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We asked the Patient Safety Group (PSG) of The Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top 10 priorities for patient safety in surgery. This resource is for surgeons, anaesthetists and other healthcare professionals who work in surgery and contains links to useful tools and further reading. See also: Safety in surgery series Top 10 tips for surgical safety: ‘Think Safety, think SEIPS’ Top 10 patient safety tips for surgical trainees 1. Foster a culture of safety through design Establish a psychologically safe environment, through design, where staff feel empowered to speak up without fear of blame. Promote a Just Culture, balancing personal accountability with systems-based learning from adverse events and near misses. Actively encourage multidisciplinary teamwork and peer support, with support from senior leadership, to enhance safety and well-being. Other useful RCSEd resources: Anti bullying and undermining campaign Sexual misconduct in surgery - Lets remove it campaign Addressing conflict in surgical teams workshop 2. Implement team-based quality and safety reviews Use team-based quality reviews (TBQRs) and structured case analysis to learn from everyday work, incidents and near misses. Translate findings into sustainable improvement initiatives that enhance both patient outcomes and staff experience. Foster a culture of collective learning, ensuring safety insights lead to actionable change. Other useful RCSEd resources: Making sense of mistakes workshop 3. Apply Human Factors principles and systems thinking principles in surgical and clinical practice Design resilient systems that mitigate work and cognitive overload and enhance performance reliability. Use TBQR principles to support this. Standardise workflows, optimise usability of IT systems and medical devices, and integrate cognitive aids (e.g. WHO Safe Surgery Checklists, prompts). Ensure governance processes support safe, efficient and user-friendly surgical environments. Other useful RCSEd resources: Systems safety on surgical ward rounds Improving the working environment for safe surgical care Improving safety out of hours 4. Enhance communication & handover processes Implement structured communication tools such as SBAR (Situation, Background, Assessment, Recommendation) to improve clarity and effective decision-making. Optimise handover processes with digital tools, checklists and standardised documentation. Reinforce closed-loop communication, ensuring critical information is confirmed and acted upon. Other useful RCSEd resources: Consultation Skills that matter for Surgeon (COSMOS) 5. Strengthen leadership & accountability in patient safety Senior leaders must visibly support safety initiatives and proactively engage frontline staff in decision-making. Embed structured mechanisms for raising concerns, including TBQR, safety huddles and escalation pathways. Ensure staff have access to training, resources and protected time for safety and quality improvement work. 6. Minimise medication errors in surgery Implement electronic prescribing and technology assisted medication administration to mitigate errors. Enforce double-check procedures for high-risk medications and standardised drug labelling. Improve intra and peri-operative medication safety with clear labelling, colour-coded syringes and real-time verification. 7. Improve early recognition & response to deterioration Appropriate regular training of teams on processes and pathways supported by good design of staff rota ensuring adequate staffing levels. Implement early warning scores and establish rapid response pathways for deteriorating patients. Standardise post-operative surveillance strategies, ensuring timely escalation and intervention. Other useful RCSEd resources: Recognition and prevention of deterioration and injury (RAPID) course for training in recognising critically ill patients 8. Engage patients & families as safety partners Encourage shared decision-making to align treatment plans with patient expectations and values. Provide clear communication on risks, benefits and post-operative care, using tools like patient safety checklists and focus on informed consent processes. Actively involve patients and families in safety and quality initiatives and hospital discharge planning. Other useful RCSEd resources: Patient/carer/families resources and information Informed consent courses (ICoNS) 9. Standardise, simplify & optimise surgical processes Reduce unnecessary complexity in clinical workflows, making processes intuitive, efficient and reliable. Co-design standard operating procedures, policies and pathways with frontline teams to minimise variation. Implement automation and digital solutions where feasible to streamline repetitive tasks. Other useful RCSEd resources: NOTSS (Non Operative Technical Skills for Surgery) courses for surgeons DenTS courses for dentists 10. Promote continuous learning & simulation-based training Conduct regular simulation training for critical scenarios (e.g. sepsis, airway emergencies, human factors). Use insights from TBQR and incident reviews to target training needs and refine clinical practice. Ensure ongoing professional development by providing staff with time, resources, incentives and institutional support for learning. Other useful RCSEd resources: Education pages Edinburgh Surgery OnLine MSc in Patient Safety and Clinical Human Factors- Posted
