. This webinar, hosted by the National NatSSIPs Network and supported by Patient Safety Learning, will feature a panel discussion on the Never Events framework and the proposals set out in this consultation. The National NatSSIPs Network is a group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. Speakers: Helen Hughes Dr Annie Hunningher Dr Sam Machen Claire Cox Guest Speaker Guest Speaker Register- Posted
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Theatres & Decontamination Conference
Patient Safety Learning posted an event in Community Calendar
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EventJoin us for a full day of education covering those topics that are the basis of our (or your) everyday practice. From risk management to infection control and patient care to practitioners wellbeing, leave the day informed, challenged and inspired. Book your tickets
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Operating Theatres Conference 2024
Sam posted an event in Community Calendar
NHS England have set out an ambitious three-year plan back in February 2022, aimed at tackling the surgical backlog that has reached a record high following the pandemic. With a major milestone on the horizon to reduce wait times over a year by March 2025, we take a look at the progress being made and how trusts around the country are collaborating in order to drive down waiting times. Join Salford Professional Development for their 9th annual conference where industry leading speakers from all corners of the healthcare sector will come together to dive into captivating discussions on the key issues operating theatres are currently facing, alongside how they are driving innovation and utilising technology to support their practices. Hear unravelling insights on how to enhance sustainability, boost surgery productivity, amplify effectiveness, and work together in order to drive down the surgical backlog, ensuring a person-centred approach. This isn't just theory – it's practical wisdom you can immediately apply to your own surgical team. Case study examples and our panel of experts will illustrate how teams have transformed their practice and brought innovative solutions into play such as the HVLC delivery, GIRFT, Robotics and Sustainability action plans, and how they are tackling challenges facing the trusts theatres and beyond. Register -
Content ArticleTheatres 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.
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Content ArticleDr Liz O’Riordan is a breast cancer surgeon who has battled against social, physical and mental challenges to practise at the top of her field. Under the Knife charts Liz’s incredible highs: performing like a couture dressmaker as she moulded and reshaped women’s breasts, while saving their lives; to the heart-breaking lows of telling ten women a day that they had cancer. But this memoir is more than just an eye-opening look at the realities of training to be a female surgeon in a man’s world. In addition to this high-powered, high-pressured role, Liz faced her own breast cancer diagnosis, severe depression and suicidal thoughts, in tandem with commonplace sexual harassment and bullying. And by revealing how she coped when her life crashed around her, she demonstrates there is always hope.
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Content ArticleIntrahospital transport is a common occurrence for many hospitalised patients. Critically ill children are an especially vulnerable population who experience preventable adverse events at least once a week, on average. Transporting these patients throughout the hospital introduces additional hazards and increases the risk of adverse events. The transport process can be decomposed into a series of steps, each incurring specific risk. These risks are numerous and few of these risks are specific to the transport process. There is a paucity of literature available on paediatric intrahospital transport and related adverse events. Elliot et al. recently reviewed the Wake Up Safe database, a paediatric anesthesia quality improvement initiative across member institutions to disseminate information on best practices, for paediatric perioperative adverse events associated with anaesthesia-directed transport. The authors present several examples of airway and respiratory events taken from the database and discuss the complexity of the transport process.
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Content ArticleTony 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.
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Marsha Jadoonanan, nurse and Head of Patient Safety and Learning at HCA Healthcare UK (HCA UK), spoke to us about a recent opportunity to learn from patient safety incidents involving wrong site anaesthetic blocks. She describes the new learning approach she and her colleagues used, which focused on engaging staff working in a variety of roles to create a safe space to focus on identifying ‘work as done’. -
Content ArticleCommercial aviation practices, including the role of the pilot monitoring, the sterile flight deck rule, and computerised checklists, have direct applicability to anaesthesia care. Checklists are commonly used in the operating room, especially the World Health Organization surgical safety checklist. However, the use of aviation-style computerised checklists offers additional benefits. In this editorial, Jelacic et al. discuss how these commercial aviation practices may be applied in the operating room.
