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Content Article
Latest issue of the Operating Theatre Journal
Patient Safety Learning posted an article in Surgery
2023 September issue Serious hazards of transfusion (SHOT) report warns of alarming increase in transfusion errors and harm to patients. Doctors cut waiting list for breast cancer surgery patients. Study reveals surgeons need to improve how they communicate with patients about new procedures. Nurses’ intentions to quit increased during the pandemic despite their high resilience August issue Most common medical claims: How to avoid malpractice allegations. Report recommends packaging and labelling change to prevent implant ‘never event’. New guidance on safe injection practice in hospitals emphasises the importance of prefilled and labelled syringes in avoiding medication errors. Progress with the new hospital programme. Advancements in minimally invasive surgery: Techniques, instruments, and patient outcomes. July issue NHS must accept accountability and learn from mistakes. Simulation based education in healthcare higher education: In what ways does it impact perceived clinical confidence, knowledge, and skills acquisition in student Operating Department Practitioners? Risk reduction in endo-tracheal tube fixation. Historic plan launched to move Wales towards zero deaths from bowel cancer. Taking higher-than-recommended doses of Vitamin D for five years reduced the risk of atrial fibrillation. As complications from cosmetic tourism rise, UK and Turkish plastic surgeons unite to issue consumer guidelines. New research highlights opportunities to improve care of patients having major surgery. June issue How to THRIVE in the Operating Theatre Preoperative optimisation: The effect of prehabilitation interventions on the postoperative recovery of cancer patients undergoing colorectal surgery – Literature review and discussion based paper. Surgeons must tackle three global health challenges to save lives. “PERUSE before you Infuse”. Artificial Intelligence could speed up heart attack diagnosis, SurgiBox: Ukraine’s SurgiBox Project has been successfully demonstrating safe surgery to patients around the world May issue Reducing mortality in emergency surgery: Focussing minds through a national clinical audit in the NHS. Majority of NHS trusts do not offer training to prevent sexual harassment, study finds. Handwashing during ‘normal times’ can reduce burden of respiratory disease. The Surgical Education Checklist as a tool to improve teaching within the operating theatre. April issue NatSSIPs 2 Sequential Steps: The NatSSIPs Eight – Flowchart. Mobile operating theatre helping drive down waiting times in Yorkshire. Why hospitals and ICBs are seeking new intel to find hidden high-risk patients on waiting lists. March issues NHS Scotland first in world to ‘clean up’ anaesthetic gases. New standards to Improve the safety of invasive procedures in the NHS. Researchers suggest novel cutpoints for diagnosing cardiac hypertrophy in adolescents and young adults. NHS patients targeted to reduce risks as they wait for hospital treatment. February New standards to improve the safety of invasive procedures in the NHS. Delphi Study Round Three – A study across NHS England hospital trust operating theatres. Crash and burn(out) – Aviation-style safety checklist and confidential helpline for surgical community to prevent mental health crisis. A Wound Care Study: has the pandemic led to new and improved ways of working? HSIB investigation: Access to critical patient information at the bedside. Artificial intelligence, Patient safety and achieving the quintuple aim in anaesthesiology. January Delphi Study Round Two – A study across NHS England hospital trust operating theatres. Intercollegiate green theatre checklist Local Interventions to support the recovery of elective surgery at the University College London Hospitals department of theatres & anaesthesia. 2022 December issue Delphi Study Round One – A study across NHS England Hospital Trust operating theatres. Managing NHS backlogs and waiting times in England. Steroid injections worsen knee arthritis, according to two new studies. First robotic hysterectomy completed in Wales. World’s first algae-based local anaesthetic another step closer to reality. How new bacterial species siscovered in Asian soil could help battle against antibiotic resistance November issue New research calls for all health and care staff to be trained in AI Reducing noise in operating theatre improves children’s behaviour after surgery, study finds Brain tumour patient operated on awake while playing saxophone No difference between spinal versus general anaesthesia in patients having hip fracture surgery finds study October issue Why are intra-operative surgical Never Events still occurring in NHS operating theatres? Radical rethink needed to improve safety in health and social care. World Anaesthesia Day 2022: History, significance, celebrations and theme. £4 million “space-age” operating theatre will help bring down eye surgery backlog. Two thirds of nurses choosing between food and fuel as cost of living bites and one in five turn to food banks. ‘An inspirational story’: Hartlepool cleaner changes career to become hospital nurse. September issue Service evaluation of the current World Health Organisation’s Surgical Safety Checklist in spine surgery at the University Hospitals of Derby & Burton. Could this lead to a change in NHS Improvement? The Anaesthetic Gas Scavenging System Project. Cancelled operations could be prevented by an earlier anaemia test and time to prepare. The top 10 things experts need you to know about screening during Gynaecological Cancer Awareness Month September 2022 £35.5m for New Friarage Hospital Operating Theatres. New robotic surgical system revolutionises patient care at UHCW. Insourcing: Giving NHS operating theatre teams a helping hand. Arterial stiffness raises blood pressure in adolescents via insulin resistance. Birmingham’s Public Health Chief is among sector leaders to receive university honours,- Posted