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Millions more to have robotic surgery in NHS plan to cut waiting lists
Patient Safety Learning posted a news article in News
Millions more people will have robotic surgery over the next decade under NHS plans to slash the huge waiting list for hospital treatment. The move will mean a significant expansion in how often surgeons use robots when treating people for cancer, hysterectomies and joint replacements, as well as in medical emergencies. The number of patients undergoing robot-assisted surgery is due to rise from 70,000 to 500,000 a year by 2035, the head of the NHS in England will announce on Wednesday. “The NHS has pledged to return to shorter elective waiting times by 2029 and we are using every tool at our disposal to ensure patients get the best possible treatment. “Expanding the use of new and exciting tech such as robotic surgery will play a huge part in this,” said Sir Jim Mackey, NHS England’s chief executive. “Not only does it speed up the number of procedures the NHS can do, but it also means better outcomes, a faster recovery and shorter hospital stays for patients.” By 2035, nine out of 10 keyhole surgery operations, in which the surgeon makes only small incisions into the patient’s body, will involve a robot, up from just one in five today. It will have become so common by then that it will be “the default” for many procedures, Mackey will say. Evidence shows that a robot, either controlled remotely by a surgeon at a console using a 3D camera or when it has been pre-programmed, can be more precise than when a surgeon undertakes the same task and often helps the patient to recover faster and get home from hospital sooner. When surgeons control the robot, they guide the surgical instruments – which in keyhole surgery can be as tiny as 5mm – to undertake the work needed. Read full story Source: The Guardian, 11 June 2025- Posted
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Poor quality ward rounds contribute to a large proportion of patient complications, delayed discharge, and increased hospital cost. This systematic review investigated all interventions aiming to improve patient and process-based outcomes in ward rounds. The review included 84 studies, from 18 countries, in 23 specialties, involving 43 570 patients. It found that checklist interventions significantly reduced ICU length of stay, improved overall documentation, and did not increase ward round duration. Structure interventions did not increase the time spent per patient or impact 30-day readmission rates or patient length of stay.- Posted
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Almost a quarter of elective operations in NHS hospitals in England that were cancelled at the last minute took longer than the required 28 days to rearrange, figures show. They also reveal that the number of cancellations breaching the 28-day standard for a new date has more than doubled within a decade, from 9,000 in 2015-16 to 19,400 in 2024-25. The figures obtained by the House of Commons library on behalf of the Liberal Democrats show that a decade ago only 7% of cancelled elective operations were not rearranged within 28 days. Last year’s total of 19,400 cancellations not rearranged in time represents 23% of the 85,400 operations due to take place. This figure was also up by 1,500 from the previous year – an increase of 8%. Helen Morgan, the Lib Dem health and social care spokesperson, said the figures showed patients were being abandoned. She said: “Patients are being left in the lurch, forced to wait in pain and distress for potentially life-altering operations. Each of these delays represents an extra month that someone’s misery is prolonged.” Read full story Source: The Guardian, 26 March 2025- Posted
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Getting It Right First Time (GIRFT) has published a new guide to help the NHS increase its use of robotic-assisted surgery (RAS) programmes in NHS trusts, including training of staff, evaluation and safety monitoring. The guide presents a framework that will help NHS providers and ICBs as commissioners to adopt a co-ordinated approach, supporting clinical teams to implement RAS programmes that are cost-effective, efficient and equitably provided for patients. Working with NHS England’s elective recovery team and the surgical Royal Colleges, GIRFT is helping to meet the commitment of the NHS Long Term Workforce Plan that seeks to ensure the provision of a fully trained, accredited RAS surgical workforce. The new guide, called ‘Implementation of robotic-assisted surgery in England’, describes the objectives and principles for robust and equitable service planning and design, as well as setting standards for safe implementation, workforce training and evaluation. -
Content Article
The Royal College of Surgeons of Edinburgh (RCSEd) have drawn up their top 10 tips for surgical safety using the SEIPS (Safety Engineering Initiative for Patient Safety) model. Click on image to enlarge or download from the attachment below: See also: Safety in surgery series Top 10 priorities for patient safety in surgery Top 10 patient safety tips for surgical trainees- Posted
