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This investigation aims to improve patient safety by supporting healthcare staff in a surgical setting to select and insert the appropriate type of implant (vascular graft) for haemodialysis treatment. The Healthcare and Safety Investigation Branch (HSIB) explored the factors that affect the ability of staff to safely select and insert vascular grafts for haemodialysis treatment. The national investigation focused on: The identification of factors within the healthcare system as a whole that influence patient safety risks associated with the selection and insertion of vascular grafts in an operating theatre environment. Exploration, using a systems approach, of the design of labelling and packaging used for the different types of vascular grafts for patients on haemodialysis treatment. Exploration of the impact on operating theatre teams of staff redeployment and repurposing of working environments in response to the COVID-19 pandemic. Reference event Teri had chronic kidney disease and needed regular haemodialysis. He had previously received haemodialysis via a connection between an artery and a vein. However, this connection was failing due to narrowing of the blood vessels and she needed to have a vascular graft implanted so that her treatment could continue. Teri was referred to her local hospital for insertion of a ‘rapid access’ type of vascular graft, to enable her haemodialysis treatment to be carried out as planned. Before Teri’s operation, a consultant vascular surgeon and members of the operating theatre team went to the store cupboard to look at the types of vascular grafts stocked. The consultant vascular surgeon was not sure which size would be needed, so two different sized vascular grafts were selected. However, it was not recognised at the time that they were different types of vascular graft, with one being the intended rapid access type and the other a delayed use graft. Following surgery, the consultant vascular surgeon immediately realised that a delayed use vascular graft had been inserted instead of a rapid access graft. Because the wrong type of vascular graft was inserted, Teri needed to have another surgical procedure and an overnight stay in hospital, which may not have otherwise been needed. Findings The packaging of rapid access and delayed use vascular grafts may be very similar, resulting in an increased risk of staff selecting and inserting the wrong type of graft. The wording used on packaging and labels to describe vascular grafts does not reflect the terminology used by clinicians in the operating theatre. There is Medicines and Healthcare products Regulatory Agency (MHRA) guidance for the labelling and packaging of medicines, but not for medical devices such as vascular grafts. There was a lack of standardisation and therefore variation in how checklists and ‘team briefs’ (procedures that aim to ensure patient safety) were completed/ conducted and recorded in different operating theatres. The incorporation of national safety standards alone may not be successful without an embedded safety culture being in place. Barcode scanning technology (Scan4Safety) can be used to mitigate the risk of an incorrect medical device being selected/inserted. Due to the reduced central management of the Scan4Safety programme, trusts have been developing applications and using adaptations of the scanning technology, resulting in inconsistent use and variable effectiveness. Safety recommendations HSIB made four safety recommendations as a result of this investigation. HSIB recommends that NHS England reviews system requirements for barcode scanning technology, in order to support local organisations to reduce the risk of incorrect selection and insertion of prostheses/implants. HSIB recommends that the British Standards Institution updates the applicable standard/s, and raises with the International Organization for Standardization, to state that medical device labelling and packaging should detail the specific use of an item. This should be developed with user input to drive consistency in the terminology used on medical device labelling/packaging. HSIB recommends that the Medicines and Healthcare products Regulatory Agency ensures the assurance processes for designated approved bodies (to check medical device manufacturers conform to packaging standards) are amended to consider context of use and usability guidelines, to reduce the risk of selecting and inserting the incorrect device. HSIB recommends that the Medicines and Healthcare products Regulatory Agency publishes guidance on the labelling and packaging of medical devices, to promote best practice and reduce selection of the incorrect item. Safety observations HSIB makes the following safety observations: It may be beneficial if the term ‘user’ in the context of medical devices was defined in international and national standards to incorporate all staff who interact with the device, including those who select the device, check it before use and use it. It may be beneficial for healthcare organisations to deliver multi-disciplinary team training on the key principles of the revised ‘National safety standards for invasive procedures’ to support the implementation and embedding of these standards. It may be beneficial for trusts to assign experienced operating theatre clinicians to lead on the implementation of the ‘National safety standards for invasive procedures’, to address the cultural issues hindering implementation. Related resources on the hub: NatSSIP2 sequential steps: The NatSSIPs Eight – Flow chart Error traps gallery

European guidelines advise that patients suffering ST-segment elevation myocardial infarction (STEMI) should be revascularised within 120 minutes of diagnosis. The preferred method of revascularization is primary percutaneous coronary intervention (pPCI). This study in BMJ Heart analysed the Northern Irish STEMI database to establish the proportion of pPCI delivered within the recommended treatment window. It aimed to determine whether there was any difference in long-term survival for patients treated beyond the recommended time window. The authors found that delays that result in primary PCI beyond 120 minutes from diagnostic ECG are associated with a significantly increased risk of mortality following STEMI in Northern Ireland.

