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Found 242 results
  1. Community Post
    I was just listening to a podcast interview between Dr Rangan Chatterjee and Matthew McConaughey (In the series 'Feel better, live more'). Matthew M. mentioned that he came from a highly resilient family. If someone fell over, his mother would tell them to get right back up straight away and carry on. He added that he thought that while this resilience was generally a good thing, there should be (what he called) a 'loophole' in it so that there was time to learn why they have fallen over to begin with. Was there a crack in the pavement that needed to be avoided? That way, it wouldn't happen again in the future. This made me think about whether there really was a conflict between resilience in organisations and the need to learn from failure. What do you think??
  2. News Article
    RaDonda Vaught was sentenced to three years of supervised probation on the 13 May for a fatal medication error she made in 2017 while working as a nurse at the Vanderbilt University Medical Center in the USA. In remarks made during the sentencing hearing, Ms. Vaught expressed concerns over what her case means for clinicians and patient safety reporting. "This sentencing is bound to have an effect on how [nurses] proceed both in reporting medical errors, medication errors, raising concerns if they see something they feel needs to be brought to someone's attention," she said. "I worry this is going to have a deep impact on patient safety." Numerous medical organisations expressed similar concerns in statements circulated after Ms. Vaught's sentencing. "To achieve our goal of zero patient harm and death from preventable medical errors, we need to foster a culture where leadership of hospitals and healthcare organizations support healthcare workers and encourage them to share near misses," the Patient Safety Movement Foundation said in a statement. "Healthcare workers are human and healthcare systems need to ensure there are appropriate processes in place to provide their staff with a safe and reliable working environment so they can provide their patients with the best care. Only by identifying potential problems and learning from them can change occur." Read full story Source: Becker's Hospital Review, 16 May 2022
  3. News Article
    On 25 March2022, a Tennessee jury convicted RaDonda Vaught, a nurse at Vanderbilt University Medical Center, of criminally negligent homicide and impaired adult abuse in a 2017 medication administration error that tragically resulted in a patient death. The Washington State Nurses Association have issued a joint statement adamantly opposed to criminalization of patient care errors. "Focusing on blame and punishment solves nothing. It can only discourage reporting and drive errors underground. It not only undermines patient safety; it fosters an environment of fear and lack of respect for health care workers." "The Vaught case has drawn intense national attention and concern. We join with health care workers and patient safety experts around the country and the world in rejecting the criminalization of medical errors. Further, we are committed to redoubling our efforts to achieve health care environments that are safe for patients and health care workers alike. This includes the ongoing, critical fight to achieve safe staffing standards in Washington state." Read full statement Source: Washington State Nurses Association, 8 April 2022
  4. News Article
    Emma Moore felt cornered. At a community health clinic in Portland, Oregon, USA, the 29-year-old nurse practitioner said she felt overwhelmed and undertrained. Coronavirus patients flooded the clinic for two years, and Moore struggled to keep up. Then the stakes became clear. On 25 March, about 2,400 miles away in a Tennessee courtroom, former nurse RaDonda Vaught was convicted of two felonies and facing eight years in prison for a fatal medication mistake. Like many nurses, Moore wondered if that could be her. She'd made medication errors before, although none so grievous. But what about the next one? In the pressure cooker of pandemic-era health care, another mistake felt inevitable. Four days after Vaught's verdict, Moore quit. She said Vaught's verdict contributed to her decision. "It's not worth the possibility or the likelihood that this will happen," Moore said, "if I'm in a situation where I'm set up to fail." In the wake of Vaught's trial ― an extremely rare case of a health care worker being criminally prosecuted for a medical error ― nurses and nursing organizations have condemned the verdict through tens of thousands of social media posts, shares, comments, and videos. They warn that the fallout will ripple through their profession, demoralizing and depleting the ranks of nurses already stretched thin by the pandemic. Ultimately, they say, it will worsen health care for all. Read full story Source: Kaiser Health News, 5 April 2022