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Many errors in surgical patient care are caused by poor non-technical skills (NTS). This includes skills like decision-making and communication. How often these errors cause harm and death is not known. This goal of this study was to report how many surgical deaths are associated with NTS errors in Australia by assessing all surgical deaths from 2012 to 2019. Some 64% of cases had an NTS error linked to death. Decision-Making and Situational Awareness errors were the most common. The results of this study can be used to guide improvement and reduce future errors and patient death.- Posted
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CORESS Annual Safety in Surgery Symposiums
Patient Safety Learning posted an article in Surgery
The Royal College of Surgeons of Edinburgh is an independent, charitable professional organisation committed to advancing surgical excellence through education, training, examinations and CPD, with a focus on patient care and patient outcomes. CORESS publishes Surgical Safety Feedback reports in Surgeons’ News, a journal of the Royal College of Surgeons of Edinburgh. View all their Annual Safety it Surgery Symposiums. -
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Professor Frank Smith's presentation to the Royal College of Surgeons of Edinburgh on confidential reporting and surgical safety.- Posted
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Safety in surgery series
Patient Safety Learning posted an article in Surgery
Patient Safety Learning asked the Patient Safety Group (PSG) of the Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top tips for patient safety in surgery to share on the hub. They came up with three useful resources for surgeons and surgical trainees: Top 10 priorities for patient safety in surgery Top 10 tips for surgical safety: Think Safety, think SEIPS Top 10 patient safety tips for surgical trainees In this blog, Anna Paisley, Consultant Upper GI Surgeon and RCSEd Council Member and Chair of the PSG, reflects on the process her and the team went through to collate these patient safety resources. We hope you find these resources useful. When asked to do this by Patient Safety Leaning, we were delighted to contribute. However, what seemed initially to be a straightforward task, turned out to be rather challenging. Patient safety covers such a vast area, and it proved very difficult to select only 10 key tips. Each member of the multi-disciplinary surgical team will have a slightly different outlook and perspective; the safety principles most important to their specific practice will inevitably vary. No one size fits all. Each member of the PSG had a slightly different set of tips based on their experience, skill set and discipline. All submissions were of course valid and we thought it would be helpful to include the three main approaches. 1 Top 10 priorities for patient safety in surgery Manoj Kumar, Consultant General and Upper GI Surgeon in Aberdeen, PSG Educational Lead and Convenor of the RCSEd Team Based Quality Review workshop, spearheaded a comprehensive set of patient safety tips for surgery aimed primarily for surgical patient safety leaders. His strong belief is that improving patient safety in surgery requires more than isolated interventions—it demands a sustained cultural and systemic shift. His top 10 priorities are grounded in evidence-based practice and real-world experience, recognising that safer care emerges when we design systems that support people to do the right thing, every time. This approach combines Human Factors principles, team-based quality reviews and learning, psychological safety as well as leadership engagement to drive improvement from the ground up. It moves beyond reactive fixes to proactive action, reduces unwarranted variation and enables learning across all levels of the organisation. By embedding these principles into daily practice, surgical teams can move toward high reliability environments and deliver safer, more effective care for every patient. 2 Top 10 tips for surgical safety: ‘Think Safety, think SEIPS’” When asked to give her top 10 tips for patient safety in surgery, Claire Morgan, Consultant in Restorative Dentistry, PSG Deputy Chair and Member of RCSEd Dental Council, chose to structure her response using Carayon’s Systems Engineering Initiative for Patient Safety (SEIPS). The SEIPS framework allows us to consider any patient safety issue or question using a systems-based approach. This affords a broad view, including application of a Safety 2 thinking; i.e. why do things normally go well. From Claire’s personal perspective, ’Think Safety, Think SEIPS’ ensures a constant recheck of all factors that might contribute to any patient safety incident. SEIPS is a relatively simple tool to use with consideration of six contributory systems to patient safety: tasks tools and technology person organisation internal environment external factors. However, it does not stop there, as it is the interaction between all these systems and then processes that determines outcomes. This approach produced a visual map demonstrating the complexity of the socio-technical systems involved in surgical safety from a human factors perspective. 