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Found 243 results
  1. Event
    until
    Cardiovascular disease (conditions affecting the heart or blood vessels) accounts for around 1 in 4 deaths in the UK each year. A person’s risk of cardiovascular disease depends on their blood pressure, weight, cholesterol, smoking status, family history, and other factors. Identifying an individual’s risk allows preventative measures, such as changes in lifestyle or taking medicines, to reduce risk and improve health outcomes. An assessment of cardiovascular risk is part of routine care, during the NHS Health Check, for example, but more can be done to optimise the identification of risk for the future. Join this webinar to learn about NIHR research on 3 promising new ways to identify people at risk of heart and circulation problems using information from clinical care that could enable intervention at an earlier stage leading to improved outcomes. Presentations will be followed by a Q&A session. This 1-hour, online webinar will cover new tools to predict future cardiovascular risk including: a heart disease calculator n AI-enabled ECG AI analysis of heart scans. Presenters include: Professor Julia Hippisley-Cox Dr Fu Siong Ng Dr Kenneth Chan Register
  2. News Article
    Mental health patients and nursing staff are being failed by a system “buckling under the weight of demand and decades of underinvestment”, nursing leaders have warned. Their comments came in response to the publication of the Health Services Safety Investigations Body (HSSIB)'s final report in its series of investigations focusing on mental health inpatient services in England. The report warned that staffing and resource constraints in inpatient and community mental health settings were impacting the ability to provide safe and therapeutic care to patients. Read full article Source: Nursing Times, 29 May 2025
  3. Content Article
    In June 2023 the Secretary of State for Health and Social Care announced that HSSIB would undertake a series of investigations focused on mental health inpatient settings. This overarching report brings together and explores cross-cutting patient safety risks across five individual investigations. The aim of this report is to examine patient safety risks identified across the following HSSIB investigations: Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of suicide risk and safety planning (12 September 2024) Creating conditions for the delivery of safe and therapeutic care to adults in mental health inpatient settings (24 October 2024) Mental health inpatient settings: out of area placements (21 November 2024) Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s mental health services to adult mental health services (12 December 2024) Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge (30 January 2025) Findings Safety, investigation, and learning culture There remains a fear of blame in mental health settings when safety events happen. This contributes to a more defensive culture despite staff actively wanting to learn. Many recommendations to support learning for improvements in mental health care do not lead to implemented actions. Reasons for this include a lack of impact assessment resulting in unintended consequences, no clear recipient involved in the development of recommendations, and duplicated recommendations across organisations. System integration and accountability The integration of health and social care within an integrated care system currently relies on relationships, with an expectation and hope that they will work well. However, where this is not the case, a lack of clear accountability can result in poor outcomes for people with mental illness and severe mental illness. The delivery of care for people with mental illness and severe mental illness is challenging because health and social care services are not always integrated and their goals are not always aligned. Physical health of patients in mental health inpatient settings There are gaps in the provision of physical health care for people with severe mental illness, including inconsistent health checks, poor emergency responses, and misattribution of physical symptoms to mental illness. The misattribution of physical symptoms to patients’ mental health was observed and had the potential to contribute to worsened patient outcomes. National reports, strategies and research have made recommendations to improve the physical health of people with severe mental illness. However, there is evidence that recommendations are delayed in implementation and people continue to die prematurely. Integrated care boards lack the required data and the necessary analytical capability to assess disparities in access, experience and outcomes related to the physical health needs of people with severe mental illness. There is variation in how the physical health checks are carried out on mental health inpatient wards, with limitations in processes for following up on patients’ physical health needs. There is variation in the knowledge, skills and experience of staff who undertake physical health checks and in the environments in which these checks take place. Patients may not always be supported in terms of health education about their physical health risks and modifiable risk factors, for example smoking, dietary advice and physical activity. Caring for people in the community Integrated care boards cannot consistently draw reliable insights from data at national, system or local level, to optimise and improve services, patient care, and outcomes across mental health pathways of care. This results in variability in service provision which does not always meet the needs of individual patients or local populations. Inpatient ‘bed days’ are taken up by people who no longer need them, because people who are clinically fit for discharge are delayed in being transferred to their home or