  5. News Article
    Patient safety and nursing groups around the country are lamenting the guilty verdict in the trial of a former nurse in Tennessee, USA. The moment nurse RaDonda Vaught realised she had given a patient the wrong medication, she rushed to the doctors working to revive 75-year-old Charlene Murphey and told them what she had done. Within hours, she made a full report of her mistake to the Vanderbilt University Medical Center. Murphey died the next day, on 27 December 2017. On Friday, a jury found Vaught guilty of criminally negligent homicide and gross neglect. That verdict — and the fact that Vaught was charged at all — worries patient safety and nursing groups that have worked for years to move hospital culture away from cover-ups, blame and punishment, and toward the honest reporting of mistakes. The move to a “Just Culture" seeks to improve safety by analyzing human errors and making systemic changes to prevent their recurrence. And that can't happen if providers think they could go to prison, they say. “The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent,” the American Nurses Association said. “Health care delivery is highly complex. It is inevitable that mistakes will happen. ... It is completely unrealistic to think otherwise.” Read full story Source: The Independent, 31 March 2022
  6. News Article
    RaDonda Vaught, a former nurse criminally prosecuted for a fatal drug error in 2017, was convicted of gross neglect of an impaired adult and negligent homicide on Friday after a three-day trial in Nashville, Tenn., that gripped nurses across the country. Vaught faces three to six years in prison for neglect and one to two years for negligent homicide as a defendant with no prior convictions, according to sentencing guidelines provided by the Nashville district attorney's office. Vaught is scheduled to be sentenced 13, and her sentences are likely to run concurrently, said the district attorney's spokesperson, Steve Hayslip. Vaught was acquitted of reckless homicide. Criminally negligent homicide was a lesser charge included under reckless homicide. Vaught's trial has been closely watched by nurses and medical professionals across the U.S., many of whom worry it could set a precedent of criminalising medical mistakes. Medical errors are generally handled by professional licensing boards or civil courts, and criminal prosecutions like Vaught's case are exceedingly rare. Read full story Source: OPB, 26 March 2022 See also: As a nurse in the US faces prison for a deadly error, her colleagues worry: Could I be next?
  7. News Article
    A California couple gave birth to a stranger's child after being given the wrong embryo by a fertility clinic during in vitro fertilisation (IVF), says a lawsuit. Daphna and Alexander Cardinale say they gave birth in September 2019 to a girl that looked nothing like them. After a DNA test, they found the couple that carried their daughter to term, and together decided to swap the girls. This is not the first alleged mix-up during an IVF procedure. IVF is a procedure during which a woman's eggs are fertilised by man's sperm in a laboratory before the embryos are implanted into a woman's uterus. The Cardinales are suing the Los Angeles-based fertility centre, the California Center for Reproductive Health (CCRH), as well as In VitroTech Labs, an embryology lab. The lawsuit alleges medical malpractice, negligence and fraudulent concealment. Neither company responded to a BBC News request for comment. In an emotional news conference on Monday, Mrs Cardinale said her family's "heartbreak and confusion can't be understated". "Our memories of childbirth will always be tainted by the sick reality that our biological child was given to someone else, and the baby that I fought to bring into this world was not mine to keep." Read full story Source: BBC News, 9 November 2021
  8. News Article
