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Showing results for tags 'Risk management'.
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Content ArticleA fire at the University Hospital of Leicester in 2023 led to the recommendation of a full evacuation of the tertiary neonatal unit. The incident was ultimately stood down—however, it highlighted the lack of inter-agency understanding regarding the difficulty and complexity of moving critically unwell and premature babies in the event of a major incident. In response, the Leicester Royal Infirmary and other agencies staged a simulation exercise to enable teams to prepare for possible future incidents. This HSJ article describes the simulation exercise and the lessons it revealed about managing neonatal unit evacuations during major incidents. It highlights key learnings around the two themes of communication and estates.
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Content ArticleThis increased implementation of artificial intelligence (AI) in healthcare could be either great or terrible news for the safety of services, depending on how organisations develop and implement it. This blog, written by the Professional Record Standards Body in partnership with the user experience company HD Labs, looks at the safety risks associated with using AI in health and care and outlines how standards can help keep AI safe.
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Content ArticleUse of artificial intelligence (AI) in healthcare is on the rise. Bodies including UK Governments, the National Institute for Health and Care Research and the NHS AI Lab are all investing in developing and deploying the technology. The Patient Information Forum (PIF) is an independent UK membership body for people working in health information and support. Developed in collaboration with PIF’s AI working group, this position statement aims to help members understand the AI landscape and how to manage it.
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News Article
‘Massive’ cybersecurity risk in NHS supply chain, trust and ICB leader warns
Patient Safety Learning posted a news article in News
The NHS supply chain contains “absolutely massive” cybersecurity risks which have not “really been talked about”, an integrated care board and trust chair has warned. Lena Samuels, who is chair of two London trusts and of Hampshire and Isle of Wight Integrated Care Board, said: “We’ve been talking internally about our own organisations but we haven’t really talked about the supply chain and the risks within that – and that is absolutely massive.” Ms Samuels, speaking at the NHS Confed Expo conference yesterday, said many NHS organisations still needed to question: “How do our risk registers capture what our supply chain resilience looks like in terms of cyber protection?” She said NHS organisations also needed to be considering “who on my board is going to ask that question” and “whether they’re going to even think of asking that question”, adding: “There’s so much that we’ve got to think about.” Read full story (paywalled) Source: HSJ, 14 June 2024 -
Content Article
Surgical Burns Action Group
Patient Safety Learning posted an article in Preventing surgical burns
The Surgical Burns Action Group (SBAG) is a leading reference point for conversations around surgical burn and fire prevention. The SBAG consolidates clinical and patient support to remove the significant gaps in the NHS’ reporting of surgical burns, ensuring patients are properly informed on the risk of a fire, and clinicians on the necessary safety requirements. The SBAG website includes useful information and materials about surgical fires and burns. -
Content ArticleFrom 1 April 2009 to 31 March 2019, NHS Resolution were notified of 631 clinical negligence claims relating to surgical burns to patients. Out of these 631 claims, 459 were settled, 58 were unmeritorious and 114 are still open. This has led to NHS Resolution paying £13.9m in damages and legal costs on behalf of NHS organisations.
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EventThis masterclass will focus on developing your role as a SIRO (Senior Information Risk Owner) in health and social care. Key learning objectives: Understanding the role of the Senior Information Risk Owner Identifying Information Risks across the organisation Working with others to mitigate the risk to patients, staff and organization. Confidence that all reasonable technical and organisation measure are in place Giving assurance to the Board that risks have been considered, mitigated or owned Understand the requirements of external confidence that policies, procedures are in place to deal with Data Breaches. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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News Article
Epidural in labour can reduce risk of serious complications by 35%, study finds
Patient-Safety-Learning posted a news article in News
Having an epidural during labour can reduce the risk of serious childbirth complications by 35%, according to research that suggests expanding access to the treatment may improve maternal health. An epidural is an injection in the back to stop someone feeling pain in part of their body. Making them more widely available and providing more information to those who would benefit from one was even more important than previously thought, researchers said. The study by the University of Glasgow and the University of Bristol involved 567,216 women who were in labour in Scottish NHS hospitals from 2007 and 2019, and went on to give birth vaginally or by an unplanned caesarean section. Of the total, 125,024 of the women had an epidural. Researchers analysed the rate of serious complications, including heart attacks, eclampsia, and hysterectomies during childbirth. Having an epidural cut the risk of these events by 35%, the study found. The lead author, Prof Rachel Kearns, of the University of Glasgow, said: “This finding underscores the need to ensure access to epidurals, particularly for those who are most vulnerable – women facing higher medical risks or delivering prematurely. “By broadening access and improving awareness, we can significantly reduce the risk of serious health outcomes and ensure safer childbirth experiences.” Read full story Source: The Guardian, 22 May 2024 -
Content ArticleThis handbook produced by the Healthcare Financial Management Association (HFMA) is designed to help NHS governing bodies and audit committees in reviewing and reassessing their system of governance, risk management and control. This is to make sure the governance remains effective and fit for purpose, whilst also ensuring that there is a robust system of assurance to evidence it.
