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Found 75 results
  1. Content Article
    The objectives of this study protocol is to establish baseline data related to the types and frequency of infusion pump alarms from the B. Braun Outlook 400ES Safety Infusion System with the accompanying DoseTrac Infusion Management Software. This exploratory study will analyse the aggregate alarm data for each hospital by care area, drug infused, time of day, and day of week, including overall infusion pump alarm frequency (number of alarms per active infusion), duration of alarms (average, range, median), and type and frequency of alarms distributed by care area. Infusion pump alarm data collected and analyzed in this study will be used to help establish a baseline of infusion pump alarm types and relative frequencies. Understanding the incidences and characteristics of infusion pump alarms will result in more informed quality improvement recommendations to decrease and/or modify infusion
  2. Community Post
    Overview Human error (HE) in global medicine kills 2.6 million annually placing patient safety on the G20 Summit (1). Solutions available (a) more staff training dominated by a HE-rate of about one error in 200 tasks and (b) a simple computer system used by high reliability organisations such as Banking with zero HE. With 70% of adverse events occurring on wards, patients should electronically acknowledge each intervention with their wristband-data. Missed interventions now detectable are compellingly alarmed reducing the consequences of HE 10,000 fold. Problem: The Healthcare sector have no “HE Recovery Protocols” on their wards (2a) This massive management error is punishable with fines and imprisonment across every other sector including Nuclear Rail Shipping etc. by the CPS here in the U.K. HE recovery protocol for ward-patient safety The patient is placed in a computerised quality-loop enabling them to acknowledge received MDT interventions by tagging their personal wristband-data back to the computer care plan. Missed interventions easily detected by the software-checklist now compellingly alarmed on-screen in front of health worker and patient. Nigh impossible to ignore, missed interventions are corrected, reducing the consequences of HE by more than a factor of ten thousand (104) (2b). Example: Opioid overdose prevention Software analyses patient's analgesic ladder. Their previously tagged opioid consumption displayed with opioid headroom warning. The patient tags acknowledging and updating the new opioid volume correctly administered. The system would have saved 450 Gosport patients 30-years ago, and currently under live investigation by Police (Operation Magenta). Conclusion Placing the ward patient in a computer driven tagged quality loop significantly reduces HE-consequences improving compliance lowering death rates adverse events bed-days and litigation. The tag system has a long-standing pedigree too. U.K. Bank customers have electronically tagged 30 million times a day, keeping accounts healthy and error free for decades. Please could colleagues on the hub help the NHS/CQC understand this established Industrial H&S concept with a view to trialling it. (Sums: 2.6m/10,000=2600 saving 2,597,400 annually?) References: [1] The cost of patient safety inaction: Why doing more of the … A .M. Alhawsawi. Patient Safety Hub 2020. [2a] The Blame Machine. R B Whittingham. ISBN 0-7506-5510-0. Industrial H&S. https://books.google.co.uk/then type “5.3 error recovery ” (page 74-75). [2b] https://books.google.co.uk/ then type “1. compelling feedback ” (page 78-79). Compelling feedback reduces HE by a factor of 10,000. Foot note: Sometimes whole industries become unwilling to look too closely at system faults and the blame machine swings into action. Pity the individual health worker not protected by management HE recovery protocols. https://books.google.co.uk/ type “The blame machine preface xii” last two paragraphs and xiii. Derek Malyon. 24.11.2020. Ward-Patient eQMS with Error Recovery Protocols.3 pdf.pdf
  3. Community Post
    Hi there, I represent a team of researchers in Reading, who are submitting ethical approval for a project investigating pain research and knee surgery. Part of this process is receiving feedback from an NHS ethics committee and addressing this for the benefit of the science, patients and clinicians involved. One suggestion they have made is that we involve patients within the review of our information sheets, which detail the procedures (both medical & research) that they may consent to. There is no requirement of expertise or experience from any patient who wishes to be involved, we are just very eager to make sure our information is clear, free of jargon and doesn't come across as confusing or intimidating. The committee have indicated this is an optional recommendation, but it is one that I am very keen to engage with. As it's optional, we are unable to shift our deadline for this, and I would unfortunately need the documents reviewed and submitted by Thursday 26th November. If this is something that anybody would be willing to help us with, I'd be very grateful. One information sheet is 2 pages, and the other is 7 pages, if this offers a good idea of how much time it may require. My hope it it would take no more than 30 minutes. If you are able to volunteer your time, please contact me on rich.harrison@reading.ac.uk, and I will forward you the documents for your review. Once again, thank you in advance! Richard
  4. Community Post
    Healthcare staff have had to adapt their way of working as a result of the pandemic, which has made pre-Covid guidance obsolete. Different Trusts are doing different things. What’s the solution?