3 Top 10 patient safety tips for surgical trainees As a consultant Upper Gastro-intestinal surgeon from Edinburgh, RCSEd Council Member and PSG Chair, I compiled a simple list with trainee members of the surgical team in mind. Introducing key patient safety principles early in a training pathway is crucial to helping develop an appropriate patient safety culture in any workplace. I wanted to highlight the principle that patient safety is everyone’s responsibility, and not just that of the quality improvement team. I also wanted to emphasise the crucial point that all members of the team have an important voice and should feel empowered and able to speak up if they feel something is not right. So, the RCSEd PSG have used three separate approaches in defining our top ten tips for patient safety in surgery. I hope that you find them useful and that one will resonate with you from your own individual perspective. Share your resources and top tips What more is needed to support surgeons and trainees? Do you have a tool or policy, a personal reflection, peer-reviewed literature that we could share and highlight on the hub. What other top tips would be useful to surgeons, students and patients? Share your ideas in the comments below (you will need to be a hub member, sign up is free and easy) or contact our editorial team at [email protected].- Posted
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We asked the Patient Safety Group (PSG) of The Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top 10 patient safety tips for surgical trainees. See also: Safety in surgery series Top 10 tips for surgical safety: ‘Think Safety, think SEIPS’ Top 10 priorities for patient safety in surgery Listen to the patient and what matters to them; share decisions with them. Encourage the patient to be in control of their care; they only have to consider their own care and will not be lost to follow up. Trust your instincts; always speak up if you think something is not right. Never be afraid to ask for help if you need it. Look after yourself and your team; there can be no patient safety without team safety. Foster good team working; recognise and respect the value of all team members; take account of everyone’s strengths and weaknesses. Take responsibility for the safety of your patients; patient safety is everyone’s responsibility, not just that of the quality improvement team. Help design systems that make it easier for you to do the right thing. Do not make assumptions. Work as imagined is not the same as work done; make sure you always test any process in practice and confirm that what you think is the case is actually happening. Regularly audit your practice. Celebrate good practice and share your experiences. Take on board feedback and learn from it; be willing to change practice. When outcomes are not as expected, openly discuss and learn, to enable you and your team to reduce the risk of the same thing happening again.- Posted
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AHRQ's MRSA prevention toolkit: Targeting SSI
Patient Safety Learning posted an article in Surgical site infections
The Agency for Healthcare Research and Quality (AHRQ) toolkit for MRSA Prevention: Targeting SSI highlights four key evidence-based strategies to prevent MRSA and SSI: nasal decolonisation, preoperative skin antisepsis, antimicrobial prophylaxis and evidence-based prevention strategies. Surgical teams can incorporate concepts from the AHRQ Comprehensive Unit-based Safety Programme framework into their current care team to promote patient safety culture and enhance teamwork and communication. Access the toolkit’s extensive resources, including presentations and facilitator guides, plus staff and patient training materials to help your facility get started or supplement your existing MRSA and SSI prevention efforts.- Posted
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Waiting list patients ‘should be on standby to fill cancellations’
Patient Safety Learning posted a news article in News
Patients stuck on NHS waiting lists for routine surgery should be kept on “standby” and contacted at short notice to fill last-minute cancellations, a report has suggested. There are 135,000 on-the-day surgical cancellations in the UK each year because of patient absence or illness, costing the NHS an estimated £400 million. Instead of leaving operating theatres unused, a report by the health tech firm Proximie has called for the NHS to implement a new “standby patient system” to drive up efficiency and productivity in the health service. This would require hospitals to identify patients living nearby who could be called up with a few hours’ notice to get operations before their scheduled date. The system could cover all elective surgery, including hernia repair and knee or hip replacements, helping to tackle waiting lists of 7.4 million and reduce the number of people having to wait months for life-changing surgery. Some NHS trusts are already testing the standby approach, finding it can save money and cut waiting lists. In one pilot at University Hospitals Bristol and Weston NHS Foundation Trust, surgeons put 12 patients who had been waiting on average 44 weeks for operations on a standby list. Six were able to get their operations earlier after being called to fill on-the-day cancellations and reported excellent experiences of the initiative. The scheme saved the trust £15,240, and surgeons concluded that it “provides a cost-effective solution to optimise theatre utilisation, reduce waiting list times and improve patient care”. Read full story (paywalled) Source: The Times, 23 April 2025 -
