Search the hub
Showing results for tags 'Risk assessment'.
Found 122 results
-
Content Article
Extravasation: a patient safety priority
Patient Safety Learning posted an article in Medication administration
-
Content Article
-
Content Article
-
Content Article
-
Content Article
-
News Article
Inadequate Reading surgery had 'backlogs of test results', CQC says
Patient Safety Learning posted a news article in News
A GP surgery that provides treatment to about 5,600 patients has been placed in special measures by a regulator. London Street Surgery, in Reading, Berkshire, was found to have "significant backlogs of test results and care-related tasks". The Care Quality Commission (CQC) found there was "poor identification of risks to patients" during an inspection in April. The surgery has been approached for comment. The regulator rated the surgery's safety and leadership as inadequate, and said it had insufficient processes to ensure services' safety and effectiveness. Repeat pre -
Content Article
Safety Chats: Part 2 – Safety as measured
Gina Winter-Bates posted an article in Good practice
How do we know we are safe? This is the Holy Grail that has led to many publications and much research. Authors such as Berwick, Dekker and Syed have written insightful and clear reports that detail that safety is about much more than mere compliance to rules, reporting of incidents and monitoring risk. Local context In my previous blog I shared Solent NHS Trust’s staff survey results, which show high confidence in our staff about safety, having a voice and speaking up. The organisation works hard to define how safe we are and uses a variety of measures for this. Inci -
Content Article
-
Event
Masterclass: Developing your role as a Senior Information Risk Owner (SIRO)
Patient Safety Learning posted a calendar event in Community Calendar
This masterclass will focus on developing your role as a SIRO (Senior Information Risk Owner) in health and social care. Key learning objectives: Understanding the role of the Senior Information Risk Owner Identifying Information Risks across the organisation Working with others to mitigate the risk to patients, staff and organisation. Confidence that all reasonable technical and organisation measure are in place Giving assurance to the Board that risks have been considered, mitigated or owned Understand the requirements of external confidence that po -
Content ArticleEveryone who works in health and social care should listen to this podcast in full. I've followed Will's search for justice and I am proud to know Will. A man of great integrity who is campaigning for an individual #dutyofcandour in #healthcare, for the benefit of us all. I remain shocked, when I teach on this, how few know Robbie's story. There has been so much lost learning, a failure of accountability, and a failure to deliver an effective statutory duty of candour. For me, this appalling story of failure and cover up highlights clearly why we have to recognise the value of w
-
Content ArticleThe Matters of Concern are as follows: For the Priory Hospital: 1. Record keeping: During the inquest staff confirmed that they record information about patients in two ways. On the electronic records and on handwritten handover sheets. During the inquest the evidence confirmed that different information was recorded on each. There are serious concerns that staff are recording information in two places and this creates a real risk, as materialised in Matthew’s case, that different information is recorded in each place and key information gets lost. 2. Record Keeping quality: The
-
Content ArticleBrooke was admitted to Chadwick Lodge on 15 April 2019 and had been diagnosed with Emotionally Unstable Personality Disorder and Autism Spectrum Disorder; she initially failed to engage and was violent to staff and self-harming. By the middle of May 2019 she had made progress. On 5th June 2019 she was found with a ligature around her neck, which was suspended from the door of her room. Following this incident consideration should have been given to a formal risk assessment to include consideration of her level of observation. The details of the incident should have been fully disclosed to
-
News Article
Autistic girl, 14, unlawfully detained in hospital, high court judge finds
Patient Safety Learning posted a news article in News
A 14-year-old autistic girl was unlawfully detained in hospital and restrained in front of scared young patients, a high court judge has found. On one occasion last month the teenager managed to break into a treatment room where a dying infant was receiving palliative care. She was restrained there by three security guards, Mr Justice MacDonald said in a judgment in the family court that ordered Manchester city council (MCC) to find the girl a suitable community care placement instead of what he described as the “brutal and abusive” and “manifestly unsuitable” hospital environment. N -
News Article
Patient care and safety put at risk in A&E at brand new £350m hospital
Patient Safety Learning posted a news article in News
Patients visiting Wales' newest emergency department were likely to have been put at risk of harm due to the lack of processes and systems in place, inspectors found. Healthcare Inspectorate Wales (HIW) carried out an unannounced inspection of The Grange University Hospital in Cwmbran between 1 and 3 November last year and published its findings on 29 March. On the day of their arrival inspectors said The Grange was at full capacity with no empty beds in A&E or in the hospital in general. Despite the best efforts of staff who were "working hard under pressure" the report stated the em -