a suitable residence (appropriate placement). Reasons for delayed discharges include issues with housing support and establishing suitable accommodation. This means patients are not always in the right place of care. Barriers to discharge affect patient flow and may result in delays in admission for people with severe mental illness. This means they have to be cared for in a community setting while waiting for an inpatient bed. There is variation across the country in how drug and alcohol services are provided. The variation does not allow for fair and equitable treatment for all patients. Community services are vital to support people to stay as well as possible and to prevent hospital admissions. However, there is variation in community service provision across the country. Staffing and resourcing Staffing and resource constraints in inpatient and community mental health settings impact their ability to provide safe and therapeutic care. In inpatient settings, constraints contribute to mental health wards aiming to staff for ‘safety’ but not always for ‘therapy’. Challenges for staff include the emotionally demanding nature of their work; this can lead to staff burnout and sickness, and further strain on services. There are gaps in mental health workforce planning, particularly in community services where there is no evidence based workforce planning tool to support a standardised staffing establishment setting model. Digital support for safe and therapeutic care A lack of interoperability or integration between digital systems affects the provision of care across mental health, acute and community providers. Challenges in securing appropriate funding impacts on the ability of hospitals to integrate and update their digital services and infrastructure. Electronic patient record functionality is often not available or does not meet staff needs, and so it is not used. Examples include absent functions for food and fluid balance monitoring and risk assessment of venous thromboembolism (blood clots). Challenges in providing and maintaining patient-facing technology, for example televisions and payphones, impacts on the therapeutic environment and the ability of patients to maintain contact with families and loved ones. Where technology for monitoring patients had been introduced, implementation has required considerations to ensure it is used appropriately, is patient-centred, maintains therapeutic engagement, and supports patients to feel safe. Suicide risk and safety assessment ‘Doing’ tasks, like ‘ticking’ checklists, overshadow meaningful, empathetic ‘being’ interactions with patients. Open, compassionate conversations that build trust and therapeutic relationships, enabling patients to own their risk while feeling supported, can help mitigate this. Investigation processes can contribute to a fear of blame, and subsequently contribute to defensive practices such as checklists and a ‘tick box’ culture. This inhibits open and honest conversations and the ability to put the patient, as their authentic self, at the heart of them. Safety recommendations HSSIB recommends that the Department of Health and Social Care continues to work with the ‘recommendations but no action working group’ and other relevant organisations, to ensure that recommendations made by national organisations specific to mental health inpatient settings are reviewed. This work should consider the mechanisms that supported or hindered the implementation of actions from these recommendations. This may help the Department of Health and Social Care understand what has worked when implementing actions from recommendations and enable learning about why some recommendations have not achieved their intention. HSSIB recommends that the Secretary of State for Health and Social Care directs and oversees the identification and development of a patient safety responsibilities and accountabilities strategy related to health and social care integration. This is to support the management of patient safety risks and issues that span integrated care systems. Safety observation National bodies can improve patient safety in mental health inpatient settings in England by supporting provider investment in equipment, digital systems and physical environments to enable conditions within which staff are able to provide, and patients can receive, safe and therapeutic care.
  4. Content Article
    This letter from the London Fire Brigade draws attention to two key issues that may have implications for fire safety within your hospital, and to request that you review your Fire Risk Assessments accordingly. 1. Corridor use for additional bed capacity Recent news reports and material circulating on social media indicate that some hospitals are increasingly using corridors for additional bed capacity. The use of corridors in this way can present significant challenges to fire safety, including: obstruction of fire escape routes increased fire load in circulation spaces. delayed evacuation times in the event of an emergency. 2. Fire Door Recall – Office for Product Safety and Standards You will be aware that there has been a Product Recall concerning certain hospital fire doors installed across England and Wales, affecting approximately 70 sites, with a significant concentration in London and the Southeast. The manufacturer has identified the affected units and has been in contact with project managers at impacted locations. Where correct fire doors are not used, properly fitted and maintained, and corridors are used to house patients, this can exacerbate the spread of smoke and fire, compromise escape routes, and significantly increasing the risk to life. Given the above risks, we ask that you review your fire risk assessment to ensure that you are compliant with the Regulatory Reform (Fire Safety) Safety and appropriate guidance, to safeguard your patients, staff and visitors in the event of a fire.