    A nurse in Somerset has been struck off after she failed to give morphine to a patient before they underwent surgery. Amanda-Jane Price had been suspended from front-line duties since the incident in March 2019. The Nursing and Midwifery Council ruled that Miss Price had been "dishonest" with her colleagues and her ability to practice medicine safely was "impaired". Miss Price had been a nurse at Musgrove Park Hospital in Taunton since 2018. On 31 March 2019, Miss Price did not administer morphine to an individual in her care, falsely recording in her notes that morphine had been given. An investigation by the hospital's emergency medicine consultant found that the morphine dose of 6mg had been noted on the patient's chart, but that the drug had not actually been administered. Miss Price subsequently admitted to falsifying the prescription chart, and to "being consciously aware of her decision". As a result of Miss Price's actions, the patient underwent an invasive procedure without analgesia, and subsequently complained of being in pain. The panel concluded that Miss Price was guilty of misconduct and would initially be suspended. "This was deliberate dishonesty which concealed her failure in clinical issues and caused actual patient harm to a vulnerable victim," the panel concluded. Read full story Source: BBC News, 20 September 2022
  9. News Article
    A grieving family has welcomed new guidance to try to prevent a common surgical procedure from going wrong and causing deaths. Oesophageal intubation occurs when a breathing tube is placed into the oesophagus, the tube leading to the stomach, instead of the trachea, the tube leading to the windpipe. It can lead to brain damage or death if not spotted promptly. Glenda Logsdail died at Milton Keynes University Hospital in 2020 after a breathing tube was accidentally inserted into her oesophagus. The 60-year-old radiographer was being prepared for an appendicitis operation when the error occurred. Her family welcomed the guidance, saying in a statement: “We miss her terribly but we know that she’d be happy that something good will come from her tragic death and that nobody else will go through what we’ve had to go through as a family." Oesophageal intubation can occur for a number of reasons including technical difficulties, clinician inexperience, movement of the tube or “distorted anatomy”. The mistake is relatively common but usually detected quickly with no resulting harm. The new guidance, published in the journal Anaesthesia, recommends that exhaled carbon dioxide monitoring and pulse oximetry – which measures oxygen levels in the blood – should be available and used for all procedures that require a breathing tube. Experts from the UK and Australia also recommended the use of a video-laryngoscope – an intubation device fitted with a video camera to improve the view – when a breathing tube is being inserted. Read full story Source: The Independent,18 August 2022
  10. News Article
    A mother was killed at her hospital appointment by a doctor who botched a routine procedure, a court has heard. Dr Isyaka Mamman, 85, was responsible for a series of critical incidents before the fatal appointment, Manchester Crown Court heard. Mamman, who admitted gross negligence manslaughter, had already been sacked by medical watchdogs for lying about his age but was re-employed by the Royal Oldham Hospital. He is due to be sentenced on Tuesday. Mother-of-three Shahida Parveen, 48, had gone to hospital with her husband for investigations into possible myeloproliferative disorder on 3 September 2018 and a bone marrow biopsy had been advised, Andrew Thomas QC, prosecuting, told the hearing. Normally, bone marrow samples are taken from the hip bone but Mamman, of Cumberland Drive, Royton, Oldham, failed to obtain a sample at the first attempt, he said. Instead, he attempted a rare and "highly dangerous" procedure of getting a sample from Ms Parveen's sternum - despite objections from the patient and her husband, the court heard. Mamman, using the wrong biopsy needle, missed the bone and pierced her pericardium, the sac containing the heart, causing massive internal bleeding. Ms Parveen lost consciousness as soon as the needle was inserted. She died later that day. Read full story Source: BBC News, 4 July 2022
  11. Content Article
    The study identified a total of 1,004 events involving a medication error and use of an infusion pump, which occurred at 132 different hospitals in Pennsylvania. Fortunately, a majority of medication errors did not cause patient harm or death; however, it did find that 22% of events involved a high-alert medication. The study shows that the frequency of events varies widely across the stages of medication process and types of medication error. In a subset of our data, a free-text narrative field in each event was manually reviewed and reported to better understand the nature of errors. Overall, results from our study can help providers identify areas to target for risk mitigation related to medication errors and the use of infusion pumps.