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Content ArticleAccording to the World Health Organization, humanity faces its greatest ever threat: the climate and ecological crisis. Healthcare services globally have a large carbon footprint, accounting for 4-5% of total carbon emissions. Surgery is particularly carbon intensive, with a typical single operation estimated to generate between 150-170kgCO2e, equivalent to driving 450 miles in an average petrol car. The UK and Ireland surgical colleges have recognised that it is imperative for us to act collectively and urgently to address this issue. The Royal College of Surgeons of Edinburgh have collated a compendium of peer-reviewed evidence, guidelines and policies that inform the interventions included in the Intercollegiate Green Theatre Checklist. This compendium should support members of the surgical team to introduce changes in their own operating departments. The recommendations apply the principles of sustainable quality improvement in healthcare, which aim to achieve the “triple bottom line” of environmental, social and economic impacts. How to use the checklist The checklist is divided into four sections, the first dedicated to anaesthetic care, and the subsequent three looking at preparation for surgery, intra-operative practice and post-operative measures. It is suggested the checklist is initially used at the daily brief at the start of an operating list, as an aide-memoire for the team of the modifications that could be applied there and then. Once these practices become embedded into practice, then the checklist may be used less frequently. At present, some theatres will lack the infrastructure required to enact all the suggested interventions and so the checklist can serve as a roadmap for discussion with management, or at departmental meetings, to guide required changes. Finally, if completed regularly, the checklist could also be used as a scorecard to monitor progress.
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Content ArticleTraditional approaches to patient safety and handoffs need redesigning to acknowledge the different constraints, goals, and requirements necessary for each individual patient. There is no “one size fits all” approach to patient safety, handoffs or a perfect checklist. Despite the inherit complexity present in healthcare systems, we tend to reduce our thinking about handoffs into simple solutions of checklists and cognitive aids. In studies of these tools, their association with patient outcomes is unclear with mixed results in large studies. Incorporating general resilience engineering principles of visibility, understanding, anticipation, and learning provides new opportunities for increased patient safety. This involves situating the handoff in the context of the system - understanding the process of summarising pre-handoff and of developing understanding post-handoff, tracing flows of information and patients, and considering the role of feedback and control loops in the system. Direct observations, analysis of multiple outcomes, focus on patient evolving specific exceptions, reducing the number of handoffs, taking time for two-way discussions, and user-centred design and redesign may promote acceptability and sustainability of a new view of handoffs for improved patient safety.
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News Article
Researchers study brain activity of surgeons for signs of cognitive overload
Patient Safety Learning posted a news article in News
It is a high-stakes scenario for any surgeon: a 65-year-old male patient with a high BMI and a heart condition is undergoing emergency surgery for a perforated appendix. An internal bleed has been detected, an anaesthetics monitor is malfunctioning and various bleepers are sounding – before an urgent call comes in about an ectopic pregnancy on another ward. This kind of drama routinely plays out in operating theatres, but in this case trainee surgeon Mary Goble is being put through her paces by a team of researchers at Imperial College London who are studying what goes on inside the brains of surgeons as they perform life-or-death procedures. Goble looks cool and collected as she laparoscopically excises the silicon appendix, while fending off a barrage of distractions. But her brain activity, monitored through a cap covered in optical probes, may tell a different story. The researchers, led by Daniel Leff, a senior researcher and consultant breast surgeon at Imperial College healthcare NHS Trust, are working to detect telltale signs of cognitive overload based on brain activity. In future, they say, this could help flag warning signs during surgery. “The operating theatre can be a very chaotic environment and, as a surgeon, you have to keep your head and stay calm when everyone is losing theirs,” said Leff. “As the cognitive load increases, it has major implications for patient safety. There’s no tool we can use to know that surgeon is coping with the cognitive demands of that environment. What happens when the surgeon is maxed out?” In the future, Leff envisages a system that could read out brain activity in real-time in the operating theatre and trigger an intervention if a surgeon is at risk of overload. Read full story Source: 2 March 2024 -
News ArticleTheatre staff at a major hospital “deliberately slowed down” elective activity to limit the number of operations that could be done each day, an NHS England review has been told. The culture in theatres at the William Harvey Hospital in Ashford, run by East Kent Hospitals University Foundation Trust, was a “significant issue” according to an education quality intervention review report into trauma and orthopaedic training at the hospital. The review, dated October and made public by NHSE in December 2023, was launched after concerns were raised by staff at the trust in the General Medical Council’s national training survey, published every July. Problems raised by junior doctors and their supervisors to the NHSE review included perceptions that juniors were made to feel uncomfortable by the trauma theatre team and that there was also “animosity” from the trauma theatre team towards surgeons. The review said trauma theatre staff were heard “bragging” about their behaviour towards surgeons and that they resisted the number of cases scheduled on a list, claiming it was “unrealistic". Read full story (paywalled) Source: HSJ, 19 January 2024