  5. News Article
    "Reasonable precautions" could have prevented the deaths of three newborn babies, a fatal accident inquiry has found. Leo Lamont, Ellie McCormick and Mira-Belle Bosch all died within hours of their births in two Lanarkshire hospitals, in 2019 and 2021. The report found all three deaths could "realistically" have been avoided had different advice been given by midwives or procedures followed. The McCormick family said they could "never have imagined" the amount of failures that led to their daughter's death and called it a "catalogue of errors". The inquiry ruled "defects" within the system contributed to each death, including that there was a "lack of an effective means" to highlight risks in one of the pregnancies and that midwives had no guidance to assess preterm labour symptoms. Sheriff Principal Aisha Anwar KC made 11 recommendations for the future, including creating a "trigger list" to identify and assess early labour symptoms. Among these are reviewing electronic patient information records to improve alerts for at risk mothers, and having a direct telephone line to each maternity unit in Scotland for ambulance crews. In a statement, the McCormick family said: "The family could simply never have imagined the scale of both the individual and systems failures that came to light during the inquiry. "What seemed to be flaws with the electronic system of record keeping actually turned out to be a catalogue of errors with numerous opportunities to avoid the tragic outcome that followed." Read full story Source: BBC News, 18 March 2025
  6. Content Article
    In this paper from The Strategy Unit, authors make no attempt whatsoever to dispute the upsides of digital. Time, experience and evaluation will show what gains digital technology has to offer. Instead, they focus exclusively on digital downsides, primarily from the perspective of ‘person-centred care’: They used a wide lens. Rather than focusing down on specific digital technologies, they took a broad definition and sought to examine more general risks and challenges.  Cited downsides included: Making care more transactional: ‘With triage through an algorithm you're only allowed to have one [problem]...It forces consultations to be very transactional’. Compounding disadvantage: ‘Having multiple interacting disadvantages makes it harder to keep with the pace that digital access to care is going at’. Creating disadvantage: ‘We are creating the inverse data quality law: the availability of high-quality data varies inversely with the need for healthcare’. ‘Blaming’ individuals: ‘We use digital products to say to people ‘you should lose weight’ or ‘you have a gambling problem’ - and this puts systemic issues back onto the individual’. Making Evidence Based Medicine harder: ‘When I tried to get data about how many people were using it [an app they were evaluating], and at what times of day, and then how much it costs to provide, how many staff were doing what - I was told I couldn't have this data because it was commercially sensitive’. Attraction to the ‘cutting edge’ rather than the basics: ‘You've got finite resources. Do you spend on bytes versus bricks, for example? So, where you invest in cutting edge technology, that might be expensive, and that means you've got less to spend on physical infrastructure to deliver care in’. Fuelling mechanical thinking: ‘I'm not so much worried about machines becoming more like us…what I worry about is people becoming more and more like machines…Our work [as clinicians] has become less fulfilling as it has been taken over by mechanistic thinking’.
  7. Content Article
    Patient falls are a significant concern in healthcare settings, often leading to severe injuries, prolonged hospital stays and increased healthcare costs. The importance of fall prevention extends beyond patient safety—it reduces hospital liability, enhances patient outcomes and improves overall healthcare efficiency. By proactively assessing and addressing fall risks, healthcare providers can significantly lower the incidence of falls, ensuring a safer environment for patients. Given the aging population and increasing chronic disease burden, fall prevention remains a top priority in improving patient care and quality of life. This blog from Augustine Kumah, Deputy Quality Manager at The Bank Hospital, Accra, Ghana, explores the significance of fall risk assessment, its implementation and its role in reducing fall-related incidents in healthcare settings. Introduction Falls among patients, particularly in healthcare facilities, remain a pressing concern worldwide. These incidents not only lead to injuries, prolonged hospital stays and increased healthcare costs, but can also have lasting psychological impacts on patients. Preventing patient falls necessitates a multifaceted approach, with fall risk assessment at its core.[1] Understanding the impact of patient falls Patient falls are defined as unintentional descents to the ground that occur in healthcare facilities, including hospitals, nursing homes and rehabilitation centres. According to the World Health Organization (WHO), falls are the second leading cause of unintentional injury deaths globally, with older adults being most at risk.