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Event
CORESS 'Safety in Surgery' Symposium 2023
Sam posted an event in Community Calendar
untilCORESS invites you to join their free educational webinar and hear from four speakers as they talk about their area of expertise in relation to patient safety. Programme overview: 14:00 - Introduction to CORESS and Welcome - Professor Frank Smith, Professor of Vascular Surgery & Surgical Education, University of Bristol and North Bristol NHS Trust and CORESS Past-Programme Director 14:03 - Symposium Programme Overview - Miss Harriet Corbett FRCS Paed Consultant Paediatric Urologist, Alder Hey Children’s Foundation NHS Trust, British Association of Paediatric Urologists and CORESS Programme Director 14:05 - SPOT Programme: The National inpatient PEWS Chart - Professor Damien Roland, Consultant in Paediatric Emergency Medicine, Head of Service Children's Emergency Department, University Hospitals of Leicester NHS Trust 14:30 - Championing Patient Safety with Evidence Based Medicine - Robotically Assisted Surgery - Dr John Burke, Chief Medical Officer, AXA Health 14:55 - What’s new at HSIB - Saskia Fursland, National Investigator, HSIB 15:20 - Patient Safety in a Medico-legal Context - Dr Michael Devlin, LLM, MBA, FRCP, FRCGP, FFFLM , Head of Professional Standards and Liaison, MDU 15:45 - Symposium Summary and Close - Harriet Corbett, CORESS Programme Director Intended Audience: This session is for Consultant Surgeons, medics, students with a surgical healthcare background and those in healthcare and insurance sectors with an interest in surgical improvement and patient safety. Register- Posted
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Surgical Voices podcasts
Patient Safety Learning posted an article in Surgery
Episodes: Sustainability in the operating theatre - guest speakers Tod Brindle, Molnlycke Medical Director, and Toby Cobbledick, Molnlycke Sustainability Specialist. Preventing surgical site infections: pre-surgery - guest speaker Lindsay Keeley, Patient Safety and Quality Lead AfPP. Preventing surgical site infections: post-surgery - guest speaker Lindsay Keeley, Patient Safety and Quality Lead AfPP. Supporting patients in their recovery from surgery - guest speaker Helen Hughes - Chief Executive of Patient Safety Learning.- Posted
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News Article
In 2018 the British Association of Aesthetic Plastic Surgeons (www.baaps.org.uk) dissuaded all its members from performing Brazilian Buttock Lift (BBL) surgery, until more data could be collated. The decision was taken due to the high death rate associated with the procedure. Now, following an extensive four-year review of clinical data, new technology and techniques, BAAPS has published its Gluteal Fat Grafting (GFG) guidelines. Gluteal fat grafting is currently the procedure with the biggest growth rate in plastic surgery worldwide, with an increase of around 20% year-on-year). It has become the most popular means of buttock volume augmentation, overtaking gluteal augmentation with implants. In 2020, The Aesthetic Society statistics recorded 40,320 buttock augmentation procedures, which included both fat grafting and buttock implants. In 2015, there were reports of intraoperative mortality related to pulmonary fat emboli associated with BBL surgery and in 2018 with growing concern about the high mortality rate associated with this procedure BAAPS recommended it was not performed by its members. The development of the present guidelines and recommendations has been stimulated by the evidence that has emerged since 2018, based on scientific review and analysis. BAAPS guidelines now recommend that Gluteal Fat Grafting is safe to perform under two key conditions: Injection into the subcutaneous plane only - there is a plethora of evidence to suggest this significantly reduces mortality related to the procedure perhaps this needs to be changed to – the evidence shows that the only deaths from the procedure have been when fat has been injected into the deeper muscle layer. Intraoperative ultrasound must be used during the placement of fat in the gluteal area to ensure that the cannula remains in the subcutaneous plane – this is the only way that surgeons can be confident they are not in the muscle layer. Read full story Source: BAAPS, 17 October 2022- Posted
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Brazilian Butt Lift can be made safer say surgeons
Patient Safety Learning posted a news article in News