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Trust orders review into breast cancer services
Patient Safety Learning posted a news article in News
A North East trust has begun a full review of its breast cancer services after finding unexplained variation in its surgical practices. County Durham and Darlington Foundation Trust said feedback from national audits and external reviews suggested its approach to surgery may differ from that seen elsewhere in the NHS. In a statement, CDDFT said the audit findings did not necessarily mean breast cancer surgery carried out at the trust was unsafe, however, “we felt it was important to take a closer look to ensure we are delivering the highest quality care”. The trust said it does not yet know how many patients would see their care covered by the review, and refused to say what time period it would cover. The review includes input from internal teams and external experts, including a review by the Royal College of Surgeons. The trust has also commissioned an external review of governance to ensure a “fair, balanced, and independent perspective”. A new clinical lead has been appointed for the service, and two new consultants hired to address “capacity challenges”. Other steps include strengthening the role played by multidisciplinary teams through stronger coordination and clinical governance, as well as “maintaining close oversight at senior clinical and executive levels”. Read full story (paywalled) Source: HSJ, 17 April 2025- Posted
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Robotics approved for use in NHS surgeries across England
Patient Safety Learning posted a news article in News
State-of-the-art robotic systems approved for use on the NHS could transform treatment for thousands of people across England. The technology, given the green light by the National Institute for Health and Care Excellence (NICE) under its early value assessment programme, offers a range of applications, from helping remove tumours to replacing a patient’s knee. The rollout is expected to reduce hospital stays, faster recovery times, and a lower risk of complications. A total of 11 systems have been approved, including five for soft tissue surgeries, such as removing tumours, repairing hernias and removing gallbladders and six for orthopaedics, including knee and hip replacements. Some allow surgeons to perform operations using mechanical arms controlled from a console, while others are hand-held. Dr Anastasia Chalkidou, programme director of NICE’s HealthTech programme, said: “These innovative technologies have the potential to transform both soft tissue and orthopaedic surgical care in the NHS. “Robot-assisted surgery may help overcome key limitations of conventional techniques through precise movements and enhanced 3D visualisation, potentially transforming surgical options and outcomes for NHS patients. “Both applications could benefit patients who might not otherwise be candidates for minimally invasive approaches.” Read full story Source: The Independent, 17 April 2025- Posted
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To support the implementation of the National Patient Safety Plan of the Republic of North Macedonia, this handbook provides a structured framework using the Plan-Do-Check-Act (PDCA) cycle and focuses on six core intervention areas, including infection prevention, medication safety, surgical safety, safe birth practices, capacity strengthening, and error-reduction strategies. It emphasises stakeholder engagement, monitoring and evaluation, risk management, and sustainability planning. By providing a clear roadmap, this initiative aims to foster a culture of patient safety and improve health-care quality in North Macedonia.- Posted
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The future of surgical pathways
Patient Safety Learning posted an event in Community Calendar
untilSurgical teams are under growing pressure, from rising case complexity and elective backlogs to increasing care demands and system fragmentation. But is it possible to redesign surgical pathways to improve both outcomes and efficiency? And what does good clinical pathway management really look like? On Wednesday 16 April 2025, Surgery International will host a free online webinar exploring the future of clinical pathway management through the lens of perioperative medicine. The session will bring together leading voices in surgery and digital health to explore how we can build safer, smarter and more connected surgical pathways, without losing sight of individual patient needs. Register- Posted
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'Fit and well' surgery waitlist details to be revealed in Wales
Patient Safety Learning posted a news article in News