[2] In healthcare facilities, the consequences of falls extend beyond physical injuries; they also affect a patient’s confidence, independence, and quality of life. The financial burden of falls on healthcare systems is substantial. Costs include direct expenses such as treatment for fall-related injuries and indirect costs like litigation, reputation damage and loss of trust. Additionally, healthcare providers experience emotional distress and professional repercussions when preventable falls occur under their watch. Hence, fall prevention is not just a patient safety priority but also an ethical obligation and a cost-saving measure. The role of fall risk assessment Fall risk assessment is a systematic process to identify patients at risk of falling. Healthcare providers can implement targeted interventions to mitigate these risks by evaluating intrinsic and extrinsic factors. Intrinsic factors include age, medical history, mobility impairments and cognitive status, while extrinsic factors encompass environmental hazards, medication side effects and inadequate assistive devices. Risk assessment tools, such as the Morse Fall Scale, Hendrich II Fall Risk Model and STRATIFY Risk Assessment Tool have been widely used. These tools provide a structured approach to assess risk levels and guide preventative measures. However, their effectiveness depends on accurate application and regular updates based on patient conditions. Implementing effective fall risk assessments To maximise the efficacy of fall risk assessments, healthcare facilities must adopt evidence-based strategies and integrate them into their workflows. Key steps include: Standardised assessment protocols: Developing and adhering to standardised protocols ensures consistency in evaluating fall risks across different departments and shifts. Protocols should specify the frequency of assessments, criteria for reassessment and documentation requirements. Staff training: Comprehensive training programme for healthcare workers are essential to enhance their competency in conducting fall risk assessments. Training should cover assessment tools, recognition of risk factors and communication of findings to the care team. Patient and family education: Involving patients and their families in fall prevention efforts fosters a collaborative approach. Educating them about potential risks and preventive measures empowers them to contribute to safety. Technology integration: Advanced technologies such as wearable sensors, predictive analytics and electronic health records (EHRs) can augment traditional fall risk assessments. For instance, sensors can monitor patient movements and alert staff to potential falls, while EHRs can flag high-risk patients for closer observation. Challenges in implementing fall risk assessments Despite its benefits, implementing fall risk assessments is not without challenges. Common barriers include: Resource constraints: Limited staffing, time pressures and inadequate funding can hinder comprehensive risk assessments. Overburdened staff may struggle to prioritise fall prevention alongside other responsibilities. Inconsistent application: Variability in applying risk assessment tools can lead to inaccurate results. Subjective judgment, incomplete data collection and lack of protocol adherence contribute to inconsistencies. Resistance to change: Resistance from staff and administrators to adopt new practices or technologies can impede the integration of fall risk assessments into routine care. Patient non-compliance: Some patients may resist interventions such as bed alarms, mobility aids or supervision, increasing their risk of falling. Strategies to overcome the challenges To address these challenges, healthcare facilities can adopt the following strategies: Leadership support: Strong leadership commitment is crucial to allocating resources, establishing accountability and creating a safety culture. Interdisciplinary collaboration: Engaging multidisciplinary teams, including nurses, physicians, physical therapists and pharmacists, ensures a holistic approach to fall risk assessment and prevention. Continuous Quality Improvement: Regular audits, feedback sessions and performance evaluations help identify gaps in fall prevention efforts and drive improvements. Tailored interventions: Personalising interventions based on individual patient needs and preferences increases their acceptability and effectiveness. Conclusion Preventing patient falls requires a proactive and comprehensive approach, with fall risk assessment as a foundational element. Healthcare facilities can significantly reduce fall-related incidents and their associated consequences by identifying at-risk individuals and implementing tailored interventions. However, the success of fall prevention efforts hinges on overcoming implementation challenges through leadership support, interdisciplinary collaboration and continuous improvement. As healthcare systems evolve, leveraging technology and prioritising patient-centred care will be instrumental in advancing fall risk assessments. By embracing these advancements, healthcare providers can create safer environments that uphold all patients' dignity, independence, and well-being. References The Joint Commission. Fall Reduction Program - Definition and Resources, 28 August 2017 WHO. Falls Factsheet. World Health Organization, 26 April 2021.