  12. Content Article
    In the report the Coroner states her main concerns as follows: The inquest heard that there were significant delays in patients being seen in secondary care for gynaecological referrals from GPs. The inquest was told that these delays had now increased. In November 2020 the wait time for an appointment was 1 month for an urgent appointment and 4 months for a routine appointment. The wait times now in Tameside for gynaecology were 8 months for a routine appointment and 4 months for urgent appointments. The increase in wait times reflected a national picture the inquest was told and reflected a significant backlog and a rising demand across the NHS. The inquest heard that understanding and application of the NICE guidance on heavy premenstrual bleeding in General Practice was a factor in recognising the risk to her health and that the risks around heavy premenstrual bleeding were not well understood in General Practice and in particular where it was necessary to expedite referral to specialist services. The quality of the documentation in the referral to secondary care form the GP was poor and the inquest was told that this hampered the triage of her case by secondary care. Standardisation of GPs referrals in relation to detail and guidance regarding key information for referral would assist with effective triage and identification of high risk patients by secondary care. There was no evidence available that GP practices had clear systems of follow up in relation to referrals to identify where they had not taken place or identify if the risk had increased and to escalate the referral. This report was sent to the Secretary of State for Health and Social Care and Tameside Clinical Commissioning Group.
  13. Content Article
    This online survey takes five minutes to complete and will contribute to understanding of this potential patient safety risk. Prevention of Future Death reports have been issued on this subject, but without data it is difficult to identify if this is a specific problem, and if it is, how a big a problem.
  14. Content Article
    On her admission to hospital, the patient had been assigned the NHS number of another patient, who had the same date of birth and a similar name. During her stay she initially received medication prescribed to her based on her own supply, brought in by her family. However, following a pharmacy review on day 7 of admission, the medications were changed to those of the patient whose NHS number she had been incorrectly assigned. The patient declined to take the incorrect medication and the error was subsequently identified by a pharmacist the following day. Findings The investigation identified the following learning points for potential national benefit: The correct identification of patients relies on staff checking patient details, and therefore will not always occur effectively. There may be opportunities for further engineered or technological barriers to decrease the chance of incorrect identification. The design of the digital systems considered in this investigation did not always account for variations in how people identify themselves (for example, by different names). Those systems also did not make it clear to staff where patient demographics (that is, details such as the patient’s name, date of birth, address and NHS number) might be incorrect. The investigation recognises that a single hospital trust may receive patients from multiple ambulance trusts, and ambulances from a single trust may go to several hospital trusts. Pathways and processes potentially vary across different trusts and a consistently agreed approach may not exist. The use of NHS numbers to identify patients may vary across the country. The investigation found that the NHS number may not be being used according to national expectations. Recommendations The report makes the following local safety recommendations: HSIB recommends that the Ambulance Trust develops and implements a standardised approach to patient identification in the emergency operations centre. HSIB recommends that the Acute Trust develops and implements a standardised approach to patient identification in the emergency department. HSIB recommends that the Acute Trust explores the barriers to checking three identifiers when confirming a patient’s identification for their wristband, and takes appropriate action. The report also made the following regional safety recommendation: HSIB recommends the Acute Trust work with the Ambulance Trust to develop and implement a standardised approach to verifying and confirming a patient’s identification during the handover process. Response from Patient Safety Learning Patient Safety Learning welcomes the publication of this report and HSIB exploring new approaches to their patient safety investigations through this pilot programme. Our reflections on this report are as follows: Wider value of these findings In their report HSIB make four recommendations relating to the Acute Trust and Ambulance Trust in this case. It may be that there are similar issues occurring in other trusts across the country and that there would be value in NHS England and NHS Improvement reviewing patient identification processes more broadly in line with these findings. We would also suggest it would be helpful if NHS England and NHS Improvement could identify examples of patient identification good practice that could be shared more widely. Role of patient and family engagement HSIB states in its report that the patient, when offered the incorrect medication, declined this, but for unclear reasons. It also notes the role played by the patient’s Granddaughter in identifying this error on two separate occasions: On the first day she alerted staff to incorrect information on the patient’s wristband, but no record was made of this. On the fifth day she alerted staff to an error regarding her grandmother’s details on medical records. It is notable however that the error was not formally addressed until the pharmacist noticed a discrepancy and confirmed this was an error when speaking to the patient’s Granddaughter. We believe this serves to underline the importance of engaging and listening to patients and their family members. This patient safety issue may have been identified and addressed much more swiftly if the patients Granddaughter’s concerns about incorrect patient information had been followed up on appropriately.
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