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Showing results for tags 'Safety process'.
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Content ArticleMedicines reconciliation is the process of compiling a complete list of a person’s current medicines. When a patient registers at a new primary care setting, medicines reconciliation contributes to patient safety and continuity of care. This article in The Pharmaceutical Journal explores how to optimise the multidisciplinary team and involve pharmacy technicians in the process, using four case scenarios. The article aims to help those working in community pharmacy teams to: identify potential risks and appropriate management strategies for new patients with complex medication needs, including those with chronic conditions and those requiring specialist care. understand the importance of timely referrals, communication with specialists, and adherence to guidelines in ensuring safe and effective medication management. recognise the significance of interdisciplinary collaboration and patient-centred approaches in addressing the diverse healthcare needs of patients, particularly those from other cultural backgrounds. You can access this article by signing up for a free account with The Pharmaceutical Journal.
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Content ArticleSafety risks exist in all medical care settings, but emergency medicine professionals face particular challenges as they strive to deliver the safest, highest quality care to their patients. Massachusetts emergency departments rank high in a national review of ED quality and safety. Yet many frontline staff express concerns that the environment is not as safe as it needs to be for patients or staff. In response to these concerns from their members, leaders of the Massachusetts College of Emergency Physicians (MACEP) reached out to the Betsy Lehman Center to help facilitate work to improve safety in emergency departments across the state. The Massachusetts Emergency Nurses Association (MENA) and the Massachusetts Association of Physician Assistants (MAPA) joined as partners in the effort. Through this collaboration, the Betsy Lehman Center convened an expert panel to identify key risks to safety in emergency departments, recommend practical steps for mitigating these risks, and develop a toolkit to support implementation of the recommendations. Recognising the broad range of safety issues facing emergency medicine clinicians and staff, the expert panel focused on interventions that could be executed from “within the four walls” of the emergency department in three key areas: (1) crowding; (2) cognitive overload; and (3) care coordination.
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In this blog, Laura Green, Consultant Haematologist at NHS Blood and Transplant and Barts Health NHS Trust, describes how a new electronic process to improve the safety of blood transfusions was implemented across all four Barts Health sites. She explains why the new system was needed, outlines the benefits for staff and patients and highlights the role of project governance and staff training in successful implementation. -
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The Safety of Work podcast
Patient Safety Learning posted an article in Recommended video and audio resources
Do you know the science behind what works and doesn’t work when it comes to keeping people safe in your organisation? Each week join Dr Drew Rae and Dr David Provan from the Safety Science Innovation Lab at Griffith University as they break down the latest safety research and provide you with practical management tips. -
Content ArticleThis multihospital prospective study in Surgery aimed to determine whether strict adherence to an enhanced recovery after surgery protocol leads to improvement in outcomes, compared with less strict compliance. The study looked at all consecutive anatomic lung resection patients on the thoracic enhanced recovery after surgery pathway from May 2021 to March 2023 and compared this cohort with a historical control from January 2019 to April 2021. The authors found that enhanced recovery after surgery protocols improve outcomes after anatomic lung resection, and that increasing compliance to individual elements further improves patient outcomes. They argue that continued efforts should be directed at increasing compliance to individual protocol elements.
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Medtech companies are continually developing new medical devices and products for use in healthcare, and ensuring that each one is safe to use should be the top priority of every company. In this anonymous blog, a nurse shares their experience of being employed by a start-up producing a new piece of equipment for use in cardiac surgery. They soon discovered their values did not match up, as the company prioritised getting their new product to market above patient safety. The writer talks about the personal cost of repeatedly speaking up for safety and describes the importance of working for an employer that sees patient safety as the top priority and recognises that it goes hand in hand with commercial success.- Posted
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Content ArticleWhen GP practices have a patient who is violent or exhibiting behaviour that makes them fear for their safety, the patient should immediately be removed from the practice list. This guidance from the BMA explains how to do this as well as outlining the special allocation scheme (SAS), which provides primary care medical services in a secure environment to patients who meet the criteria. In the SAS, designated GP practices provide services to patients by appointment at specific locations and times as detailed in individually agreed contracts. Patients join the scheme after being immediately removed as a result of an incident that was reported to the police. It aims to protect GPs, practice staff and patients who have the right to be in the practice without fear of intimidating behaviour.