  8. Content Article
    When someone needs a joint replacement, there are many factors that affect how well they will respond, how quickly they will recover from the procedure and the potential risks of surgery. Patient complexity is the term used to describe these factors and includes other health conditions, sometimes called co-morbidities, as well as local risk factors related to the specific joint needing to be replaced. In this interview, consultant orthopaedic surgeon Sunny Deo and engineer and founder of TCC-Casemix Matthew Bacon, discuss how new technology is allowing surgeons to more accurately predict the surgical risk and outcomes for patients having knee replacement surgery. They describe how a new approach to data modelling is allowing the orthopaedic team at Great Western Hospital NHS Foundation Trust to more accurately assess complexity for individual patients. This has benefits for patient care and outcomes, theatre productivity and the development of pathways that are more patient-centred. They also highlight some patient safety issues associated with elective surgical hubs, which were set up to deal with high volume low complexity patients, including the deprioritising of more complex patients who may be at greatest need of surgery. Finally, they discuss the applicability of this approach to other specialties and areas of healthcare. Read more about clinical complexity in joint replacement surgery in this presentation by Sunny Presentation - Overview of clinical complexity by Sunny Deo.pdf
  9. News Article
    The NHS is "looking into" allegations that patient data was left vulnerable to hacking due to a software flaw at a private medical services company. The flaw was found last November at Medefer, which handles 1,500 NHS patient referrals a month. The software engineer who discovered the flaw believes the problem had existed for at least six years. Medefer says there is no evidence the flaw had been in place that long and stressed that patient data has not been compromised. The flaw was fixed a few days after being discovered. In late February the company commissioned an external security agency to undertake a review of its data management systems. An NHS spokesperson said: "We are looking into the concerns raised about Medefer and will take further action if appropriate." Read full story Source: BBC News, 10 March 2025
  10. Content Article
    Healthcare is a dynamic and complex industry, where even minor errors can have far-reaching consequences for patients, providers, and organisations. “Beyond the Bedside” takes you on a transformative journey through the intricacies of patient safety, equipping healthcare professionals, leaders, and policymakers with the knowledge and tools needed to navigate risks, investigate incidents, and foster a safety culture. These two books goes beyond surface-level understanding to explore the hidden hazards within healthcare systems. They illuminates the interplay between human factors, system design, and environmental risks, highlighting how these elements combine to create vulnerabilities. Through real-life examples, the text sheds light on the human stories behind the statistics, creating a compelling case for why patient safety must remain at the forefront of healthcare priorities. The books delves into the foundational concepts of identifying hazards in healthcare. Readers will gain insights into cutting-edge tools like Bowtie analysis, Safety-II approaches, and STAMP (Systems-Theoretic Accident Model and Processes) that go beyond traditional methods. Adopting a proactive stance, the book empowers healthcare professionals to spot risks before they escalate into incidents. Beyond the Bedside: Unveiling Hazards, Mitigating Risks, and Mastering Patient Safety Investigations: 1 Beyond the Bedside: Unveiling Hazards, Mitigating Risks, and Mastering Patient Safety Investigations: 2
  11. Content Article
    Decades of steady improvements in life expectancy in Europe slowed down from around 2011, well before the COVID-19 pandemic, for reasons which remain disputed. We aimed to assess how changes in risk factors and cause-specific death rates in different European countries related to changes in life expectancy in those countries before and during the COVID-19 pandemic. The countries that best maintained improvements in life expectancy after 2011 (Norway, Iceland, Belgium, Denmark, and Sweden) did so through better maintenance of reductions in mortality from cardiovascular diseases and neoplasms, underpinned by decreased exposures to major risks, possibly mitigated by government policies. The continued improvements in life expectancy in these five countries during 2019–21 indicate that these countries were better prepared to withstand the COVID-19 pandemic. By contrast, countries with the greatest slowdown in life expectancy improvements after 2011 went on to have some of the largest decreases in life expectancy in 2019–21. These findings suggest that government policies that improve population health also build resilience to future shocks. Such policies include reducing population exposure to major upstream risks for cardiovascular diseases and neoplasms, such as harmful diets and low physical activity, tackling the commercial determinants of poor health, and ensuring access to affordable health services.
  12. News Article
    The repairs bill at 18 crumbling hospitals is set to soar to £5.7bn because replacing them will take so long, new analysis shows. Reconstruction of 18 of the 40 new hospitals in England first promised by Boris Johnson in 2019 will not start until at least 2030 – the date by which all 40 were originally meant to open – to help spread the cost, amid stretched public finances. NHS trust bosses have warned that some of the 18 hospitals hit by the delays, such as St Mary’s in London, will collapse before work starts because they are already in such an advanced state of disrepair. Read full story Source: Guardian, 16 February 2025
  13. Content Article
    In healthcare environments, staff members can become exposed to substances hazardous to health as part of their day-to-day work that can lead to adverse outcomes to health. By sharing our claims data as a catalyst for learning, we aim to encourage improvements in reducing harm and improving staff safety. This resource outlines risks associated with these exposures, and illustrates learning from claims through illustrative case stories and an analysis of recurring themes in settled claims. NHS Resolution received 371 claims for harm caused by exposure to substances hazardous to health from incidents occurring between 1 April 2013 and 31 March 2023. The total cost for closed claims was £5,989,451. Of these 371 claims, there were 165 that were settled with damages paid. The total cost of damages paid was £2,471,880, excluding defence and claimant costs. 58 of the 371 claims are still open, they have been excluded from this analysis. These claims could go on to settle with or without damages.