News Article
Private hospital rated ‘inadequate’ again amid safety concerns
Patient Safety Learning posted a news article in News
A privately run mental health hospital put in special measures last year has been rated “inadequate” again following a fresh Care Quality Commission inspection. Inspectors raised serious concerns about unsafe ward environments and staff not managing patient risks at the Priory Hospital Arnold, which has beds commissioned by Nottinghamshire Healthcare Foundation Trust. Inspectors said that while the leadership team was experienced, the registered manager had been in post since April last year and the improvements they had made “had not been fully embedded”. The registered manager -
Content ArticleClaire Cox, one of the PSMN founders, took the bull by the horns and shared with us a fascinating insight into how she’s been applying the Systems Engineering Initiative for Patient Safety (SEIPS) model in her role as Patient Safety Lead (clinical) at King’s College London. Claire was looking for an observational tool but wasn’t quite sure the best way to apply it (as she’d never had any formal training). What is the SEIPS model? “The SEIPS model is a theoretical model rooted in human-centred systems engineering or ‘human factors/ergonomics’. All versions of the model depict three maj
-
News Article
'Overworked staff' impacting patient safety at Torbay Hospital
Patient Safety Learning posted a news article in News
The Care Quality Commission (CQC) has raised concerns about Torbay Hospital being understaffed and the impact that has had on patient safety. It carried out an unannounced focused inspection of medical care services at Torbay Hospital in December, after receiving information of concern about the service. Cath Campbell, CQC’s head of hospital inspection, said: “When we inspected medical care services at Torbay Hospital, we were mindful of the pressures that the COVID-19 pandemic had had on the trust, and aware that staff were working extremely hard during this time. However, we were -
Content Article
-
Content Article
HSIB Maternity newsletter (May 2021)
Patient Safety Learning posted an article in HSIB investigations
-
Content ArticleA number of recommendations have been made in the report, including: Understanding it is the vulnerable, minoritised and disadvantaged women in society that have an increased risk of maternal death. These women are often living in an entangled web of complex inequalities that is beyond their control, which impacts on the care they receive and the outcomes of that care. Strategies and care pathways need to be identified and put in place to improve their situation. These women have been let down in the way that our maternity and reproductive health services are currently delivered.
-
News ArticleA vulnerable woman judged to be at medium risk of self harm was on a mental-health ward that catered for low-risk patients, an inquest heard. Zoe Wilson, 22, died on the Larch Ward at Bristol's Callington Road Hospital in June 2019 after being found unconscious in her room at 01.30 BST. She had previously told staff that voices were telling her to kill herself, her inquest heard. Healthcare assistant Sarah Sharma found her and immediately called for help. Addressing a jury inquest at Avon Coroners' Court, she said that "patients admitted to Larch should have all been low risk".
-
News Article
Coroner concerned with Barts NHS trust after woman 'unlawfully killed'
Patient Safety Learning posted a news article in News
Barts Health NHS Trust has been told to take action to prevent future deaths after an elderly woman was unlawfully killed at one of its hospitals. East London acting senior coroner Graeme Irvine sent a report to the trust in which he raised concerns over the death of 78-year-old Surekha Shivalkar in 2018. The report follows an inquest into Mrs Shivalkar's death, which reached a narrative conclusion incorporating a finding of unlawful killing. A Barts spokesperson said the trust had made a number of changes after carrying out an investigation. Mrs Shivalkar underwent hip rep -
Content ArticleIn this report, the Coroner states their concerns as follows: No formal risk assessment tool was adopted to assess preoperative risk prior to Mrs Shivalkar's total hip replacement revision surgery. Despite policy changes at Barts Heath NHS Trust since 2018, there remains no requirement to utilise such a tool. Poor communication between the orthopaedic surgical team and the anaesthetist during surgery led to a collective failure to identify a critically ill patient. General and non-specific questions regarding the patient's welfare passed between the two teams but no targeted que
-
Content ArticleThe study identified a total of 1,004 events involving a medication error and use of an infusion pump, which occurred at 132 different hospitals in Pennsylvania. Fortunately, a majority of medication errors did not cause patient harm or death; however, it did find that 22% of events involved a high-alert medication. The study shows that the frequency of events varies widely across the stages of medication process and types of medication error. In a subset of our data, a free-text narrative field in each event was manually reviewed and reported to better understand the nature of errors. Overall
-
Content ArticleYou can use a risk assessment template to help you keep a simple record of: who might be harmed and how what you're already doing to control the risks what further action you need to take to control the risks who needs to carry out the action when the action is needed by.