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Content ArticleIn this long read, inews health correspondent Paul Gallagher looks at the processes now in place to ensure patient safety in blood transfusions and mitigate the risk of another infected blood scandal. He talks to Will Irving, Professor of Virology at the University of Nottingham, who outlines at although the risk is low, there may be transmission risks associated with blood transfusions that we are not yet aware of. The article also describes the work of the Serious Hazards of Transfusion (SHOT) committee, which has been collecting and analysing anonymised information on adverse events and reactions in blood transfusion from all healthcare organisations that are involved in the transfusion of blood and blood components in the UK since 1996.
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Action cards - Incorrect swab, instrument and suture counts
Patient-Safety-Learning posted an article in Surgery
These action cards developed by Mark Rigby, Head of Theatre Services at Warrington and Halton Teaching Hospitals NHS Foundation Trust, contain a checklist of actions to be taken in the event of: incorrect swab count incorrect instrument count incorrect missing sutures or small metal items count -
Content Article
Five steps to safer surgery audit tool
Patient-Safety-Learning posted an article in Surgery
This audit tool developed by Mark Rigby, Head of Theatre Services at Warrington and Halton Teaching Hospitals NHS Foundation Trust, is designed to assess theatre compliance with the five steps to safer surgery, which includes the World Health Organization (WHO) Surgical Safety Checklist. The checks included in the five steps are designed to reduce the number of errors and complications resulting from surgical procedures by improving team communication and by verifying and checking essential care interventions. The tool features a monthly observation audit and documentation audit and presents recorded data in a results tab which tracks progress by month, providing more timely data locally than the clinical scorecard. -
News ArticleThe use of mixed-sex wards has gone “through the roof” after the number of men and women being put in beds next to each other soared to nearly its highest level in a decade. Official figures from NHS England show the government’s strict rules against doing so were broken nearly 5,000 times in February alone. NHS leaders voiced concerns over the high number of breaches and warned that care that was “unthinkable a decade ago is at risk of becoming the new normal”. Shadow health secretary Wes Streeting said patients were left feeling humiliated and at risk, adding: “The use of mixed-sex wards has gone through the roof under the Tories.” The government outlawed mixed wards in the NHS in 2010. Under the guidance, patients should not share wards overnight, share bathroom facilities or have to walk through areas occupied by patients of the opposite sex to get to the toilets. Despite promises more than a decade ago to eliminate mixed wards, The Independent found: 4,811 reported breaches in February, up from 3,789 last November Nurses warning “sky-high breaches” are the tip of the iceberg Evidence that patients are suffering sexual assaults while on mixed mental health wards Under the guidance, no mental health units should have mixed wards. However, earlier this year, The Independent revealed the practice is widespread, with more than 500 sexual assaults reported across almost half of the NHS mental health hospitals in England. Read full story Source: Independent, 28 April 2024
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Content ArticleDespite widespread efforts to combat the opioid epidemic, post-operative opioid overprescribing by doctors remains an ongoing contributor to opioid misuse. This US study aimed to evaluate the impact of a low-cost, reproducible “just in time” intervention on opioid prescribing in dialysis access operations. Standardised opioid prescribing guidelines were emailed to residents on the vascular service on the first day of the rotation. Opioid prescriptions were reviewed for four years before and one year after this intervention. The results showed a decrease in patients discharged with opioids following the intervention, from 58% to 36%. For patients prescribed opioids, the median quantity decreased from 90 to 45 oral morphine equivalents.
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Content ArticleBatches of some products made by Legency Remedies Pvt Ltd have been found to contain a bacteria called Ralstonia pickettii (R. pickettii). All potentially affected batches are being recalled following an MHRA investigation.
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Content ArticleThe Health Action Process Approach (HAPA) suggests that the adoption, initiation, and maintenance of health behaviours must be explicitly conceived as a process that consists of at least a motivation phase and a volition phase. Follow the link below to be directed to more information and resources on the HAPA approach.