  14. News Article
    A new method for detecting bowel cancer is more than 90% accurate at predicting which higher-risk people will develop the disease, according to research. About 500,000 people in the UK live with inflammatory bowel disease (IBD), including Crohn's and ulcerative colitis. Currently, they are offered regular checks for pre-cancerous growths in their gut, which, if detected, indicate about a 30% chance of bowel cancer developing over 10 years. But the UK research found DNA changes in those pre-cancerous cells, when analysed by an algorithm, were more than 90% accurate in predicting who would develop bowel cancer over the next five years. Prof Trevor Graham, from the Institute of Cancer Research in London, said: "Most people with ulcerative colitis or Crohn's disease won't develop bowel cancer. "But for those that have these conditions and are showing signs of pre-cancer in their colon, there are some tough decisions to make. "Either they have it monitored regularly, in the hope that it doesn't become cancer, or they have their bowel removed to guarantee they don't get cancer in the future. "Neither of these options are particularly pleasant. "Our test and algorithm give people with IBD, and the doctors who care for them, the best possible information so that they can make the right decision about how to manage their cancer risk." Read full story Source: BBC News, 30 January 2025
  15. Content Article
    This page describes how a Functional Resonance Analysis Method (FRAM) model is built, and how it can be used for either event analysis or risk assessment. A brief “How To” outline A FRAM primer How to use FRAM The FRAM model visualiser - The FMV allows a user to build and edit a FRAM model and to visualise it. The FMV runs as a web application in any modern web browser on any operating system. It has been most extensively tested (and therefore has the most predictable behaviour) using Microsoft Edge and Google Chrome.
  16. Content Article
    Compression stockings might be unnecessary for patients at moderate or high risk of blood clots who are undergoing planned surgery. A study called GAPS suggests that anti-clotting medicine alone is just as effective as using it in combination with compression stockings.  Researchers involved in the large randomised controlled study recommend that guidelines for preventing blood clots such as deep vein thrombosis (DVT) and pulmonary embolism (PE) should be changed. They suggest that compression stockings should no longer be standard care for most patients having planned surgery and taking anti-clotting medicine while in hospital. This could save the NHS in England around £63 million per year.
  17. Content Article
    Society faces a growing set of risks from advanced emerging technologies. While there has been discussion on some of these risks, a comprehensive overview does not exist, and it is not clear what methods are suited to identify future risks. This scoping review aimed to synthesise current knowledge regarding the risks associated with emerging technologies. The findings show that a diverse set of technologies and risks have been considered, with ten risk themes identified: risks to human health and wellbeing, sub-standard technology risks, legal and ethical risks, privacy and security risks, socioeconomic impacts, ecological and environmental risks, malicious use risks, geopolitical risks, technological unemployment risks, and existential threats. It is concluded that there is a need to expand the focus of prospective risk assessments to consider the organisational, sociotechnical and societal systems in which emerging technologies will be deployed. The development of a future technology risks classification scheme is also recommended.
  18. Content Article
    Project proposal to improve equality and reduce health inequalities. This NHS guidance is to assist organisations to develop a Standard Operating Process (SOP) for managing Covid-19 risk assessments.
  19. Content Article
    This cohort study examined how hospital six early warning scores compare with one another, based on 362,926 patient encounters. The authors compared three proprietary artificial intelligence (AI) early warning scores: Simultaneous Epic Deterioration Index (EDI) Rothman Index (RI) eCARTv5 (eCART) against three publicly available simple aggregated weighted scores: Modified Early Warning Score (MEWS) National Early Warning Score (NEWS) NEWS2 scores. In the study, eCART outperformed the other AI and non-AI scores, identifying more deteriorating patients with fewer false alarms and sufficient time to intervene. NEWS, a non-AI, publicly available early warning score, significantly outperformed EDI. The authors concluded that, given the wide variation in accuracy, additional transparency and oversight of early warning tools may be warranted.