This guide, published in the Health Service Journal, looks at how greater standardisation and ultimately accreditation of specialised vascular access teams would ensure a basic level of competency and quality of care.

Written by Benjamin W. Starnes, MD (professor and chief) and Niten Singh, MD (professor and associate chief) in the division of vascular surgery at the University of Washington, Seattle. This letter, published in Vascular Specialist, provides statistical and personal insight into how coronovirus is playing out for hospitals, and the measures they are having to put in place to deal with overwhelmed services.

Pulmonary embolism resulting from deep vein thrombosis, collectively referred to as venous thromboembolism, is the most common preventable cause of hospital death in the US. Pharmacologic methods to prevent venous thromboembolism are safe, effective, cost-effective, and advocated by authoritative guidelines, yet large prospective studies continue to demonstrate that these preventive methods are significantly underused. Based on quality improvement initiatives undertaken at the University of California, San Diego Medical Center and Emory University Hospitals, this guide assists quality improvement practitioners in leading an effort to improve prevention of hospital-acquired venous thromboembolism.

In this blog, Kristy Widdicombe-Dutch shares her decades-long experience of harmful healthcare that has left her with a complete loss of trust in the system. She describes how, starting in her 20s, she has experienced disbelief, gaslighting and poor care in relation to her vascular issues, which has left her with long-term physical harm and psychological trauma.

This cohort study in JAMA Network Open aimed to determine the prognostic performance of the simplified Geneva score and other validated risk assessment models (RAMs) to predict venous thromboembolism (VTE) in medical inpatients. The study provided a head-to-head comparison of validated RAMs among 1352 medical inpatients. It found that sensitivity of RAMs to predict 90-day VTE ranged from 39.3% to 82.1% and specificity of RAMs ranged from 34.3% to 70.4%. The authors concluded that the clinical usefulness of existing RAMs is questionable, highlighting the need for more accurate VTE prediction strategies.

This systematic review and meta-analysis in JAMA Internal Medicine aimed to assess the rates of complications from central venous catheter (CVC) use. The authors found that rates of complications varied substantially across studies, but on average, the rate of serious complications (arterial cannulation, pneumothorax, infection or deep vein thrombosis) from a CVC placed for three days was estimated to be 30 events per 1000 catheters placed (3%). Use of ultrasonography was associated with lower rates of immediate insertion-related complications.

Hospital-acquired venous thromboembolism (VTE) continues to be a significant source of preventable patient harm. This study from Richie et al. retrospectively examined patients admitted with VTE and found that only 15% received correct risk stratification and appropriate management and treatment. The case review found that patients were commonly incorrectly stratified, received incorrect pharmaceutical treatment, or inadequate application of mechanical prophylaxis (e.g., intermittent compression).

Vonda Vaden Bates is an alliance builder and leadership coach. For over 30 years Vonda has guided professionals to succeed on behalf of their organisations and careers. She helps people move from potential to action, set and reach goals, manage engaged teams, and communicate with influence. In 2013 Vonda decided to contribute her skills on behalf of safety in healthcare after researching how her husband, Yogiraj Charles Bates, died from one of the most common preventable causes of death, hospital-associated venous thromboembolism. Advocating for every person in the care system, Vonda brings a compassionate voice, strategic skills, and collaboration expertise to improve communication and safety in healthcare. The Patient Safety Movement share her story.

This short report from the National Vascular Registry (NVR) provides information on medical devices implanted during primary and revision abdominal aortic aneurysm (AAA) repair procedures during the past three years. In response to the Cumberlege review in 2020, the NVR has enabled information on implantable devices used in aortic aneurysm repairs to be entered in its datasets from July 2020. This was accompanied by the launch of the revision aortic datasets, which capture revision procedures both after open repair and endovascular stent grafting for abdominal aortic aneurysm (AAA). In total, there were 10,678 AAA procedures in the NVR performed from 1st January 2020 to 31st July 2022 and 5,383 (50%) contained information on implanted devices. This report also contains information on the: patterns for elective and non-elective procedures. type of repair for elective and non-elective surgery, for example, open procedures. type of device and components used during the procedures.

