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Found 73 results
  1. Content Article
    The team addresses the following questions: What are typical organizational protocols for requiring formal risk assessments? What factors should be considered that may change the patient's risk profile and how can clinicians parallel this change with appropriate reassessment and prophylaxis adjustment? What is the current discrepancy between attitudes versus evidence regarding prophylactic efforts? (Particular emphasis on ambulation) What information can be shared between patients and clinicians, and between healthcare settings to improve VTE prevention? What are the barriers to objective reporting and reporting the all too common VTE events post-discharge?
  2. Content Article
    Let’s imagine that you’re in your early 70s and you have a few chronic health problems. Your mobility has been getting worse due to arthritis in your hip. You’ve tried pain killers, had some physiotherapy and now use a stick but the pain and restriction in your function is getting you down. Your GP refers you to your local hospital to see an orthopaedic surgeon to discuss surgery. How do you know if having surgery is the right decision for you? On the face of it the decision may seem easy; have the surgery to cure the problem. Indeed many, or even most of us, would choose this option to be rid of the pain. What, however, about the short- and long-term risks of surgery? We know that with increasing age, and in particular with increasing number of chronic health problems, the medical risks associated with surgery increase. That is to say, the surgical procedure, the hip replacement itself, may go smoothly but the overall process of surgery, anaesthesia and hospitalisation may make existing medical problems worse or create new ones. This is a situation that hundreds of older people face each week in the UK, and as the population ages and advances in medicine and surgery increase, will become even more common. However, quantifying these risks has been a major challenge for researchers to date. The Optimising Shared Decision Making In high RIsk Surgery (OSIRIS) research programme is funded by the National Institute of Health Research (NIHR). We’re focussing on the group of older patients who often have significant chronic health issues and are at greater risk of complications around and after surgery. We’re asking some big questions about how these patients and their doctors currently make decisions about major surgery and how we could improve that process. We are also looking at the data on over 5 million patients to truly understand what happens to older patients in the year after surgery. This will then allow us to develop a tool to forecast and present risks associated with surgery. This will be tested in a trial across UK hospitals, to see if it improves the decisions people make. Presenting a more detailed risk forecast to patients will help them to understand how the choice about surgery may specifically impact them and their lives and so support genuine shared decision-making. Surgery improves the lives of millions of people a year around the world, but it is not without risks and patients and doctors need to be more aware of these and be able to discuss them openly. The outputs of the OSIRIS research programme will help increase that awareness and allow people to make informed decisions where all the risks can be weighed up against all the benefits. Shared decision making and informed consent are hot topics right now in the health care professions and in the media. We’re 2 years into our 6-year research programme and we already know so much more about the decision-making process and how we might improve this. Ultimately, doctors need access to better, more individualised information and patients need to be presented this information in a way that is clear and comprehensible. We are very hopeful that OSIRIS will provide a model to empower patients to make a major decision that is right for them. Watch this space! You can find out more about the research by visiting the OSIRIS Programme website or following @osirisprogramme on Twitter. If you'd like to share your thoughts on any of the issues raised in the blog or another patient safety topic, please get in touch with Patient Safety Learning by emailing content@pslhub.org or leave a comment below.
  3. Content Article
    The Optimising Shared decision-makIng for high RIsk Surgery (OSIRIS) programme is funded by the National Institute for Health Research and investigates different aspects of the decision making process for major surgery. Improving our knowledge of how patients and doctors make decisions about major surgery is an important step in designing and trialling ways of improving this process for patients. We know that a lot of surgery has been cancelled due to COVID-19 and this is a cause of great concern for both patients and healthcare professionals. However, looking to the future, this research it is important to ensure that we optimise decision making process once normal elective surgical services are resumed. We would like to invite you to take part in a research study run as part of OSIRIS Programme. We are looking for volunteers who are 50+ years old, live in the UK and are currently not contemplating undergoing surgery. This study involves an online questionnaire, where you will be presented with a hypothetical medical situation and asked to imagine how you would make decisions in that particular situation. The study will take approximately 25 min to complete. More information is available about the study before you commit to participating. If you are interested in taking part please follow the link below.