  20. Event
    until
    Join a conversation with industry experts on cyber risk, response and claims. With increasing and high profile cyber-attacks on both health and care organisations we discuss the issues that organisations face, what can be done prevent and minimise attacks, what to do if your organisation falls victim to an attack and the steps that should be taken to minimise the impact on your organisation which can far ranging in terms of patient safety, work force, and finance. Your panel of expert speakers: Richard Hearn - Divisional Director, Howden Dave Allen - CEO, Cysiam Vicki Bowles - Partner, Bevan Brittan Julie Charlton - Partner, Bevan Brittan Register
  21. News Article
    Artificial intelligence experts and healthcare professionals in Portsmouth have come together to help prevent a common and painful complication in advanced kidney failure treatment. A study led by the University of Portsmouth and Portsmouth Hospitals University NHS Trust (PHUT) has developed an AI model to predict which patients are most at risk of their blood pressure dropping during dialysis; a condition known as intradialytic hypotension (IDH). 3 million people have Chronic Kidney Disease in the UK and 31,000 of these are on haemodialysis (Kidney Care UK), where their blood is circulated through a machine to clean it of toxins. One of the most common complications for patients undergoing this treatment at home or in centres is IDH, which occurs when their blood pressure drops suddenly. It is associated with increased mortality and hospitalisations, and until now there has been no reliable way to predict if it will occur. Pre-dialysis and real-time data were collected from 10 treatment centres over two decades (2000-2020), involving 3,944 patients. The team used data comprising a total of 73,323 sessions with 36,662 IDH events. Using this information, they identified 33 variables to determine the most at-risk individuals. These were all observations that are routinely collected during clinical care, such as weight, temperature, age, blood pressure, medication and treatment details. Project lead, Dr Shamsul Masum from the University’s School of Electrical and Mechanical Engineering, said: “This research highlights the value of using machine learning in healthcare, particularly in complex situations like haemodialysis. Predicting hypotension not only helps clinicians intervene early but also opens the door to personalised care. "As we continue to develop and refine these models, the goal is to create a practical decision-support system that could enhance dialysis management, patient safety and quality of care.” Read full story Source: University of Portsmouth, 23 October 2024
  22. Content Article
    Healthcare professionals are reminded to inform patients about the common and serious side effects associated with glucagon-like peptide-1 receptor agonists (GLP-1RAs). Advice for healthcare professionals: Inform patients upon initial prescription and when increasing the dose about the common risk of gastrointestinal side effects which may affect more than 1 in 10 patients. These are usually non-serious, however can sometimes lead to more serious complications such as severe dehydration, resulting in hospitalisation. Be aware that hypoglycaemia can occur in non-diabetic patients using some GLP-1RAs for weight management; ensure patients are aware of the symptoms and signs of hypoglycaemia and know to urgently seek medical advice should they occur. Patients should also be warned of the risk of falsified GLP-1RA medicines for weight loss if not prescribed by a registered healthcare professional, and be aware that some falsified medicines have been found to contain insulin. Be aware there have been reports of potential misuse of GLP-1RAs for unauthorised indications such as aesthetic weight loss report suspected adverse drug reactions to the Yellow Card scheme.
  23. Content Article
    Anaesthetic techniques and equipment have greatly improved over the last 60 years, as has the training and safety equipment to protect patients. If you are in good health modern anaesthetics are really very safe. However, all procedures have some risks and it is important that patients are fully informed and that the anaesthetist discusses the procedure and the risks with the patient, taking into account the patient's medical history. At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. We have pulled together 9 useful resources about anaesthesia that have been shared on the hub. They include insights from anaesthetists and examples of good practice. 1 Patient Safety Spotlight interview with Annie Hunningher, Consultant Anaesthetist at the Royal London Hospital, Barts Health In this interview, Annie talks to us about her work training teams in safety behaviours, why productivity and safety must go hand-in-hand, and how working on patient safety is like running a marathon. 2 Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals Human factors is an evidence-based scientific discipline used in safety critical industries to improve safety and worker wellbeing; implementing human factors strategies in anaesthesia has the potential to reduce the reliance on exceptional personal and team performance to provide safe and high-quality patient care. A three-stage Delphi process was used to formulate a set of 12 recommendations: these are described using a ‘hierarchy of controls’ model and classified into design, barriers, mitigations and education and training strategies. 3 Reviewing ‘work as done’ to prevent wrong site anaesthetic blocks: An interview with Marsha Jadoonanan, HCA Healthcare UK Marsha Jadoonanan, nurse and Head of Patient Safety and Learning at HCA Healthcare UK (HCA UK), shares 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’. 4 Hysteroscopy pain: A discussion with anaesthetists. A blog by Helen Hughes In this blog, Patient Safety Learning’s Chief Executive, Helen Hughes, reflects on a recent discussion about hysteroscopy and patient safety at a conference in January 2023, hosted by the Association of Anaesthetists. 