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Found 208 results
  1. Content Article
    Despite widespread efforts to combat the opioid epidemic, post-operative opioid overprescribing by doctors remains an ongoing contributor to opioid misuse. This US study aimed to evaluate the impact of a low-cost, reproducible “just in time” intervention on opioid prescribing in dialysis access operations. Standardised opioid prescribing guidelines were emailed to residents on the vascular service on the first day of the rotation. Opioid prescriptions were reviewed for four years before and one year after this intervention. The results showed a decrease in patients discharged with opioids following the intervention, from 58% to 36%. For patients prescribed opioids, the median quantity decreased from 90 to 45 oral morphine equivalents.
  2. Content Article
    Batches of some products made by Legency Remedies Pvt Ltd have been found to contain a bacteria called Ralstonia pickettii (R. pickettii). All potentially affected batches are being recalled following an MHRA investigation.
  3. Content Article
    The Health Action Process Approach (HAPA) suggests that the adoption, initiation, and maintenance of health behaviours must be explicitly conceived as a process that consists of at least a motivation phase and a volition phase.  Follow the link below to be directed to more information and resources on the HAPA approach.
  4. Content Article
    Peripheral nerve blocks (PNB) are safe and effective alternatives or supplements to general anaesthesia. They may improve pain control both during and after surgery, thus avoiding many of the side effects of systemic opioids. PNBs may also lead to improved patient satisfaction, decreased resource utilization, and may be better for the environment by decreasing usage of aesthetic gases and other medications. With the growing use of peripheral nerve blocks in the United States, this paper examines safety issues surrounding the procedures. It examines the safety of nerve blocks as it relates to: nerve injury recognition and treatment of local anaesthetic systemic toxicity (LAST) appropriate health care professional performance of timeouts to avoid wrong-site blocks.
  5. Content Article
    Intravenous therapy is an essential aspect of modern healthcare. While the benefits of using intravenous therapy usually outweigh the risks, occasionally the administration of IV therapies can go wrong. Infiltration and extravasation is a complication whereby the drug or IV therapy leaks into the tissues surrounding the vascular access device. This toolkit, developed by the National Infusion and Vascular Access Society (NIVAS), is intended to enable local services and healthcare organisations to implement polices, protocols and guidelines that will increase awareness about non-chemotherapy extravasations.
  6. Content Article
    The leadership and management functions of Patient Safety Incident Response Framework (PSIRF) oversight are wider and more multifaceted compared to previous response approaches. When working under PSIRF, NHS providers, integrated care boards (ICBs) and regulators should design their systems for oversight “in a way that allows organisations to demonstrate [improvement], rather than compliance with prescriptive, centrally mandated measures”. To achieve this, organisations must look carefully not only at what they need to improve but also what they need to stop doing (eg panels to declare or review Serious Incident investigations). Oversight of patient safety incident response has traditionally included activity to hold provider organisations to account for the quality of their patient safety incident investigation reports. Oversight under PSIRF focuses on engagement and empowerment rather than the more traditional command and control. 
  7. Content Article
    Emergence delirium is a temporary but potentially dangerous condition that can occur when a patient awakens after a procedure. In this video, staff at the VA Pittsburgh Healthcare System (VAPHS) share how they implemented a perioperative intervention to reduce the risk of patient and staff harm.
  8. Content Article
    Great Ormond Street Hospital NHS Foundation Trust is one of the world’s leading children’s hospitals, receiving 242,694 outpatient visits and 42,112 inpatient visits every year (figures from 2021/22). This paper seeks to provide an overview of the safety systems and processes Great Ormond Street Hospital has in place to keep patients, staff, and healthcare environments safe.
  9. Content Article
    This is a video presentation from the Royal College of Surgeons in Ireland, looking at facilitation skills for after action reviews (AAR) and the wider process.
  10. Content Article
    TOXBASE is the poisons information database created and maintained by the National Poisons Information Service (NPIS). It should be the first port of call for healthcare professionals seeking poisons information in the UK. NHS facilities can register for free and individual advice on more serious or complex cases is available via the NPIS 24-hour telephone service.
  11. Content Article
    This tool is based on the Surgical Safety Checklist developed by the World Health Organization (WHO) in 2009. It should be used at three key transitions in care: Before anaesthesia is given Immediately prior to incision Before the patient is taken out of the operating room The checklist is not intended to be comprehensive, and additions and modifications to fit local practice are encouraged.