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News ArticleHalf of surgeons in England have considered leaving the NHS amid frustration over a lack of access to operating rooms, a new survey shows. More than 3,000 surgeons contemplated quitting the health service in the last year, with two-thirds reporting burn out and work-related stress to be their main challenge, a new survey by the Royal College of Surgeons England has revealed. As the NHS tries to reduce the 7.61 million waiting list backlog, the survey, covering one quarter of all UK surgeons, found that 56% believe that access to operating theatres is a major challenge. RCS England president, Mr Tim Mitchell, said: “At a time when record waiting lists persist across the UK, it is deeply concerning that NHS productivity has decreased. “The reasons for this are multifactorial, but access to operating theatres and staff wellbeing certainly play a major part. If surgical teams cannot get into operating theatres, patients will continue to endure unacceptably long waits for surgery. “There is an urgent need to increase theatre capacity and ensure existing theatre spaces are used to maximum capacity. There is also a lot of work to be done to retain staff at all levels by reducing burnout and improving morale.” Read full story Source: The Independent, 18 January 2024
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EventThis session will focus on blood and bodily fluids exposure, including sharps injuries as well as their risk factors and prevention strategies. This webinar will present the 2020 RCN study and the 2022 UK NHS Trust study of sharps injury (SI) among UK HCW and, by comparing these results with other countries, question whether UK 2013 Sharps Regulations went far enough, and whether increased emphasis may be required on reporting, recording and implementation of effective prevention strategies. Learning outcomes: Define sharps injuries (SI); the four steps in sharps usage that place staff at risk; and the top two staff groups at risk of SI. Discuss the incidence of SI in the UK and UK HCW staff groups compared with international incidences. Appraise whether facility’s reporting and recording of SI enables benchmarking of the efficacy of their preventive strategies. Define three prevention strategies proven to reduce SI. Register
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EventuntilThe aim of this webinar is to share, engage and discuss with clinicians, patient safety managers, patients and leaders the latest standards. There will be 2 sessions: 17.30: Session 1 – NatSSIPs 2: what it is and why it matters Welcome and introduction The CPOC perspective The Patient Safety Learning perspective Photo review of why NatSIPPs matters The patient perspective What is new in NatSIPPs 2? Resources to support Implementation: Checklists, infographics Q&A 18.30: Session 2 – NatSSIPs 2: implementation, practical insights and tips Our NatSIPPs 2 Workshop and how to consider a NatSSIPs gap analysis Team training for NatSIPPs 2 Q&A Register
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EventuntilThe provision of safe and quality care is the most fundamental principle to consider for patients in perioperative practice. Alongside this commitment, is the safety and welfare of all staff and visitors within the setting. Risk assessment, staffing ratios, competency and skill are crucial to ensuring that the intended outcome for patients is achieved as far as is reasonably practicable. The discussion will outline how this can be achieved utilising the recommendations by the Association for Perioperative Practice (AfPP). Learning outcomes: Understanding risk and the process of risk assessment in perioperative practice. The components of a safe perioperative environment. How to calculate a safe staffing model for your environment based on the AfPP standard. Register
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Human factors in operating theatres
Patient Safety Learning posted an event in Community Calendar
Understanding human factors will allow surgical teams to enhance performance, culture and organisation of operating theatres. This one day masterclass will concentrate on human factors within the operating room. This is aimed at all theatre staff. It will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This Masterclass will focus on systems to improve patient safety as well as looking at never events and how to learn from them using a human factors approach. Key learning objectives: Safety culture Human factors Leadership Never events This masterclass is aimed at all theatre staff. Register hub members receive 20% discount using code hcuk20kh. -
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The Trauma of Trauma
Patient Safety Learning posted an event in Community Calendar
Treating trauma can be traumatic. The UK now has over 30 major trauma centres which treat more than 40,000 patients with traumatic injuries each year. For people under the age of 40, trauma remains a leading cause of death, and trauma survivors often experience life-changing injury and long-term disability. This study day examines the impact of various traumatic injuries on patients and the teams who care for them. Exploring burns, orthopaedic and battlefield trauma, as well as how to manage mass casualty events, you’ll learn about a wide range of trauma care scenarios. The speakers will outline how battlefield experience can be adapted for frontline work in within the NHS, with a key focus on the mental, physical and practical skills required to manage trauma to achieve the best outcomes for both patient and practitioner. The goal is to provide you with theory and practical skills to help you manage the mental and physical aspects of trauma in different settings. The sessions will also support you with understanding how skills learnt in one area can be transferred to another. Topics include: Treatment of acute burn injuries. The role of the Orthopaedic Trauma Coordinator. Introduction to AO Trauma Principles. Mass Casualty Events and the Citizen Aid App – with practical demo. Trauma and resilience in the armed forces: A Captain’s perspective. Trauma management on the battlefield. Register
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