UK plastic surgeons have released new guidelines to try to make Brazilian Butt Lift (BBL) procedures safer for people who desire a bigger bottom. Some women have died from the operation, which involves sucking out fat from elsewhere - such as the belly - and injecting it into butt cheeks. The British Association of Plastic Surgeons (BAAPS) says the injections should not go very deep to help avoid complications such as dangerous clots. According to the NHS, it has the highest death rate of all cosmetic procedures, and the risk of death from BBL surgery is at least 10 times higher than many other procedures. A major concern is that the injected fat can cause a blockage in a blood vessel in the lungs - called a pulmonary embolism - which can be fatal. This happened to Leah Cambridge, a beautician and mother of three from Leeds. She suffered a massive pulmonary embolism during the operation at a private hospital in Turkey in 2018, a coroner found. BAAPS president Marc Pacifico told the BBC: "Unfortunately we don't know how many people have been going for these risky BBL procedures. We have been recommending against it for a number of years after seeing quite a frightening death rate associated with it. But people have been going abroad to get it done." "Make sure you ask if the surgeon will be using ultrasound for gluteal fat grafting. We are recommending that surgeons should only perform this with real time ultrasound guidance as the only way to ensure the procedure is performed superficially and safely." Read full story Source: BBC News, 10 October 2022- Posted
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BBL surgery: Woman who died in Turkey 'not told of risks'
Patient Safety Learning posted a news article in News
A woman who died during an operation for a buttock enlargement in Turkey was not given enough information to make a safe decision about the procedure, a coroner has concluded. Melissa Kerr, 31, from Gorleston, Norfolk, died at the private Medicana Haznedar Hospital in Istanbul, in 2019. Ms Kerr had gone abroad to have what is commonly referred to as a Brazilian butt-lift or BBL, the Norwich inquest heard. The inquest was told Brazilian butt-lift operations carried the highest risk of all cosmetic surgery procedures. The UK has an agreed moratorium on carrying out such operations due to the dangers involved, expert witness and plastic surgeon Simon Withey said in a report for the inquest. Mr Withey said if the risk of the procedure had been explained to Ms Kerr before she had financially committed to the procedure she would not "in all probability" have gone through with it. Coroner Jaqueline Lake said she would be writing a report for the health secretary to try and prevent further deaths from this "risky" procedure. She said she was "concerned patients are not being made aware of the risks or the mortality rate associated with such surgery". She added, while the UK government had no control over what happens in other countries, "the danger to citizens who continue to travel abroad for such procedures continues... and I'm of the view future deaths can be prevented by way of better information". Read full story Source: BBC News, 12 September 2023- Posted
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Surgical treatment like facelifts and hair transplants should only be carried out by regulated professionals e.g. surgeons. But the landscape isn’t as clear for non-surgical treatments. The facts are as follows: Practitioners offering treatments such as lip fillers, anti-wrinkle injections (like Botox) and lasers do not need to be regulated by law (although legislation may change in the future) In theory, anyone can offer these treatments Anti-wrinkle injections require a prescription, but lip fillers don’t This means that if you’re having Botox (or similar), the prescriber should speak to you to assess your suitability for the procedure. There are no plans to make lip fillers prescription-only, but there are plans to reclassify them as ‘medical devices’. This should standardise the quality of filler products on the market and eliminate cheap imports from abroad.- Posted
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untilThis webinar looks at a project by the Patients' Association and the Getting It Right First Time (GIRFT) programme that focuses on elective surgical hubs. These are surgical centres on existing hospital sites, separated from emergency services, which means the facilities can be kept free for patients waiting for planned operations, reducing the risk of short-notice cancellations. They can help reduce waiting times for some patients. They tend to specialise in uncomplicated surgical procedures, with particular emphasis on ophthalmology, general surgery, trauma and orthopaedics, gynaecology, ear nose and throat and urology. Speakers: Chloe Scruton, Senior Implementation Manager, GIRFT Hannah Verghese, Project Manager, the Patients Association Raj Patel, patient Shivani Shah, Head of Programmes (event chair) They will be joined by one of the patients who was part of the project. Register for the webinar -
News Article
A woman who suffered chronic abdominal pain for 18 months after undergoing a caesarean section was found to have a surgical instrument the size of a dinner plate inside her abdomen. The Alexis retractor, or AWR, was left inside the New Zealand mother after her baby was delivered at Auckland City Hospital in 2020. Following initial investigations into the case, Te Whatu Ora Auckland, formerly Auckland District Health Board, claimed it had not failed to exercise reasonable skill and care towards the patient, who was in her 20s. But on Monday, New Zealand’s Health and Disability Commissioner, Morag McDowell, found Te Whatu Ora Auckland in breach of the code of patient rights. Read full story Source: Guardian, 4 September 2023- Posted
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SEIPS in surgery
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS surgery. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. Register- Posted
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Mölnlycke survey: Spotlighting surgical excellence
Patient Safety Learning posted an article in Surgery