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News Article
ECG-based AI could reduce hospital mortality
Patient-Safety-Learning posted a news article in News
An artificial intelligence (AI) system that sends text messages to alert hospital physicians about the high risk for mortality in their patients reduces the number of deaths, according to a study published in Nature Medicine. Chin-Sheng Lin, PhD, associate professor of cardiology at the Tri-Service General Hospital of the National Defense Medical Center in Taipei, Taiwan, and his colleagues have developed an AI system that identifies patients with a high risk for mortality on the basis of a 12-lead ECG. The system is intended to identify patients who would benefit from intensified care. "It is widely acknowledged that providing intensive care to critically ill patients reduces mortality. Delays in providing intensive care for critically ill patients result in catastrophic outcomes. Most in-hospital cardiac arrests are potentially preventable; however, the early signs of deterioration might be difficult to identify," wrote the researchers. The authors emphasized that exactly how the AI warning messages lead to a decrease in overall mortality must still be clarified. But the results suggest that they help in detecting high-risk patients, triggering timely clinical care, and reducing mortality, they wrote. Read full story Source: Medscape, 21 May 2024 -
Content ArticleFatigue is a perpetual risk in safety-critical industries. If that risk is not managed appropriately, it can result in a significant reduction in human performance, with associated impacts on safety. This paper from the Chartered Institute of Ergonomics & Human Factors (CIEHF) aims to present a roadmap for improving fatigue risk management in health and social care to improve patient safety and individual health workers' health and wellbeing. It makes a case for UK health and social care national bodies and organisations managing fatigue as a systemic risk.
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Content ArticleIn this blog, Peter Provonost MD, Chief Quality and Transformation Officer at University Hospitals Cleveland Medical Center, offers advice about what patients and their families can do to prevent health risks associated with hospital stays. He looks ways to mitigate against medication errors, surgical errors, infections, blood clots and other medical complications.
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Content ArticleIn this report for Stat, technology correspondent Casey Ross looks at the dangers involved in using AI to predict patient outcomes, especially in life-or-death situations such as suspected sepsis. He looks at the recent case of US electronic health record provider Epic who were force to rewrite the algorithm being used by tens of thousands of US clinicians to predict sepsis.
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Content ArticleItalian law No. 24/2017 focused on patient safety and medical liability in the Italian National Health Service. The law required the establishment of healthcare risk management and patient safety centres in all Italian regions and the appointment of a Clinical Risk Manager (CRM) in all Italian public and private healthcare facilities. Through a survey, this study in Healthcare looks at the law's implementation since it was passed five years ago. The results demonstrate that it has not yet been fully implemented, revealing: a lack of adequate permanent staff in all the Regional Centres, with two employees on average per Centre. few meetings were held with the Regional Healthcare System decision-makers with less than four meetings per year. This reduces the capacity to carry out functions. the role of the CRMs is weak in most healthcare facilities, with over 20% of CRMs have other roles in the same organisation. some important tasks have reduced application, e.g., assessment of the inappropriateness risk (reported only by 35.3% of CRM) and use of patient safety indicators for monitoring hospitals (20.6% of CRM). the function of the Regional Centres during the Covid-19 pandemic was limited despite the CRMs being very committed. the CRMs' units undertake limited research and have reduced collaboration with citizen associations. Despite most of the CRMs believing that the law has had an important role in improving patient safety, 70% of them identified clinicians’ resistance to change and lack of funding dedicated to implementing the law as the main barriers to the management of risk.
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Content ArticleThis guidance, from the Government Finance Function and HM Treasury, establishes the concept of risk management.