  4. Content Article
    I believe all clinicians should read this latest report. There is so much to be learned and so many changes in clinical practice that can be made right away. Since 2018, I have been teaching using Oliver's tragic story to promote reflection on best practice in prescribing and in implementing the Mental Capacity Act. I could write a lot here; however, I believe this is a report all clinicians, and especially all prescribers, need to read in full. A summary of how I see this (or indeed how any individual sees it) it will not be adequate.
  5. Content Article
    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.
  6. Content Article
    Key points Novel clinical risk prediction models (QCOVID) have been developed and evaluated to identify risks of short term severe outcomes due to COVID-19 The risk models have excellent discrimination and are well calibrated; they will be regularly updated as the absolute risks change over time QCOVID has the potential to support public health policy by enabling shared decision making between clinicians and patients, targeted recruitment for clinical trials, and prioritisation for vaccination.
  7. News Article
    Almost half of NHS Trusts in England have reported risks classified as “significant” or “extreme”, with issues facing funding, buildings and failing equipment, according to an analysis by Labour. Highlighting warnings of staff shortages and patient safety, the party demanded urgent action from the government to prepare the health service for the winter months as cases of COVID-19 accelerate across the country. Labour said its study of 114 NHS Trusts’ risks registers showed that over three quarters of trusts logged a workforce risk. The analysis also revealed that 66% reported a financial risk, 82% highlighted risks directly related to COVID-19 and 84% recorded a risk to patient safety. Almost half of Trusts (54), the party said, had outlined risks described as “significant” or “extreme”. One hospital trust reported it was “not financially stable” beyond the current financial year while another recorded a potential risk to patient safety due to “structural deficiencies” in roof structure. NHS hospitals are expected to consider risks to their operations and processes and when risks are identified, it is likely they will have been considered at board level and mitigations put in place. Describing the registers – compiled between March and August - as “worrying” in a normal winter, Jonathan Ashworth, the shadow health secretary, said: “In the coming winter, with the incompetent handling of the test and trace system leaving the NHS wide open and poorly supported, they take on a whole new meaning." "We urgently need a commitment from ministers to fix the problems with test and trace and a timetable by which these issues will finally be sorted. On top of this it is vital that ministers confirm that the NHS will get the additional support it needs to address these risks." Read full story Source: The Independent, 6 October 2020
  8. Content Article
    The link below will take to you a number of case studies showing how healthcare teams have responded and made changes to improve how they protect, support and engage staff. The case studies include examples from primary care, secondary care, infection prevention and staff education programmes. Also included is information and guidance on: risk assessments protecting all staff speaking up regional support.
  9. Event
    The Flight Safety Foundation goal with this Seminar is to promote further globally the practical implementation of the concepts of system safety thinking, resilience and Safety II. There will be two sessions, one for each day, that will consist of briefings and a Q&A panel afterwards. The following themes are suggested for briefings and discussions for the Seminar 1.The limits of only learning from unwanted events. 2. Individuals’ natural versus organisations’ consciously pursued resilience. 3. How the ancient evolutionary individual instincts for psychological safety affect individual and team learning and how these can be positively managed? 4. The slow- and fast-moving sands of operations and environment change over time and their significance for safety. 5. How to pay as much attention to why work usually goes well as to why it occasionally goes wrong? 6. Understanding performance adjustments of individuals to get the job done. 7. The blessings and perils of performance variability. 8. Learning from data versus learning from observing. 9. Learning from differences in operations versus learning from monitoring for excrescences. 10. Can risk- and resilience-based concepts work together? 11. Does just culture matter for learning from success? 12. How to document explicitly, maintain current and use the information about success factors and safety barriers and shall this be a part of organisational SMS? Further information