More details on plans to only add people who are "fit and well" to surgery waiting lists and crack down on missed appointments are expected to be revealed on Monday. Health Secretary Jeremy Miles will give a speech to health leaders on the Welsh government's bid to cut waiting lists by around one quarter by March 2026. Hospital volunteer John Timmons, 70, said he saw "a ridiculous number" of patients not turning up for appointments and would support the plans. But health equality charity, Fair Treatment for the Women of Wales (FTWW), said "fear of weight stigma" could delay some people from seeking help. The proposed changes are part of a number of Welsh government ideas being discussed to improve the NHS, which has recently seen small reductions in record waiting lists. These include: Patients who miss hospital appointments twice or more being referred back to their GP, in effect placing them at the back of the queue. An improved Welsh NHS app, allowing patients to track their progress through the system and make or amend appointments. Increased levels of intervention to get patients fit for surgery, such as people being asked to lose weight or exercise more before they are placed on a waiting list. The Welsh government said patients who were fit and well before surgery were more likely to recover quickly and support would be given to get them "in the best possible shape" for treatment. Read full story Source: BBC News, 6 April 2025- Posted
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Don’t get surgery on a Friday
Patient Safety Learning posted a news article in News
If you have any say, you might want to avoid scheduling your next surgery on a Friday. The most comprehensive analysis of what happens to patients who have surgery on Fridays versus Mondays, published in JAMA by more than a dozen US and Canadian researchers, is unequivocal: The people who underwent all kinds of procedures before the weekend suffered on average more short-term, medium-term, and long-term complications than people who went under the knife after the weekend was over. The study was based in Ontario and included more than 450,000 patients who received one of the 25 most common surgeries between 2007 and 2019. Previous studies have generally found the same effects across different types of health systems: One UK-based study had reported better outcomes for Monday surgeries after 30 days. A paper looking at Dutch patients detected higher mortality rates after one month for patients who had Friday surgeries compared to Monday. This appears to be a phenomenon no matter the country, as prior US-based research also attests. People who received pre-weekend surgeries — defined as a Friday or a Thursday before a long weekend — were overall about 5% more likely to experience one of those complications within a year of their surgery than people who got post-weekend procedures (on Monday or the Tuesday after a long weekend). The effect was stronger for heart and vascular surgeries; it was negligible for obstetric and plastic surgeries. Researchers found Friday surgeries were more likely to be performed by junior surgeons when compared to Monday surgeries. “This difference in expertise may play a role in the observed differences in outcomes,” they wrote, based on a statistical analysis that controlled for other factors. There could also be fewer senior colleagues on the hospital campus for the junior physicians to consult with, the authors said. In addition, the weekend doctors and nurses may be less familiar with the patient’s case, raising the risk that complications will be caught later and therefore lead to worse outcomes. Read full story Source: Vox, 21 March 2025- Posted
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Probe into claims people allowed in to watch hospital surgeries
Patient Safety Learning posted a news article in News
An investigation has been launched into allegations that unauthorised people were allowed to watch procedures being carried out in hospital operating theatres. Cardiff and Vale University Health Board said it was undertaking an internal review following the "deeply concerning" allegations. An internal staff survey found that previous concerns regarding unauthorised people in theatres had been raised but not thoroughly investigated, the health board said. "We want to reassure patients and their families that we are committed to providing safe and high-quality care, and patient safety and confidentiality is always of utmost importance to us," it said in a statement. It is not clear how the individuals gained access to the operating theatres or who gave them permission to watch surgeons at work. BBC Wales asked the health board to clarify whether the unauthorised people were friends and families of staff, but it said it was "unable to go into any further detail" and pointed out that the investigations was an "internal and confidential". Read full story Source: BBC News, 20 March 2025 -
Content Article