The Sentinel Stroke National Audit Programme (SSNAP), which assesses the care provided for patients during and after they receive inpatient care following a stroke, has published its ninth annual report. Based on data from April 2021 to March 2022, the report aims to identify which aspects of stroke care need to be improved with a particular focus on changes in stroke care over the last two years and the ‘roads’ that need to be followed in order to restore the quality of care. SSNAP measures the process of care against evidence-based quality standards referring to the interventions that any patient may be expected to receive. These standards are laid out in the latest clinical guidelines and include: whether patients receive clot busting drugs (thrombolysis). interventions for clot retrieval (thrombectomy). how quickly they receive a brain scan. how much therapy is delivered in hospital and at home.

The National Vascular Registry, which measures the quality and outcomes of care for adult patients who undergo major vascular procedures in the NHS, has published its latest annual report. This report provides comparative information on five major emergency and elective vascular interventions between 2019 and 2021: Repair of aortic aneurysms, including elective infra-renal, ruptured infra-renal, and more complex aneurysms Lower limb bypass Lower limb angioplasty/stenting Major lower limb amputation Carotid endarterectomy The report also includes the results from an organisational audit of NHS vascular services in 2022.

The Stroke Association's Saving Brains campaign aims to raise awareness of thrombectomy, a game-changing surgical treatment for stroke that many patients in the UK are currently missing out on. Thrombectomy can prevent further damage occurring to the brain in people having a stroke. It is a time-critical treatment and there is variation in access to the procedure across the country, In this video, stroke patients Karen and Phil talk about their experiences of treatment. Karen was able to have a timely thrombectomy and regained full mobility immediately following the procedure. Phil wasn't able to access thrombectomy due to the service not being available in his area at weekends; as a result, his recovery has been slower and more difficult.

This report published by the National Vascular Registry (NVR) contains information on emergency (non-elective) and elective procedures for the following patient groups: patients with peripheral arterial disease (PAD) who undergo either (a) lower limb angioplasty/stent, (b) lower limb bypass surgery, or (c) lower limb amputation patients who have a repair procedure for abdominal aortic aneurysm (AAA) patients who undergo carotid endarterectomy or carotid stenting.

Getting It Right First Time (GIRFT) is designed to improve the quality of care within the NHS by reducing unwarranted variations. By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings. This GIRFT report for vascular surgery recommends the adoption of a fully-fledged vascular networks model across the NHS in England, to give patients faster access to urgent surgery and save lives. According to the report, the model would help reduce the likelihood of life-threatening strokes, TIAs (transient ischaemic attacks), aortic aneurysm ruptures and arterial blockages. The report makes 17 recommendations, including: developing formal 'hub' and 'spoke' networks. reducing the time to treatment for vital surgical interventions. improving perioperative and follow-up care. Short video summary of the report

Surgeons' News is a magazine for surgical, dental and allied healthcare professionals. Published quarterly by the Royal College of Surgeons of Edinburgh, it features comment and opinion from leading professionals, plus reviews and reports on subjects relevant to all career levels.

CORESS is an independent charity, which aims to promote safety in surgical practice in the NHS and the private sector. CORESS receives confidential incident reports from surgeons and theatre staff. These reports are analysed by the Advisory Board, who make comments and extract lessons to be learned. Aiming to educate, and avoid blame, CORESS calls on surgeons to recognise a near miss or adverse event, react by taking action to stop it happening and then report the incident to CORESS so that the lessons can be published. The focus of CORESS is on detecting and learning from no-harm, near-miss and low harm events encountered during routine surgical practice. The programme collects reports of such events, analyses them and disseminates the learning contained within them to a wide surgical audience and other agencies involved in Patient Safety matters. These events are known collectively as ‘Accident Precursor Events’ or simply ‘Precursors’. CORESS Online reporting form Any surgeon or surgical trainee, irrespective of specialty, can submit reports in confidence. CORESS encourages all to report incidents of actual or near harm, as well as near misses, where there are lessons from which the whole community can learn. Every submission is treated in the strictest confidence and when published will never contain any clues as to its origin. CORESS Case Database Reports are analysed, edited and anonymised by members of the CORESS Advisory Board. They are then converted into narrative reports or vignettes. These are then published in a number of widely read surgical journals, in particular RCSEd Surgeons’ News and RCSEng Annals. The published reports are also available via the CORESS database. CORESS Reports

A monthly journal for all operating theatre staff covering surgical and anaesthesia news.