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Content Article
In this blog, Jo Jerrome, CEO of Thrombosis UK, explains the dangers of deep vein thrombosis (DVT) and why it is important for patients and staff to be aware of the risk factors. Jo offers advice on how we can all manage our risk of DVT, and introduces their award-winning, free patient app – “Let’s talk clots”. -
Content ArticleProgress on cardiovascular disease (CVD) was a significant driver of better population health and greater prosperity in the latter half of the 20th century. However, progress has recently stalled, with indications it may be in reverse. This may be due to policy choices made in the last 15 years, particularly since the global financial crisis, above and beyond the more recent impact of the Covid-19 pandemic. This report by Chris Thomas from the Institute for Public Policy Research (IPPR) shows, among other findings, that people are more likely to leave work due to a heart condition than any other health issue.
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Content Article
The theme of this year’s International Long Covid Awareness Day is ‘Confront Long Covid: Recognise, prevent, act’. In this interview, we speak to retired occupational physician Dr Clare Rayner about her work in understanding Long Covid and its impact on individuals, the health service and the wider economy. She talks about recent guidance she has developed on people with Long Covid returning to work and outlines the impact Long Covid has on the workforce. She calls on healthcare leaders and the Government to invest in treatment-related research as well as highlighting the significant health risks associated with Covid reinfection. -
News Article
Researchers study brain activity of surgeons for signs of cognitive overload
Patient Safety Learning posted a news article in News
It is a high-stakes scenario for any surgeon: a 65-year-old male patient with a high BMI and a heart condition is undergoing emergency surgery for a perforated appendix. An internal bleed has been detected, an anaesthetics monitor is malfunctioning and various bleepers are sounding – before an urgent call comes in about an ectopic pregnancy on another ward. This kind of drama routinely plays out in operating theatres, but in this case trainee surgeon Mary Goble is being put through her paces by a team of researchers at Imperial College London who are studying what goes on inside the brains of surgeons as they perform life-or-death procedures. Goble looks cool and collected as she laparoscopically excises the silicon appendix, while fending off a barrage of distractions. But her brain activity, monitored through a cap covered in optical probes, may tell a different story. The researchers, led by Daniel Leff, a senior researcher and consultant breast surgeon at Imperial College healthcare NHS Trust, are working to detect telltale signs of cognitive overload based on brain activity. In future, they say, this could help flag warning signs during surgery. “The operating theatre can be a very chaotic environment and, as a surgeon, you have to keep your head and stay calm when everyone is losing theirs,” said Leff. “As the cognitive load increases, it has major implications for patient safety. There’s no tool we can use to know that surgeon is coping with the cognitive demands of that environment. What happens when the surgeon is maxed out?” In the future, Leff envisages a system that could read out brain activity in real-time in the operating theatre and trigger an intervention if a surgeon is at risk of overload. Read full story Source: 2 March 2024 -
EventJoin us for a full day of education covering those topics that are the basis of our (or your) everyday practice. From risk management to infection control and patient care to practitioners wellbeing, leave the day informed, challenged and inspired. Book your tickets
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Content Article
Online healthcare services and apps can help people take more control of their health, by getting access to care easily and when it suits them. You need to make sure any medicine, treatment or health advice you get is safe and right for you. These six top tips from UK health organisations will help you keep safe if you decide to go online. -
Content ArticleA framework for boards and an example of what has worked in practice.
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Content ArticlePrimary care appointments may provide an opportunity to identify patients at higher risk of suicide. This study in the British Journal of General Practice aimed to explore primary care consultation patterns in the five years before suicide to identify suicide high-risk groups and common reasons for seeing a healthcare professional. The authors found that frequent consultations (more than once per month in the final year) were associated with increased suicide risk. The associated rise in suicide risk was seen across all sociodemographic groups as well as in those with and without psychiatric comorbidities. However, specific groups were more influenced by the effect of high-frequency consultation, including females, patients experiencing less socioeconomic deprivation and those with psychiatric conditions. The commonest reasons that patients who went on to commit suicide requested consultations in the year before their death, were medication review, depression and pain.
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Content Article
A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift
Anonymous posted an article in Florence in the Machine
Corridor nursing is increasingly being used in the NHS as demand for emergency care grows and A&E departments struggle with patient numbers. In this anonymous account, a nurse shares their experience of corridor nursing, highlighting that corridor settings lack essential infrastructure and pose many safety risks for patients. They also outline the practical difficulties providing corridor care causes for staff, as well as the potential for moral injury. Using the System Engineering Initiative for Patient Safety (SEIPS) framework, they describe the work system, the processes and how that influences the outcomes.- Posted
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Content ArticleNorth Central London Integrated Care System has piloted new guidelines and a local dashboard to ensure there is a safety net in place for females taking sodium valproate.This is a paywalled article published by the Pharmaceutical Journal.