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The independent sector demonstrated its ability and willingness to work collaboratively with the NHS towards a common goal during the pandemic. It currently delivers 6% of diagnostic tests, and 9% of appointments or treatments that completed a patient pathway and removed them from the waiting list, with even more care delivered through close partnerships with NHS providers. All independent sector activity undertaken on behalf of the NHS is delivered free at the point of use (and independent sector providers (ISPs) are paid in line with NHS unit prices), upholding the founding principles of the NHS that access should be based on clinical need, not an individual’s ability to pay. Maximising the use of all NHS assets and available independent sector capacity is a key part of the plan to tackle the elective backlog and, while use of the independent sector is up, this is concentrated in specific specialties. The Elective Recovery Taskforce was set up in December 2022 to advise and inform the Secretary of State for Health and Social Care and the Prime Minister on how to increase the volume of elective consultations and procedures by both the NHS and the independent sector as far as possible to tackle the backlog. The taskforce, chaired by Minister Will Quince, brought together leading voices from across the NHS, independent healthcare sector and patient representatives to collaboratively come up with solutions. The taskforce concluded at the end of March 2023, agreeing to work together to implement action in 4 core areas: empower patients to exercise their right to choice deliver a post-pandemic recovery enable longer-term system sustainability deliver this plan and go further The actions are set out in this implementation plan, with a summary at Annex A. Following the conclusion of the taskforce at the end of March 2023, the focus has turned to delivery and putting these actions into practice, with appointees invited to convene after 6 months to review progress.- Posted
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Friends of African Nursing
Patient_Safety_Learning posted an article in International patient safety
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The Patient Association worked closely with this group of patients to understand what information they needed to make an informed decision about opting for a surgical hub and what they felt would improve the overall process, including scheduling of appointments, and travelling to a surgical hub which may be in a different location to their local hospital. By watching this video you’ll learn about the purpose of surgical hubs to provide more capacity for non-emergency surgery, helping to reduce waiting times for your operation. The video also explains what is involved if you are offered the option to have your surgery at a hub and presents the experiences of patients who have used a hub.- Posted
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The first half of the webinar featured the following subjects and speakers: Introduction - Professor Iain Moppett, CPOC NatSSIPs 2 Lead. The CPOC Perspective - Professor Scarlett McNally, CPOC Deputy Director. The Patient Safety Learning Perspective - Helen Hughes, Chief Exuecutive of Patient Safety Learning. Photo review of why NatSSIPs matters and what is new in NatSIPPs 2 - Dr Annie Hunningher, CPOC NatSSIPs 2 Lead. The Patient Perspective - Susanna Stanford, NatSSIPs 2 Patient Lead. The second half of the webinar featured the following subjects and speakers: Our NatSSIPs 2 workshop and how to consider a NatSSIPs gap analysis - Joe Allen, Suffolk and North East Essex Integrated Care Trust. Team Training for NatSSIPs 2 - Philip Gamston, Perfusion Service Manager at Barts Health NHS Trust. Resources to support NatSSIPs 2 implementation - Dr Dr Annie Hunningher, CPOC NatSSIPs 2 Lead. Q&A - Professor Iain Moppett, CPOC NatSSIPs 2 Lead. Are you a healthcare professional interested in learning more about NatSSIPs? On the hub we host the National NatSSIPs Network, a voluntary group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. You can join by signing up to the hub today. When putting in your details, please tick ‘National NatSSIPs Network’ in the ‘Join a private group’ section’. If you are already a member of the hub, please email hello@patientsafetylearning.org.- Posted
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Daniel was about to get the fright of his life. He was sitting in a consulting room at the Royal Free hospital in London, speaking to doctors with his limited English. The 21-year-old street trader from Lagos, Nigeria, had come to the UK days earlier for what he had been told was a "life-changing opportunity". He thought he was going to get a better job. But now doctors were talking to him about the risks of the operation and the need for lifelong medical care. It was at that moment, Daniel told investigators, that he realised there was no job opportunity and he had been brought to the UK to give a kidney to a stranger. "He was going to literally be cut up like a piece of meat, take what they wanted out of him and then stitch him back up," according to Cristina Huddleston, from the anti modern slavery group Justice and Care. Luckily for Daniel, the doctors had become suspicious that he didn't know what was going on and feared he was being coerced. So they halted the process. The BBC's File on 4 has learned that his ground-breaking case alerted UK authorities to other instances of organ trafficking. Read full story Source: BBC News, 4 July 2023- Posted
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