  12. Content Article
    In this blog, Sexual and Reproductive Health Consultant, Neda Taghinejadi tells us about the coil fitting service she is part of in Oxfordshire. Neda explains how the service has integrated a number of tools, including a triage system to identify more complex cases, to help support a safe and quality service. 
  13. Content Article
    FRAM (Functional Resonance Analysis Method) is a graphical tool for demonstrating how a process is done through multiple functions and activities. This blog describes how FRAM can be used to analyse any process using four steps: Identifying and describing essential functions to have a successful process Finding out if there is the variability of the functions (if the process can be done in another way) Determining how the variability of a function impact the process Introducing recommendation for managing the undesired outcomes
  14. Content Article
    This guide from NHS England outlines the processes involved in developing safety actions. This includes sections on: agreeing areas for improvement defining safety actions prioritising safety actions defining safety measures writing safety actions monitoring and reviewing.
  15. Content Article
    What, when, and how often you take your medications are what make up your medication routine. The routine can be confusing if you are taking two or more medications or you need to take medications at different times of the day. When possible, keeping your medication routine simple can help prevent mistakes with medications. This newsletter from SafeMedicationUse.ca shares ideas to help patients simplify and manage their medication routine.
  16. Content Article
    In this article, sponsored by DHL Supply Chain, the author argues that to tackle challenges and enable a safety-focused culture, a two-pronged approach is needed – introducing safe processes and promoting accountability.
  17. Content Article
    To improve the safety and quality of healthcare, we try to understand and improve how healthcare providers accomplish patient care "work." This work includes synthesising information from a patient's history and physical examination or from a handoff, performing tests or procedures, administering medications and providing information so that patients can make the best choices for themselves. Sometimes this work flows very well and everyone is pleased with the results, but sometimes this work does not unfold in the way that was anticipated. This article, originally published in Pennsylvania Patient Safety Advisory, argues that efforts to improve healthcare work will not succeed without recognising that there is a difference between a theoretical construct of "work-as-imagined" and the reality of "work-as-done".
  18. Content Article
    Disruptive behaviours have been shown to have a significant negative impact on staff collaboration and clinical outcomes of patient care. Disruptive episodes are more likely to occur in high stress areas such as the Emergency Department (ED). Having the structure, process, and skills in place to effectively address this issue will lower the likelihood of preventable adverse events. This study assessed the status of disruptive behaviours and staff relationships in the ED setting. It concluded that disruptive behaviours in the ED have a significant impact on team dynamics, communication efficiency, information flow, and task accountability, all of which can adversely impact patient care. EDs need to recognise the significance of disruptive behaviours and implement appropriate policies and protocols to address this issue.
  19. Content Article
    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’.
  20. News Article
    Britain’s top family doctor is calling for a “black alert” system to be introduced in general practice so that doctors can warn when surgeries are dangerously over capacity. It comes as a report reveals that almost half of GPs can no longer guarantee safe care for millions of patients, as a shortage of medics means they are unable to cope with soaring demand. Prof Kamila Hawthorne, the chair of the Royal College of General Practitioners (RCGP), which represents 54,000 family doctors across the UK, wants a patient safety alert system introduced that is modelled on the operational pressures escalation levels (Opel) warnings – known as “black alerts” – already used by hospitals. It would enable practices and GPs to flag unsafe levels of workload, triggering support from their local health system. GP surgeries would be able to temporarily suspend non-priority activities – including some regular health checkups, certain routine but mandatory staff training and non-urgent paperwork – during periods of excessive workload. This would allow surgeries to reprioritise routine and non-urgent activity and ensure patient safety is prioritised. Hawthorne said: “General practice is a safety-critical industry yet GPs have none of the mechanisms that other safety-critical professions, such as the air traffic industry, have in place to protect them. “Our number one priority is the safety of our patients, but GPs are doing more and more to try to meet the rising demand for our services. When you’re fatigued, you’re more likely to make mistakes and our survey shows that many GPs are no longer able to guarantee that the care they are providing to their patients is as safe as it could be.” Read full story Source: The Guardian, 17 October 2023
  21. Content Article
    Claire Cox, Patient Safety Lead at Kings College Hospital NHS Foundation Trust, shares a recent technique she used to explain the difference between 'work as imagined' and 'work as done'. Claire's example (a pathway for a patient coming to A&E, who also has a mental health issue) highlights the safety risks of competing guidance and the importance of co-production moving forward.