  5. News Article
    The NHS has been returned to the highest level of risk on its emergency preparedness framework, a move which allows national leaders tighter control over local resources and decision making. NHS England chief executive Sir Simon Stevens announced the decision at a press conference this morning. He said: “Unfortunately, again we are facing a serious situation [due to rising coronavirus infections and hospital admissions]. That is the reason why at midnight tonight the health service in England will be returning to its highest level of emergency preparedness, EPPR level 4, which of course we had to be at from the end of January to the end of July.” Placing the NHS on level 4 of Emergency Preparedness Reslience and Response framework allows system leaders to take control of decisions over mutual aid and other local priorities. Sir Simon was joined by NHSE/I medical director Steve Powis and Alison Pittard, dean of the Faculty of Intensive Care Medicine. They used the press conference to stress the threat the NHS faced from the second covid peak, but also set out more positive news on the covid vaccine programme. Read full story Source: HSJ, 4 November 2020
  6. News Article
    The unlawful or inappropriate use of “do not attempt cardiopulmonary resuscitation” (DNACPR) orders by some clinicians risks undermining the care of terminally ill patients, almost 40 leading doctors, nurses and charities have warned. During the coronavirus pandemic repeated examples of unlawful decisions have emerged including widespread blanket orders on care home residents and patients with learning disabilities. Now the charity Compassion in Dying along with Marie Curie, Hospice UK and Sue Ryder, as well as more than 30 GPs, nurses and doctors, are warning more must be done to listen to patients and their families. In a joint statement, signed by more than 30 clinicians, they warn: “There have been examples of poor practice in relation to DNACPR decision-making during the pandemic, and the distressing impact this has had on patients and families cannot be underestimated. It is essential to thoroughly understand and learn from these cases to ensure that they do not happen again." “We are aware that the benefits of DNACPR decisions can be easily undone if they are not accompanied by honest, open and sensitive communication with a person’s healthcare team. To ensure that everybody who encounters a DNACPR discussion has a positive experience, we need to do more to listen to individuals and their families; their wishes must be sought and documented, their questions answered and their feelings acknowledged. “A DNACPR decision must always involve the person, or those close to them, and should be part of a wider conversation about what matters to that individual.” Read full story Source: The Independent, 8 March 2021
  7. News Article
    The health secretary Matt Hancock has been threatened with a judicial review amid fears patients’ human rights are at risk from the incorrect use of controversial do not resuscitate orders during the coronavirus pandemic. Ministers have been told they should use emergency powers to issue a direction to doctors and nurses in the NHS requiring them to comply with the law on do not attempt resuscitation orders (DNARS) and to ensure patients are properly consulted. In recent weeks there have been a number of reports of patients having DNARs put in place without their knowledge or in GPs imposing blanket decisions, prompting a warning letter from NHS England’s chief nurse last month. The legal action is being brought by Kate Masters, the daughter of Janet Tracey, who died at Addenbrooke's hospital in 2011 after a DNAR was put in place without her knowledge. In 2014, Tracey's husband David won a landmark victory at the Court of Appeal which gave patients a new legal right to be consulted by doctors when DNARS were being considered. Not consulting a patient was a breach of their human rights, the court ruled. Read full story Source: The Independent, 6 May 2020
  8. News Article
