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Found 140 results
  1. News Article
    The family of a boy who died of an invasive form of strep A have said they sought medical help three times before he was admitted to hospital. Jax Albert Jefferys, who attended Morelands Primary School in Waterlooville, Hampshire, died on 1 December, aged five. His family said they were initially told he had flu. Since September, UK Health Security Agency figures show 15 UK children have died after invasive strep A infections. Paying tribute to their "darling son", Jax's family said they had sought medical advice on three occasions during the four days leading up to his death and were told that he was suffering with influenza A. "We then followed the recommended course of action: to administer a proprietary paracetamol-based medication in the prescribed dosage," they said in a statement. However, they said on the fourth day Jax's condition "deteriorated so much" they "rushed him to hospital" and he later died. "Only after his death was it confirmed that the cause was [strep A]," the family said. Read full story Source: BBC News, 14 December 2022
  2. News Article
    Thrombosis UK has warned that deaths involving blood clots are higher than expected as it called for more transparency over the work hospitals are doing to reduce the risk for patients. Before the pandemic hit, hospitals were regularly publishing data on the number of patients who had been risk assessed for blood clots. In March 2020, the NHS in England took the decision to suspend the data collection on venous thromboembolism (also known as VTE) risk assessments to “release capacity in providers and commissioners to manage the Covid-19 pandemic”. But the data collection and publication is yet to resume. The charity said the data shows how many VTE cases are missed in hospitals. One bereaved man described how his mother died last year after the condition was missed. Tim Edwards, 42, said healthcare workers missed signs of the condition while Jennifer Edwards, 74, was in hospital on the south coast. Despite having many symptoms of a pulmonary embolism she was discharged home and died three days later. Mr Edwards said: ““My mother’s symptoms were missed from her admission to hospital right up to her time in the cardiology department. “She was discharged and passed away three days after phoning the NHS with shortness of breath. She should not have died. I took it upon myself to enquire about the circumstances surrounding her death and was overwhelmed by the lack of care taken. “Sadly, I know this is not an isolated case.” Read full story Source: Wales Online, 12 May 2023 Further reading on the hub: Pulmonary embolism misdiagnosis – a systemic problem (a blog from Tim Edwards) Independent review of pulmonary embolism fatalities in England & Wales – recent trends, excess deaths, their causes and risk management concerns (Tim Edwards) Jenny, and why we must learn from her misdiagnosis of pulmonary embolism National Voices: Pulmonary embolism misdiagnosis - a blog by Helen Hughes.
  3. Content Article
    This video published by the Irish Health Service Executive (HSE) tells the story of Pat, whose bowel cancer diagnosis was missed, resulting in his premature death. His daughter Patricia talks about the two investigations that took place into her father's death and how the hospital's internal investigation failed to acknowledge that a staff member had raised concerns about Pat's initial colonoscopy on five occasions, but this had not been followed up. She describes the impact of these events on her father and the rest of the family and calls on medical professionals to "trust us (families) more and fear solicitors less."
  4. Content Article
    In a blog for National Voices, the leading coalition of health and social care charities in England, Patient Safety Learning’s Chief Executive Helen Hughes discusses an independent report written by risk expert Tim Edwards that highlights serious and widespread safety concerns around the misdiagnosis of pulmonary embolism.
  5. Content Article
    In November 2021, 15-year old Alice Tapper nearly died due to a missed diagnoses of a perforated appendix. In this opinion piece, Alice shares her experience of being admitted to hospital with intense abdominal pain and other serious symptoms. In spite of her parents' requests for imaging to rule out appendicitis, doctors diagnosed that Alice had a viral infection and refused to prescribe antibiotics. Alice's condition severely deteriorated, leading her father to call the hospital and beg a gastroenterologist for further investigation. Fortunately, the hospital granted his request and after an x-ray and ultrasound, Alice was found to have a perforated appendix. She was going into hypovolemic shock, when severe blood or other fluid loss makes the heart unable to pump enough blood to the body. Thankfully, emergency surgery and antibiotics saved Alice's life, but she reflects on the fact that without her father's intervention, she would probably have died. She describes how her doctors failed to take the concerns she and her parents repeatedly expressed seriously, and that this lack of responsiveness could have been fatal. She highlights research that shows that appendicitis is missed in up to 15% of paediatric patients, and that missed diagnosis is most common in children under five, and is more common in girls than boys.