Chloe, 24, was at high risk for aortic dissection due to her genetic history. Despite presenting alarming symptoms at the A&E department, her condition was misdiagnosed. A subsequent call to the hospital resulted in no further action, and Chloe tragically died four days later. Investigations confirmed that the hospital’s lack of correct diagnosis was a missed opportunity that could have saved her life. In this article, the Aortic Dissection Charitable Trust looks at the case of Chloe, within a framework of four key themes set out by Patient Safety Learning for World Patient Safety Day 2023: Elevating the voice of patients and families. Shared decision-making at the point of care. Engaging patients when things go wrong. Engaging patients for system improvement.

This report by Healthcare Inspectorate Wales (HIW) relates to vascular services provided by Betsi Cadwaladr University Health Board following the de-escalation of these services as a Service Requiring Significant Improvement (SRSI). The review outlines that while progress has been made against all nine recommendations made by the Royal College of Surgeons, the health board still has improvements to make. Review recommendations The health board must consider its responsibilities in line with the NHS Wales Putting Things Right process. This is to establish whether timelier responses could have been given following the two formal complaints it received, and whether it is assured that updates were given appropriately throughout the course of the complaint investigation. The health board should set out what action will be taken to ensure that in future, people are communicated with in a timely manner when raising concerns. The health board must maintain the record keeping audit process, to assure itself that the standards expected for record keeping, are consistent and are being maintained in the immediate and long term. Particularly within its vascular services, but also across the health board. This includes record keeping for all members of the MDT. The health board must explore the reasons for reported inconsistencies in the implementation of the Diabetic Foot Pathway across its three acute sites. The health board must consider and address the issues reported to us regarding the lack of clinical areas at YG, to review patients pre and post operatively. The health board must consider the comments and findings in this report regarding staff culture and the perceptions of different teams. This is to establish whether there is learning, or development required to improve the working relationships across all teams, to support a positive working culture. The health board must consider the comments made by staff regarding the ongoing issues following the implementation of new pathways. This is to establish whether the pathways need to be revised, or further action is required for compliance with the pathways as appropriately. The health board must ensure that all staff are completing all aspects of the consent process as applicable and are documenting this within the relevant clinical records. In addition, further consent process audits must be undertaken and continue on a regular basis, with feedback provided to all staff and actions implemented as applicable. The health board must ensure that: a) All clinical record entries are filed in chronological order; b) Surgical operation records are filled promptly after the surgical procedure. The health board must address the issue where we found examples of misfiling an incorrect patient clinical record, in a different person’s record. The health board must ensure that clinical documentation entries are signed with the clinician’s name legibly printed for identification of the author. The health board must ensure a process is in place to evaluate the sustainability of its vascular service support from UHNM to determine what arrangements will be in place once current agreements end in 2024.

The National Infusion and Vascular Access Society (NIVAS) is a multidisciplinary organisation made up of healthcare professionals with a special interest in vascular access and IV therapy.  This white paper by NIVAS lays out evidence that having a nursing-led vascular access team in every hospital in the UK will improve patient safety, reduce workload pressures for other staff, and save the NHS money. Vascular access involves the use of devices such as catheters to deliver or remove fluids, blood or medication from a patient’s bloodstream. The paper examines the arguments advocating for Vascular Access Services Team (VAST) across the NHS, acknowledging the current pressures of restarting the NHS following the pandemic and the roadmap to reduce the elective waiting lists. It also outlines how integrating a standardised model of VAST into the healthcare systems of the NHS will benefit patients, the new Integrated Care Systems (ICS) and the wider objectives of the NHS. Recommendations The white paper makes the following recommendations: NHS England to implement standardised vascular access provision across the whole NHS with ringfenced funding. NHS England to conduct their own national survey to understand fully the vascular access provision within all Trusts. This survey needs to provide complete information on current practice and impact on patients, staff, the Trust, and the wider integrated care system (ICS). NHS England to support NIVAS in creating a national standardised training programme for vascular access. NHS England to support the creation of academically recognised professional qualifications for training in vascular access and establish a career pathway to include recognition of qualifications. Vascular access to be recognised as an essential specialist discipline with agreed national key performance indicators. Recording and reporting of all complications associated with vascular access to be mandatory. Access the full White Paper here Related hub content: Clinical radiology workforce census 2022 report (RCR, 8 June 2023)