    All NHS hospitals in England have been ordered to create secure areas for coronavirus testing to “avoid a surge in emergency departments”, according to a leaked NHS letter. Hospitals have been told to create “coronavirus priority assessment pods”, where people will be checked for the virus, which will need to be decontaminated each time they are used. The letter, seen by The Independent and dated 31 January, instructs all chief executives and medical directors to have the pods up and running no later than Friday 7 February. It comes as the global death toll from the virus has reached 565 with around 28,000 infected. One hospital chief executive told The Independent he believed the requirement was “an overreaction”, adding: “I think we should be sending teams out to swab in patients homes as the advice is to stay at home and self-manage as with any other flu". In the letter, Professor Keith Willett, who is leading the NHS’s response to coronavirus, told NHS bosses: “Plans have been developed to avoid a surge in emergency departments due to coronavirus. “Although the risk level in this country remains moderate, and so far there have been only two confirmed cases, the NHS is putting in place appropriate measures to ensure business as usual services remain unaffected by any further cases or tests of coronavirus.” Read full story Source: 5 February 2020
  9. News Article
    Dozens of hospital trusts have failed to act on alerts warning that patients could be harmed on its wards, The Independent newspaper has revealed. Almost 50 NHS hospitals have missed key deadlines to make changes to keep patients safe – and now could face legal action. One hospital, Birmingham Women’s and Children’s Foundation Trust, has an alert that is more than five years past its deadline date and has still not been resolved. Now the Care Quality Commission (CQC) has warned it will be inspecting hospitals for their compliance with safety alerts and could take action against hospitals ignoring the deadlines. National bodies issue safety alerts to hospitals after patient deaths and serious incidents where a solution has been identified and action needs to be taken. Despite the system operating for almost 20 years, the NHS continues to see patient deaths and injuries from known and avoidable mistakes. NHS national director for safety Aidan Fowler has reorganised the system to send out fewer and simpler alerts with clear actions hospitals need to take, overseen by a new national committee. Last year the CQC made a recommendation to streamline and standardise safety alerts after it investigated why lessons were not being learnt. Professor Ted Baker, Chief Inspector of hospitals, said: “CQC fully supports the recent introduction of the new national patient safety alerts and we have committed to looking closely at how NHS trusts are implementing these safety alerts as part of our monitoring and inspection activity.” He stressed: “Failure to take the actions required under these alerts could lead to CQC taking regulatory action.” Read full story Source: The Independent, 30 December 2019
  10. Content Article
    In the study, Yonash and Taylor identified instances of WSS events (not including near misses) that occurred during 2015–2019 and were reported to PA-PSRS. During the five-year period, they found that 178 healthcare facilities reported a total of 368 WSS events, which was an average of 1.42 WSS events per week in Pennsylvania.They also found that 76% (278 of 368) of the WSS events contributed to or resulted in temporary harm or permanent harm to the patient. Overall, the study shows that the frequency of WSS varied according to a range of variables, including error type (e.g., wrong side, wrong site, wrong procedure, wrong patient); year; facility type; hospital bed size; hospital procedure location; procedure; body region; body part; and clinician specialty. Our findings are aligned with some of the previous research on WSS; however, the current study also addresses many gaps in the literature. We encourage readers to use the visuals in the manuscript and appendices to gain new insight into the relation among the variables associated with WSS. Ultimately, the findings reported in the current study help to convey a more complete account of the variables associated with WSS, which can be used to assist staff in making informed decisions about allocating resources to mitigate risk.
  11. Content Article
    Key points Communication between members of the surgical team is an integral component of the prevention of surgical fires. Open delivery of 100% oxygen should be avoided if at all possible for surgery above the xiphoid process. Surgeons usually control the ignition sources, such as electrosurgical units and lasers. Operating theatre nurses or practitioners usually control the fuel sources, such as alcohol-based preparations and surgical drapes. The use of an ignition source in close proximity of an oxidiser-enriched environment creates a high risk for surgical fires.
