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Showing results for tags 'Risk management'.
Found 240 results
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Content ArticleThe authors performed a narrative review of the literature on the current state of AUD treatment and patient safety, finding extensive evidence that patients with AUD usually go undiagnosed, unreferred and untreated. When they do receive AUD treatment, little evidence was found to indicate that a patient safety approach is incorporated into their care. Behavioural medicine is virgin territory for the patient safety movement. Medical care and behavioural medicine in the United States currently constitute two separate and unequal systems generally lacking in pathways of communication or care coo
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News ArticleOnly a quarter of patients on valproate, who do not have appropriate contraception, are being referred by their pharmacist to their GP or a specialist about the issue, an audit carried out by NHS England has found. A report on the 2019/2020 Pharmacy Quality Scheme Valproate Audit — which was carried out in community pharmacies across England — published on 11 August 2022, has indicated that the Medicines and Healthcare products Regulatory Agency’s (MHRA’s) safety requirements for use of valproate in women and girls of childbearing age, and trans men who are biologically able to be pregnan
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We need to fix it (HindSite, 2021/22)
Sam posted an article in Digital health and care service provision
Key points Digital technology supports everything we do in safety-critical industries. There are also hidden digital problems that affect everything we do, and things will go wrong. IT-related problems can have significant consequences for justice, as well as safety and security. The formal qualifications and relevant experience required for system designers in safety-critical sectors are often not specified in the way that they are for front-line staff. We have to manage digital risks more effectively to prevent associated incidents and even miscarriages of just -
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My experience of suspected 'Long COVID'
PatientSafetyLearning Team posted an article in Blogs
Dr Jake Suett: My experience of suspected 'Long COVID' I have been unwell for 109 days now, and the entire illness has been incredibly frightening, with episodes of severe shortness of breath, cardiac-type chest pains and palpitations to name a few. I think I am slowly improving but am left with residual symptoms that have never gone away entirely but regularly return strongly in waves. In March, I was working as a staff grade intensive care doctor. I was working closely with patients with COVID-19 and had an illness that began with fever, dry cough and shortness of breath. I had bra- Posted
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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 tha -
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Content ArticleKey findings The maternal deaths and incidents were not the result of deficiencies of care. Standards of care when a woman is admitted to the delivery suite are well above average. Incident reporting and investigation systems are of a high quality. There are examples of excellent practice which should be widely disseminated. Governance systems are fit for purpose and generally well applied. Recommendations The review panel made the following essential recommendations to further reduce risks for the large proportion of vulnerable and high risk women atte
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At Patient Safety Learning we believe that to reduce avoidable harm in healthcare we need a transformation in our approach to patient safety. Patient safety should not be treated as one of several strategic priorities, but instead as a core purpose of health and social care. This requires us not just to respond to, and mitigate the risk of, harm, but also to design healthcare to be safe for patients and the staff who work within it. This approach extends to how we source, supply and monitor the use of healthcare equipment and products. Procurement and supply chains can be complex and may -
News Article
Women died after ‘gross failings’ by scandal hit mental health trust
Patient Safety Learning posted a news article in News
A young woman died following “gross failings” and “neglect” by a mental health hospital in Essex which is also facing a major independent inquiry into patient deaths. Bethany Lilley, 28, died on 16 January whilst she was an inpatient at Basildon Mental Health unit, run by Essex Partnership University Hospitals. The inquest examined the circumstances of her death this week and concluded that her death was contributed by neglect due to a “plethora of failings by Essex University Partnership Trust”. Following the three week inquest, heard before coroner Sean Horstead, a jury found -
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Safety culture discussion cards (Eurocontrol)
Patient Safety Learning posted an article in Good practice
How to use these cards You scan use these cards in any way that helps you and your colleagues to think and talk about safety culture. If you are using the cards in a group, one person may need to act as discussion facilitator. You can use as many or as few cards as you like. Four possibilities are described in the following cards: Option 1: Comparing views Compare similar and different views between groups. Option 2: Safety moments Discuss just one issue for 10-15 minutes. Option 3: Focus on… Discuss all of the cards in a particular element. Option 4: SWOT an -
News Article
Somerset care home staff continue working with Covid
Patient Safety Learning posted a news article in News
Some care homes have "no choice" but to allow workers who have Covid to deliver care, a public health official said. According to Public Health England cases are rising the fastest in Somerset. As a result, care homes in the county are struggling to safely staff their services and schools are seeing a rise in staff sickness. Somerset Council said ensuring vulnerable residents received care was "lower risk" than them being infected. Health officials advised care workers to continue working only if they wore PPE and felt well enough. Council public health consultant Alis -
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Surgical fires must become 'Never Events' (July 2020)
Patient Safety Learning posted an article in Surgery
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Content ArticleKey points Smoking, poor diet, physical inactivity and harmful alcohol use are leading risk factors driving the UK’s high burden of preventable ill health and premature mortality. All are socioeconomically patterned and contribute significantly to widening health inequalities. This report summarises recent trends for each of these risk factors and reviews national-level policies for England introduced or proposed by the UK government in England between 2016 and 2021 to address them. Based on our review, it assesses the government’s recent policy position and point towards policy
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Content ArticleCoroner's Matters of Concern The concern in this case is that a vulnerable young person can be known to the County Council and Mental Health Trust and yet not receive the support they need pending substantive treatment. Danny was repeatedly assessed as not meeting the criteria for urgent intervention and yet the waiting list for psychological therapy was likely to be over a year from point of first presentation. That gap between urgent and non-urgent services is potentially dangerous for a vulnerable young person, where there is a chronic risk of an impulsive act. Although I unde
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News Article
NHSE wants ‘urgent’ meetings over ambulance handovers risk
Patient Safety Learning posted a news article in News
NHS England and the Care Quality Commission have asked systems with large numbers of ambulance handover delays to urgently hold a meeting to try to fix the problem by “balancing the risks” of long 999 waiting times. The request was made in an email to chief executives, which warned the service was “in a difficult position with all parts of the urgent and emergency care pathway under considerable strain… most acutely in ambulance response times which in turn is linked to challenges in handing patients over to emergency departments”. The NHSE headed letter was signed by its chief opera -
News ArticleOld age and having a wide range of initial symptoms increase the risk of "long Covid", say scientists. The study estimates one in 20 people are sick for least eight weeks. The research at King's College London also showed being female, excess weight and asthma raised the risk. The aim is to develop an early warning signal that can identify patients who need extra care or who might benefit from early treatment. The findings come from an analysis of people entering their symptoms and test results into the COVID Symptom Study app. Scientists scoured the data for patterns that
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