The phenomenon of a 'weekend effect' refers to a higher potential for adverse outcomes in patients receiving care over the weekend. Few prior studies have comprehensively investigated the effects of postoperative weekend care on surgical outcomes in a generalisable cohort. The aim of this study was to examine differences in short-term and long-term postoperative outcomes of patients undergoing surgical procedures immediately before vs after the weekend. In a cohort study involving 429 691 patients undergoing 25 common surgical procedures in Ontario, Canada, those who underwent surgery immediately before the weekend experienced a statistically significant increase in the composite outcome of death, complications, and readmissions at 30 days, 90 days, and 1 year compared with those treated after the weekend. These findings suggest that patients treated before the weekend are at increased risk of complications, emphasising the need for further investigation into processes of surgical care to ensure consistent high-quality care and patient outcomes. It is important for healthcare systems to assess how this phenomenon may impact their practices to ensure that patients receive excellent care irrespective of the day.- Posted
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This systematic review aimed explore the association between triclosan-containing sutures and the risk of surgical site infections. The results show that use of triclosan-containing sutures was associated with significantly fewer surgical site infections compared with sutures without triclosan.- Posted
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The Royal College of Surgeons of Edinburgh’s Patient Safety Group is dedicated to upholding patient safety and ensuring that the highest standards of care remain central to the College’s mission. These core values are at the heart of everything the College does. Learn more in the attached e-flyer, including some resources available on page 2.- Posted
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This is the second in a series of investigations exploring why medications intended to be provided to patients were not provided. Patients who need medications can suffer harm if these are not provided. This investigation explored the systems and processes in place to support staff when a patient who is usually taking an anticoagulant undergoes a procedure. An anticoagulant is a medication that reduces the ability of a patient’s blood to clot. The investigation also explored the role played by electronic prescribing and medication administration (ePMA) systems and electronic patient record (EPR) systems in supporting care in this area. The investigation explored a patient safety event involving a man aged 87 who was admitted to hospital. He usually took an anticoagulant medication (apixaban) to reduce the risk of having a stroke. A stroke is a serious medical condition that occurs when the blood supply to part of a person’s brain is lost. The patient was taken to hospital with shortness of breath and nose bleeds. He was transferred from the emergency department to a medical ward while waiting for a procedure. The medical team paused the patient’s regular apixaban, initially because of his nose bleeds. The apixaban continued to be paused while the patient was waiting for his procedure. However, delays to the procedure taking place meant that apixaban was not given for a total of 10 days. After the procedure, the apixaban was not restarted as intended. Two days after the procedure the patient had a stroke and later died. Medical staff needed to make informed prescribing decisions, balancing the patient’s risk of developing a blood clot, his everyday risk of bleeding, with the risk of bleeding from the required medical procedure. The investigation explored the range of complex, dynamic and interacting clinical and wider hospital factors that led to the difficulties in managing the patient’s anticoagulation. Findings The patient’s apixaban was appropriately paused in the emergency department. Past clinical information about the patient that would have supported anticoagulant risk assessments was not easily available to staff. Variations in the hospital care processes supported some working practices, but created uncertainty about when the patient’s procedure could happen. This made dynamic clinical decision making challenging. A lack of specialist nursing and/or administrative support limited the ability for respiratory referrals to be followed up by the respiratory team in a timely way. There was no reassessment of the ongoing decision to pause the patient’s apixaban when the procedure did not happen as expected. It was clear to staff that the patient’s apixaban was paused on the ePMA system, but the system did not prompt staff to re-review the paused apixaban. An assessment of the risks and benefits of pausing the patient’s apixaban was not documented which prevented a shared understanding of the decision for other staff involved in the patient’s care. Workforce challenges created conditions on the acute general medical ward that limited the resources available to follow up on the patient's medication status and delayed discussions around the patient’s transfer to the respiratory ward. A mismatch between demand and capacity within the respiratory service prevented the patient being transferred to the respiratory ward or receiving regular specialty respiratory input while he was being cared for on the acute general medical ward. Some local clinical guidance available to staff on the management of patients’ anticoagulant medication was overdue for a review and did not reflect updated national guidance. Local clinical