  12. Content Article
    Developing the FRAS In January 2017, I read a tragic story in Outpatient Surgery involving an elderly patient in the US who suffered multiple burns following the use of chlorohexidine bottled alcoholic prep. I'd also read that in the US there are over 600 surgical fires every year. As the Practice Development Lead for my theatre department at the time, I decided to design a Fire Risk Assessment Score (FRAS). I discussed the FRAS with my manager and my suggestion to add the FRAS to the 'Time Out' of our WHO Surgical Safety Checklist. To further develop my ideas, I attended one of the Association for Perioperative Practice (AFPP) study days. All the delegates were asked to discuss and write a plan to make an immediate change in practice on return to their theatre department. I planned the FRAS. My manager who had originally agreed to my idea in January left in March, but I persevered with the idea and in July 2017 I made copies of the FRAS, discussed the score with senior staff, laminated the copies and placed one in each theatre. It was used as part of the WHO Surgical Safety Checklist Time Out. One month later I moved on and started bank shifts as a scrub practitioner in theatres. Fast forward 3 years Imagine my delight on a bank shift in August 2020 to see the FRAS as part of the patient profile on the hospital computer system – which meant it was in all six hospitals! So have fires decreased in theatres? Research shows that fires are still occurring in some UK theatres, and around the world, where a score is not part of the 'Time Out'; where bottled alcoholic prep is still used and not allowed to dry for 3 minutes before draping; and where lighted cables are sometimes allowed to rest on paper drapes. All perioperative staff need to have an awareness of surgical fires – where each flammable item used for the procedure is counted as 1 risk, and the score highlighted to the team and also documented before the start of the surgery. In doing this we can be reassured that we have taken all the necessary fire safety precautions for patients in our care, for the perioperative surgical team and also the preservation and the reputation of the hospital. Further reading The FRAS tool Kathy implemented Yardley IE, Donaldson LJ. Surgical fires, a clear and present danger. The Surgeon 2010; 8(2):87-92. Alani H et al. Prevention of surgical fires in facial plastic surgery. Australas J Plast Surg 2019; 28:40-9. Vogel L. Surgical fires: nightmarish “never events” persist. CMAJ 2018;190(4): E120. Cowles Jr CE, Culp Jr WC. Prevention of and response to surgical fires. BJA 2019; 8:261-266.
  13. News Article
    A London hospital has launched an investigation after a woman whose baby died in the womb had to deliver her son at home due to lack of beds and keep his remains in her fridge when A&E staff said they could not store them safely. Laura Brody and her partner, Lawrence, said they were “tipped into hell” after being sent home by university hospital Lewisham to await a bed when told their baby no longer had a heartbeat but no beds were immediately available to give birth, the BBC reported. Two days later, after waking up in severe pain, Brody, who was four months into her pregnancy, gave birth in agony on the toilet in their bathroom. “And it was then,” she told the broadcaster, “I saw it was a boy”. The couple, who wanted investigative tests to be carried out at a later time, dialled 999 but were told it was not an emergency. They wrapped their baby’s remains in a wet cloth, placed him in a Tupperware box, and went to A&E where they were told to wait in the general waiting room, they said. She was eventually taken into a bay and told she would require surgery to remove the placenta. But, with the waiting room hot and stuffy and staff refusing to store the remains or even look inside the Tupperware box, they decided as it got to midnight they had no option but for her partner to take their baby’s remains home. Brody said the whole experience “felt so grotesque”. “When things go wrong with pregnancy there are not the systems in place to help you, even with all the staff and their experts – and they are working really hard – the process is so flawed that it just felt like we had been tipped into hell,” she told Radio 4’s Today programme. The case is said to have raised wider concerns among campaigners who argue that miscarriage care needs to be properly prioritised within hospitals including A&E. Read full story Source: The Guardian, 30 May 2022
  14. News Article
    Hundreds of organisations, including drug companies, private healthcare providers and universities, have breached patient data sharing agreements but not had their access to patient data withdrawn, a report reveals. “High risk” breaches were revealed to have occurred at healthcare groups, pharmaceutical giants and educational institutions including Virgin Care, GlaxoSmithKline (GSK) and Imperial College London, during audits by NHS Digital, according to an investigation by the BMJ. This means these organisations were handling information outside the remit agreed in data contracts and may be failing to protect confidentiality, the journal said. In one instance, local NHS commissioners allowed sensitive, identifiable patient data to be released to Virgin Care without permission from NHS Digital. When auditors tried to get access to Virgin Care to check their compliance, they were denied access for several weeks and the company refused to delete the patient data, the BMJ reported. Records about mental health, including children and young people, those with learning disabilities, diagnostic imaging and other confidential patient data was being processed outside the scope of objectives agreed with NHS Digital, at an address that had not been agreed, and without a data sharing contract. A spokesperson for Virgin Care said it had “robust data protection in place”. “It is outrageous that private companies and university research teams are failing to comply,” said Kingsley Manning, the former chair of NHS Digital. “How is it that these organisations can be so lax with data?” Read full story Source: The Guardian, 11 May 2022
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