5 Reducing intubation errors: A simple, accessible checklist to improve safety and support staff Sam Goodhand is a registrar in the Sussex region, specialising in anaesthetics and intensive care medicine. In this interview for Patient Safety Learning he tells us how and why he developed an accessible checklist for staff involved in intubation processes. 6 Handling injectable medications in anaesthesia: Guidelines from the Association of Anaesthetists These guidelines from the Association of Anaesthetists aim to provide pragmatic safety steps for the practitioner and other individuals within the operative environment, as well as short- to long-term goals for development of a collaborative approach to reducing errors. 7 RCOA infographic - Common events and risks for children and young people having a general anaesthetic This infographic by the Royal College of Anaesthetists shows some of the common events and risks that healthy children and young people of normal weight face when having a general anaesthetic (GA) for routine surgery. It highlights that modern anaesthetics are very safe and that most common side effects are usually not serious or long lasting. It also outlines the conversations children and their families should expect to have with their anaesthetist prior to their procedure. 8 Association of Anaesthetists case reports: Invaluable learning from mistakes In this clinical case report for the Association of Anaesthetists, the authors reflect on the importance of error reporting and implementing learning from clinical mistakes. They look at several error-related incidents and examine key learning points. They highlight that cases that do not result in serious harm to the patient are not prioritised for entry into databases or national audits, meaning they are less likely to be the subject of system-based improvement projects when compared with more ‘serious’ events. They identify that this may cause gaps in clinicians' awareness of potential risks and error traps. 9 The normalisation of patient care: Developing global guidance on securing an airway In this blog, Dawn Stott discusses the importance of consistency in care delivery, why healthcare systems must continue to develop and refine strategies for normalising care, and how she and her colleagues are developing global guidance on securing an airway when delivering anaesthesia. Do you have a resource or story about anaesthesia to share? We’d love to hear about it - leave a comment below or join the hub to share your own post.
  24. Event
    This virtual masterclass is designed to equip healthcare professionals with the essential skills and knowledge to effectively perform and manage risk assessments in the healthcare setting. It is vital for healthcare organisations to ensure staff have the necessary resources and skills to undertake risk assessments to safeguard patients, staff, equipment and premises from harm, as well as remaining compliant with legislation and national guidance (eg. Management of Health and Safety at Work Regulations 1999, Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 12). We will delve into the fundamental aspects of risk management, starting with understanding what constitutes a risk and exploring various sources of risk identification. We’ll introduce the ‘Bow-Tie’ method to visualise risk pathways by linking causes, consequences and risk events. We will also learn how to evaluate risk scores based on their potential consequence and likelihood and we will learn about the importance of implementing and assessing the effectiveness of controls. The course will cover risk response strategies using the 4T’s approach and we will be developing SMART (Specific, Measurable, Achievable, Relevant, Time-bound) action plans. This comprehensive programme will equip you with the tools needed to enhance patient safety and organisational resilience through effective risk management. Who should attend Healthcare professionals who may have involvement in risk assessment or risk management activities. This may include, but is not limited to, nursing staff, AHPs, non-clinical staff, team leaders, managers and heads of department. Key learning objectives By the end of the session delegates should be able to: Describe what a risk is. Know which methods to use for risk identification. Understand how to implement the ‘bow-tie’ model. Know how to consistently score risks. Identify existing controls and assess their effectiveness. Understand the 4Ts of risk management. Know how to design risk responses through robust action planning. Register hub members receive 20% discount. Email [email protected] for discount code.
  25. Content Article
    Delirium is a common but underdiagnosed state of disturbed attention and cognition that afflicts one in four older hospital inpatients. It is independently associated with a longer length of hospital stay, mortality, accelerated cognitive decline and new-onset dementia. Risk stratification models enable clinicians to identify patients at high risk of an adverse event and intervene where appropriate. The advent of wearables, genomics, and dynamic datasets within electronic health records (EHRs) provides big data to which machine learning (ML) can be applied to individualise clinical risk prediction. ML is a subset of artificial intelligence that uses advanced computer programmes to learn patterns and associations within large datasets and develop models (or algorithms), which can then be applied to new data in rapidly producing predictions or classifications, including diagnoses. The objectives of this review from Strating et al. were to: (1) provide a more contemporary overview of research on all ML delirium prediction models designed for use in the inpatient setting; (2) characterise them according to their stage of development, validation and deployment; and (3) assess the extent to which their performance and utility in clinical practice have been evaluated.
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