  6. Content Article
    Tim Edwards is a risk management expert and son of Jenny, who passed away in February 2022 from pulmonary embolism (PE), following a misdiagnosis. Frustrated by the quality of the initial investigation that followed her death and the lack of assurance that learning would take place, Tim conducted an independent review: Independent review of pulmonary embolism fatalities in England & Wales – recent trends, excess deaths, their causes and risk management concerns. Drawing on existing data, freedom of information requests and Jenny’s case, the report raises significant patient safety concerns relating to PE care across England and Wales. Tim calculated that from April 2021 to March 2022, there was a minimum of 400 excess deaths due to pulmonary embolism misdiagnosis. In this opinion piece, Tim draws on his research to highlight the key patient safety issues, and to encourage further dialogue around the topic. 
  7. Content Article
    Elizabeth Holmes, the 38 year old founder of failed diagnostic start-up Theranos, was sentenced to more than 11 years in prison this November. The sentence was handed down nearly a year after she was found guilty of defrauding investors about her finger prick blood testing devices, and seven years after the Wall Street Journal published its first investigation exposing the company’s struggles. Theranos’ customers received false laboratory test results indicating life threatening conditions such as cancer and HIV. Patients were left to wait anxiously while traditional laboratories repeated the tests, and at least one customer stopped taking his medication on the basis of erroneous results. Holmes was ultimately not convicted of charges relating to patient harm, instead she will be locked up for misleading wealthy investors.
  8. Content Article
    An alarming statistic shared by countless people is based on a highly problematic bit of data extrapolation and has been used to paint all of medicine as untrustworthy. In this article, Jonathan Jarry explores the evidence.
  9. Content Article
    Diagnostic errors are a known patient safety concern across all clinical settings, including the emergency department (ED). The authors from the John Hopkins University conducted a systematic review to determine the most frequent diseases and clinical presentations associated with diagnostic errors (and resulting harms) in the ED, measured error and harm frequency, as well as assessing causal factors.
  10. Content Article
    Jenny Edwards died in February 2022 from pulmonary embolism, following misdiagnosis. In this blog, her son Tim introduces us to Jenny, illustrating the deep loss felt following her premature passing. He talks about the care she received and argues that there were multiple points at which pulmonary embolism should have been suspected. Tim found the investigation that followed Jenny’s death to be lacking in objectivity and assurance that any learning could be taken forward. He has since produced an independent report, drawing on existing data, freedom of information requests and his mother’s case, to highlight broader safety issues.
  11. Content Article
    Pulmonary embolism is the third most common cause of cardiovascular death worldwide after stroke and heart attack. Although life-threatening, when diagnosed promptly survival rates are good.  This report, authored by risk expert Tim Edwards and published by Patient Safety Learning, highlights serious and widespread patient safety concerns relating to the misdiagnosis of pulmonary embolisms.  Drawing on existing data, freedom of information requests and his mother’s case, he outlines nine calls for action to improve pulmonary embolism care. 
  12. Content Article
    This article in Time reviews the documentary film 'To Err is Human', which explores the tragic outcomes of medical errors and the medical culture that allows them to persist. The film follows the Sheridans, a family from Boise, Idaho on their journey to understand how two major medical errors befell their family: one that contributed to a case of cerebral palsy, and another that involved a delayed cancer diagnosis and ended in death.