  22. Event
    This conference focuses on improving practice and patient safety to reduce Extravasation Injury, ensuring front line clinicians are aware of the risk of extravasation and how to recognise, treat and escalate extravasation injuries when they do occur. This conference will enable you to: Network with colleagues who are working to reduce Extravasation Injury Learn from outstanding practice in recognizing, treating and escalating extravasation injury Reflect on national developments and learning Ensure vesicants are administered in the safest way Develop your skills in training frontline staff to recognize evolving injuries Understand how you can implement preventative measures Identify key strategies for improvement Educate patients to raise alarm and improve consent procedures Develop protocols to support practice Understand the role and competencies of the NHS trust lead for extravasation Ensure effective treatment, and early intervention in severe wounds Learn from case studies in cancer, maternity, radiology and paediatrics Ensure you are up to date with the latest legal cases Self assess and reflect on your own practice Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  23. Content Article
    The Safety Case is a regulatory technique that requires organisations to demonstrate to regulators that they have systematically identified hazards in their systems and reduced risks to being as low as reasonably practicable. It is used in several high-risk sectors, but only in a very limited way in healthcare. This multisite case study in BMJ Quality and Safety examined the first documented attempt to apply the Safety Case methodology to clinical pathways. The study found that the Safety Case approach was recognised by those involved in the Safer Clinical Systems programme as having potential value. However, it is also fraught with challenge, highlighting the limitations of efforts to transfer safety management practices to healthcare from other sectors.
  24. Content Article
    In rare cases, healthcare providers who have contributed to accidental patient harm may be criminally prosecuted to obtain justice for the patient and family or to set an example, which theoretically prevents other providers from making similar mistakes due to fear of punishment. This strategy was chosen in the recent case of RaDonda Vaught, who was convicted of criminally negligent homicide and impaired adult abuse after a medication error killed a patient in 2017. This article in the journal Human Factors in Healthcare discusses the case and its ramifications for healthcare staff and systems. The authors provide recommendations for actions that healthcare organisations should take to foster a safer and more resilient healthcare system, including: placing an emphasis on just culture. ensuring timely, systems-level investigations of all incidents. refining and bolstering participation in national reporting systems. incorporating Human Factors professionals at multiple levels of organisations. establishing a national safety board for medicine in the US.
  25. Content Article
    During periods of extreme pressure, often exacerbated by a surge in respiratory conditions, demand on supplies of oxygen cylinders, especially the smaller sizes, increases in the NHS due to the need to provide essential oxygen treatment in areas without access to medical gas pipeline systems. This surge in demand increases the known risks associated with the use of oxygen gas cylinders, and introduces new risks, across three main areas: patient safety fire safety physical safety A search of incidents reported to the of the National Reporting and Learning System (NRLS) and Learn from Patient Safety Events (LFPSE) service in the last 12 months identified 120 patient safety incidents, including those with these themes: cylinder empty at point of use cylinder not switched on cylinders inappropriately transported cylinders inappropriately secured Some of these reports described compromised oxygen delivery to the patient, leading to serious deterioration and cardiac or respiratory arrest. In addition there is a need to conserve oxygen cylinder use to ensure a robust supply chain process. As a result of current pressures on the NHS, NHS England issued providers with a summary of best practice guidance on the ‘Safe use of oxygen cylinders’ on Friday 06 January 2023 to support providers to optimise and maintain the safe use of oxygen cylinders. This guidance was issued via the Patient Safety Specialist and Emergency Preparedness, Resilience and Response (EPRR) networks. Actions To be completed as soon as possible, and not later than 20 January 2023. 1.  The chair of acute trust medical gas committee, working with key clinical/non-clinical colleagues including the local ambulance trust, should review the NHS England ‘Safe use of oxygen cylinders’ best practice guidance and ensure a risk assessment is undertaken in all areas where patients are being acutely cared for (either temporarily or permanently) without routine access to medical gas pipeline systems.  Risk assessment should pay particular attention to: avoiding unnecessary use of cylinder oxygen and excessive flow rates by ensuring oxygen treatment is optimised to recommended target saturation ranges. ensuring safe use of oxygen cylinders by clinical staff including; - safe activation of oxygen flow - initial and ongoing checks of flow to patient - initial and ongoing checks of amount of oxygen left in the cylinder - especially during transfer or whilst undergoing diagnostic tests. fire safety, including: - appropriate ventilation (both in physical environments and in ambulances),  safe storage of cylinders physical safety, including: - awareness of manual handling requirements - safe transportation of cylinders using appropriate equipment - safe storage of cylinders. 2. Once the risk assessments have been undertaken, convene the acute trust medical gas committee as soon as possible to review the findings of the risk assessments and formalise an action plan. Ensuring that the committee has executive director representation and ambulance trust input.
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