guidance was sometimes hard to access using the Trust’s computer systems and some staff were unaware of relevant guidance that was in place. There were no cues in the post-procedure documentation to prompt staff to consider restarting the patient’s anticoagulation medication. Phased implementation of the Trust’s EPR system meant that sometimes staff were duplicating entries across paper and electronic record systems. Local level learning prompts for acute hospitals HSSIB investigations include local-level learning where this may help organisations and staff identify and think about how to respond to specific patient safety concerns at the local level. The following prompts are provided by HSSIB to help acute hospitals to improve the safety of patients who are taking anticoagulation medication who need to have a procedure. These prompts may also be useful in other settings. Anticoagulant prescribing How does your organisation support staff to identify and document decision making at critical decision points where anticoagulation should be reviewed? How does your patient record system support staff to document and clearly display the rationale behind any decision to pause anticoagulant medication? Does your organisation have systems and processes in place that support regular risk assessment of anticoagulants that have been paused? Does your organisation have a process for ensuring that guidelines that cross-refer to other relevant guidelines are reviewed together to ensure they provide consistent advice? How do you ensure that all members of the multidisciplinary team with relevant expertise are included in clinical guideline reviews? Does your organisation have processes in place to ensure that when new evidence on newer anticoagulants becomes available it is considered for inclusion in local guidance as soon as possible? How does your organisation support staff to find and readily access anticoagulation related guidelines? Care processes supporting inpatients on anticoagulants Do your organisation’s bed management meetings include a review of patients who have been waiting more than 24 hours for transfer to a specialty ward? Does your organisation have effective processes in place to ensure inpatients accepted by a speciality, but awaiting a specialty bed, receive a specialty review on a regular basis? Does your organisation have a process in place for the prioritisation of inpatient transfer to specialty services? Does your organisation have a process in place for the prioritisation of inpatients who need investigations (including imaging) and procedures? Do your organisation’s post procedure processes include a prompt to review anticoagulation? EPR/ePMA systems supporting anticoagulation Does your organisation ensure it is easy for staff to access information in patients’ records relevant to decision making about anticoagulant medication? Does your ePMA system identify patients with paused time-critical medication that may warrant a review? How does your organisation consider factors relating to equipment which may affect the successful implementation of EPR/ePMA systems?- Posted
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untilThe Invisible Hazard: Tackling Surgical Smoke for Healthcare Worker and Patient Safety will delve into the risks posed by surgical smoke, its impact on both healthcare professionals and patients, and the latest safety measures to mitigate these dangers. This webinar, hosted by the Safety For All campaign, will provide valuable insights into the health risks associated with inhaling surgical smoke, the current legislation governing its management, and the introduction of smoke evacuation products to enhance safety in operating theatres. This session is essential for perioperative practitioners, safety officers, healthcare professionals, and policymakers looking to better understand the hidden risks of surgical smoke and explore practical solutions for improved workplace safety. Speakers 🔹 Lisa Nealen – A Perioperative Practitioner at Gateshead Health NHS Foundation Trust, Lisa brings hands-on experience in the surgical field and will share insights into the real-world challenges of managing surgical smoke in operating theatres. 🔹 Daniel Rodger – A Senior Lecturer in Perioperative Practice at London South Bank University and a registered Operating Department Practitioner (ODP), Daniel is a specialist in perioperative safety and will outline evidence-based practices for surgical smoke safety. Key Topics The health risks of surgical smoke exposure for healthcare workers and patients Current legislation and standards regarding smoke evacuation in healthcare settings The introduction and benefits of smoke evacuation products in perioperative environments Best practices for mitigating risks and implementing safety protocols in operating theatres Live Q&A Session The webinar will conclude with an interactive Q&A session, where attendees can engage directly with our expert speakers, ask questions, and explore strategies for improving surgical smoke safety in their workplaces. Don’t miss this opportunity to hear from leading experts, gain actionable knowledge, and contribute to a safer and healthier surgical environment. Register here.- Posted
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