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Content ArticlePeripheral nerve blocks (PNB) are safe and effective alternatives or supplements to general anaesthesia. They may improve pain control both during and after surgery, thus avoiding many of the side effects of systemic opioids. PNBs may also lead to improved patient satisfaction, decreased resource utilization, and may be better for the environment by decreasing usage of aesthetic gases and other medications. With the growing use of peripheral nerve blocks in the United States, this paper examines safety issues surrounding the procedures. It examines the safety of nerve blocks as it relates to: nerve injury recognition and treatment of local anaesthetic systemic toxicity (LAST) appropriate health care professional performance of timeouts to avoid wrong-site blocks.
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Intravenous therapy is an essential aspect of modern healthcare. While the benefits of using intravenous therapy usually outweigh the risks, occasionally the administration of IV therapies can go wrong. Infiltration and extravasation is a complication whereby the drug or IV therapy leaks into the tissues surrounding the vascular access device. This toolkit, developed by the National Infusion and Vascular Access Society (NIVAS), is intended to enable local services and healthcare organisations to implement polices, protocols and guidelines that will increase awareness about non-chemotherapy extravasations. -
Content ArticleThe leadership and management functions of Patient Safety Incident Response Framework (PSIRF) oversight are wider and more multifaceted compared to previous response approaches. When working under PSIRF, NHS providers, integrated care boards (ICBs) and regulators should design their systems for oversight “in a way that allows organisations to demonstrate [improvement], rather than compliance with prescriptive, centrally mandated measures”. To achieve this, organisations must look carefully not only at what they need to improve but also what they need to stop doing (eg panels to declare or review Serious Incident investigations). Oversight of patient safety incident response has traditionally included activity to hold provider organisations to account for the quality of their patient safety incident investigation reports. Oversight under PSIRF focuses on engagement and empowerment rather than the more traditional command and control.
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Content ArticleEmergence delirium is a temporary but potentially dangerous condition that can occur when a patient awakens after a procedure. In this video, staff at the VA Pittsburgh Healthcare System (VAPHS) share how they implemented a perioperative intervention to reduce the risk of patient and staff harm.
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Content ArticleGreat Ormond Street Hospital NHS Foundation Trust is one of the world’s leading children’s hospitals, receiving 242,694 outpatient visits and 42,112 inpatient visits every year (figures from 2021/22). This paper seeks to provide an overview of the safety systems and processes Great Ormond Street Hospital has in place to keep patients, staff, and healthcare environments safe.
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Content ArticleThis is a video presentation from the Royal College of Surgeons in Ireland, looking at facilitation skills for after action reviews (AAR) and the wider process.
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Content ArticleTOXBASE is the poisons information database created and maintained by the National Poisons Information Service (NPIS). It should be the first port of call for healthcare professionals seeking poisons information in the UK. NHS facilities can register for free and individual advice on more serious or complex cases is available via the NPIS 24-hour telephone service.
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Before induction of anaesthesia calculator (2020)
Patient-Safety-Learning posted an article in Surgery
This tool is based on the Surgical Safety Checklist developed by the World Health Organization (WHO) in 2009. It should be used at three key transitions in care: Before anaesthesia is given Immediately prior to incision Before the patient is taken out of the operating room The checklist is not intended to be comprehensive, and additions and modifications to fit local practice are encouraged. -
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Fitting coils: developing a safe and supportive service
Patient_Safety_Learning posted an article in Women's health
In this blog, Sexual and Reproductive Health Consultant, Neda Taghinejadi tells us about the coil fitting service she is part of in Oxfordshire. Neda explains how the service has integrated a number of tools, including a triage system to identify more complex cases, to help support a safe and quality service. -
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FRAM in a nutshell (2021)
Patient-Safety-Learning posted an article in Techniques
FRAM (Functional Resonance Analysis Method) is a graphical tool for demonstrating how a process is done through multiple functions and activities. This blog describes how FRAM can be used to analyse any process using four steps: Identifying and describing essential functions to have a successful process Finding out if there is the variability of the functions (if the process can be done in another way) Determining how the variability of a function impact the process Introducing recommendation for managing the undesired outcomes -
Content ArticleThis guide from NHS England outlines the processes involved in developing safety actions. This includes sections on: agreeing areas for improvement defining safety actions prioritising safety actions defining safety measures writing safety actions monitoring and reviewing.
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