  13. Content Article
    This article by Rebecca Rosen and Trisha Greenhalgh in the BMJ looks at the safety of remote GP consultations. It begins by looking at the case of student David Nash, who tragically died in 2020 after four telephone consultations with his GP; he was denied an in-person appointment for a painful ear infection that led to a fatal brain abscess. One coroner has raised concerns that this is not a one-off incident, noting that in five inquest reports they wrote during the pandemic, they question whether deaths could have been prevented by in-person consultations. The authors look at the recommendations of the ongoing 'Remote by Default 2' study, which is exploring how best to embed remote consulting in future GP services. They highlight better triage of appointment requests, active listening, checking back, increasing the use of video consulting and better training for clinicians as factors that could improve the safety of remote consultation.
  14. Content Article
    In July 2022, HSIB launched a national investigation into the safety risk of clinical investigation booking systems failures. Specifically, the investigation explores the use of paper or hybrid booking systems and the production of appointment letters. This interim bulletin highlights a safety risk identified by the investigation and presents a safety observation for the attention of NHS care providers. Some vital NHS services still use paper-based or hybrid systems, which may have been developed over time and could leave unintended gaps where patients can be lost in the system. The reference case for this investigation is the experience of a patient whose magnetic resonance imaging (MRI) scan was not rescheduled following a cancellation, leading to a delay in the diagnosis of cancer. Hybrid systems were in use, which did not assist staff to keep track of patients. Additionally, the hybrid systems in use did not allow appointment letters in non-English languages to be produced.
  15. News Article
    The Leapfrog Group will add a section to its annual survey in 2024 asking US hospitals to report their progress on evidence-based practices designed to prevent and reduce patient injury and death from diagnostic error and delay. This Autumn, Leapfrog will pilot test survey questions about a range of diagnostic practices from holding leaders accountable for diagnostic safety to openly communicating diagnostic errors to patients and optimising electronic records to support accurate and timely diagnosis. Results of the Leapfrog Hospital Survey — completed voluntarily each year by more than 2,300 U.S. hospitals — rate participants’ progress toward Leapfrog’s standards for safety, quality and transparency and are publicly reported. Since 2000, the survey has been the centerpiece of Leapfrog’s mission to “support informed health care decisions and promote high-value care.” The results are also used by hospitals to benchmark their performance to others in the industry. The addition to the survery is part of a larger push to reduce harm caused by diagnostic error. Leapfrog is working with the Society to Improve Diagnosis in Medicine (SIDM) on a multi-year project called “Recognizing Excellence in Diagnosis.” Mark L. Graber, SIDM’s Founder and President Emeritus, expects that including diagnosis in the survey will elevate organizations’ interest in addressing diagnostic error. “Healthcare organizations need to address the harm arising from diagnostic error in their own hospitals.” says Dr. Graber. “The new Leapfrog report gives them ideas on where to start.” Read full story Source: Betsey Lehman Center, 14 September 2022
  16. Content Article
    Patient Safety Awareness Week is an annual recognition event intended to encourage everyone to learn more about health care safety. During this week, the Institute for Healthcare Improvement (IHI) seeks to advance important discussions locally and globally, and inspire action to improve the safety of the health care system — for patients and the workforce. During Patient Safety Awareness Week, IHI held three webinars. Watch the webinars from the links below.
  17. News Article
    Hospital trust ‘truly sorry that mistakes were made in care’ of Luchii Gavrilescu, who died after being sent home from hospital with undiagnosed tuberculosis. An NHS trust investigated over maternity care failings has apologised after a six-week-old child was found to have died due to mistakes at one of its hospitals. East Kent Hospitals University Trust was embroiled in a major scandal after The Independent revealed the trust had seen more than 130 babies over a four-year period suffer brain damage as a result of being starved of oxygen during birth. A report into the trust concluded in April that there had been “recurrent safety risks” at its maternity units. Read full article here.
  18. Content Article
    This article in the British Journal of General Practice aimed to develop a safety-netting intervention to reduce delays in cancer diagnosis in primary care. To develop the tool, patient representatives, GPs and nurse practitioners were invited to a series of co-design workshops. These workshops suggested the intervention format and content should incorporate visual and written communication specifying clear timelines for monitoring symptoms and when to present back. Participants also agreed that they needed to be available in paper and electronic forms, be linked to existing computer systems and be able to be delivered within a 10-minute consultation. The output of this process was the Shared Safety Net Action Plan (SSNAP), a safety-netting intervention to assist the timely diagnosis of cancer in primary care.
  19. Content Article
    The Patient Safety Movement are looking for patients, family members, health workers and administrators to reach out if they have an experience related to harm or death due to a medication error in the operating room. While the specific numbers may be debated, that medication errors, while rare in the operating, could have catastrophic consequences. The Patient Safety Movement are interested in hearing your perspective concerning this issue. Please email events@patientsafetymovement.org if you have a story that you’d like to share. If you are worried about anonymity please submit your story at the link below.
  20. Content Article
    This study in the Journal of Patient Safety aimed to describe the contributing factors in diagnosis-related and failure-to-monitor malpractice claims in which nurses are named the primary responsible party. It also aimed to identify actions healthcare leaders can take to enhance the role of nurses in diagnosis. The authors found that as nurses are held legally accountable for their role in diagnosis, leaders need to raise awareness across the system of the roles and responsibilities of nurses in this area. They also need to focus on enhancing nurses' diagnostic skills and knowledge.
  21. Content Article
    Language barriers, reduced self-advocacy, lower health literacy and biased care may hinder the diagnostic process. This US study in BMJ Quality & Safety looks at patient-reported diagnostic errors, what contributes to them and the impact they have, and examines the differences between respondents with limited English-language health literacy or disadvantaged socioeconomic position, and their counterparts. The authors conclude that: interpreter access should be viewed as a diagnostic safety imperative. social determinants affecting care access and affordability should be routinely addressed as part of the diagnostic process. patients and their families should be encouraged to access and update their medical records.
  22. Content Article
    This book examines the concept of medical narcissism and how error disclosure to patients and families is often compromised by the health professional’s need to preserve his or her self-esteem at the cost of honouring the patient’s right to the unvarnished truth about what has happened. This ground-breaking book explores common psychological reactions of healthcare professionals to the commission of a serious harm-causing error and the variety of obstacles that can compromise ethically sound, truthful disclosure.
  23. Content Article
    The objective of this study from Carey et al. was to explore medical oncology outpatients' perceived experiences of errors in their cancer care. A cross-sectional survey was conducted. English-speaking medical oncology outpatients aged 18 years or older were recruited from 9 Australian cancer treatment centres. One hundred forty-eight participants perceived that an error had been made in their care, of which one third reported that the error was associated with severe harm. Of those who perceived an error had been made, less than half reported that they had received an explanation for the error and only one third reported receiving an apology or being told that steps had been taken to prevent the error from reoccurring. Patients with university or vocational level education and those who received radiotherapy or “other” treatments were significantly more likely to report an error in care.  The authors concluded that here is significant scope to improve communication with patients and appropriate responses by the healthcare system after a perceived error in cancer care.
  24. Content Article
    This study in the journal Rheumatology looked at the experience and views of rheumatology patients and clinicians regarding telemedicine. The Covid-19 pandemic has forced a rapid transition towards telephone consultations, but there are still many research gaps in understanding the safety and acceptability of telemedicine.
  25. Content Article
    This article from the Agency for Healthcare Research and Quality (AHRQ) in the United States is the transcript of a conversation between AHRQ’s Acting Director David Meyers, MD, and the Agency’s chief patient safety official, Jeff Brady, MD MPH, about key issues in diagnostic safety. Diagnostic safety is “the newest frontier in patient safety,” according to Dr Brady, who emphasises the Agency’s commitment to improve diagnostic safety and explains how researchers are working to better understand diagnostic errors and design systems and processes to reduce errors.
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