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Showing results for tags 'Investigation'.
Found 1,559 results
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Content ArticleThis paper from Samson et al. discusses the properties of complex systems and a systems approach to incident investigation, describes the differences between reactive and proactive safety approaches and describes some of the system-focused models applied to patient safety incident investigations.
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Content ArticleAsthma is the most common lung disease in the UK. 1.1 million children are diagnosed with the condition. Healthcare Safety Investigation Branch (HSIB) looked at the risks involved in the management of children aged 16 years and under diagnosed with asthma. Diagnosis and the management of asthma, particularly in children and young people, can be complex. It is important to get it right, as otherwise significant harm or death can result. The investigation was launched after HSIB identified an event involving a 5 year old child. The child had numerous planned and unplanned (emergency) attendances at hospital with respiratory symptoms, before suffering a near fatal asthma attack. Prior to the event, the child had no formal diagnosis of asthma and issues had been identified (but not resolved) regarding adherence to treatment.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) have identified a safety risk involving outpatient follow-up appointments which are intended but not booked after an inpatient stay. If a patient does not receive their intended follow-up appointment, it could lead to patient harm owing to delayed or absent clinical care and treatment. The investigation was launched after HSIB identified an event where a patient was discharged from hospital on two separate occasions with a plan to follow-up in outpatient clinics. Neither of the outpatient appointments were made.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) report highlights a gap between the NHS and other safety-critical industries in identifying and managing barriers to reduce the risk of serious incidents occurring.
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Content ArticleThe MDU’s Michael Devlin argues in this BMJ Opinion article that the never events policy has had a limited effect on patient safety and welcomes a reassessment by the Healthcare Safety Investigation Branch.
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Content ArticleContinuing Professor Martin Langham's 'Why investigate' blog series, colleague Bobbie Enright turns to the topic of fatigue, looking at the causes and preventions, how it can impact on our work and how we can manage it.
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Mesh: Denial, half-truths and the harms (March 2021)
Patient Safety Learning posted an article in Women's health
In this article, Sharon Hartles, a member of the Harm and Evidence Research Collaborative, critically discusses the harmful impacts of mesh medical devices against the backdrop of disempowerment, denial and half-truths. Surgical meshes have been in use since the late 19th century. In the mid-20th century the clinical usage of mesh increased. Now, in the early 21st century, procedures involving mesh implantation are common surgeries that are performed around the world. Despite the frequency and worldwide usage of mesh medical devices, the debate about whether or not the benefits outweigh the alleged harms remains highly contested. Read the full article Further recommended reading: Dangerous exclusions: The risk to patient safety of sex and gender bias Healing after harm: A restorative approach to incidents Analysing the Cumberlege Review: Who should join the dots for patient safety? Findings of the Cumberlege Review: informed consent Findings of the Cumberlege Review: patient complaints -
Content ArticleRoot cause analysis (RCA) is a process widely used by health professionals to learn how and why errors occurred, but there have been inconsistencies in the success of these initiatives.
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Content ArticleRichard Armstrong, head of health registries for Northgate Public Services, explains why collecting more data is not a cure-all in a health crisis.
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Content ArticleThis guidance has been designed to support providers of care homes, premises based support services, school care accommodation, secure care and premises based offender accommodation to ensure they are appropriately assessing and providing staffing levels to meet the needs of people in their care, following the removal of staffing schedules. Inspectors may also refer to this guidance on inspection, for instance where intelligence may lead us to believe that staffing levels are not being appropriately assessed. Examples of this may be evidence of poor outcomes for people, an increase in incidents, number of complaints, staff absence, or a complaint investigation.
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Content ArticleIn the previous blog in the 'Why investigate' series, we heard from Professor Martin Langham about the error trap being an error trap in itself, and about changing our focus in investigations to look wider than simplistic ideas and models of causation. In this blog, Professor Alex Stedmon considers how we might make the wrong decision when we think it’s the right decision.
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Content ArticleThis was a debate in the House of Lords on the 2 March 2021 concerning the UK Government's plans regarding a redress scheme for those harmed by sodium valproate, stemming from recommendations in the First Do No Harm Report by the Independent Medicines and Medical Devices Safety Review chaired by Baroness Cumberlege (also known as the Cumberlege Review).
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Content ArticleThe Health Information and Quality Authority (HIQA) has published its annual overview report of lessons learned from receipt of statutory notifications of accidental and unintended exposures to ionising radiation in 2020. This report provides an overview of the findings from these notifications and shares learnings from the investigations of these incidents.
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Content ArticleThe number of intrapartum stillbirths referred to the Healthcare Safety Investigation Branch (HSIB) between April and the end of June 2020 increased compared to the same time in the previous year. The data initiated a HSIB national learning report, which explores the findings from their maternity investigations during this time. They investigated intrapartum (labour) stillbirths after 37 weeks, where a baby was thought to be alive at the start of labour and was born with no signs of life.
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This joint letter calls on Nadine Dorries MP, Minister for Patient Safety, Suicide Prevention and Mental Health, to urgently fund a confidential enquiry into the deaths of Asian and Asian British babies. It is signed by the Chief Executives of Sands, The Royal College of Midwives, NCT and the President of the Royal College of Obstetricians and Gynaecologists. -
Content ArticleDerek Richford talks to Rob Behrens about the loss of his newborn grandson, Harry, at East Kent Hospitals University Trust. He explains how his sheer persistence uncovered the truth of what went wrong and eventually led to a criminal investigation at the Trust. He also tells us what organisations involved in the complaint process can learn from his family's tragic experience.
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Why investigate? Part 12: Ethics in research
Lara Carballo posted an article in Why investigate? Blog series
Ethics in medical science have been borne out of practices that occurred during the second world war, with the Nuremberg code being set up to prevent unethical experimentation on humans from being carried out. This was further supported by the Declaration of Helsinki that strengthened the protection of participants within medical research by setting out the stipulations that informed consent should be obtained before research. It ensured that data should be kept confidential so that medical research that ultimately requires input from human participants would be able to be carried out with minimal risk to the individual. Lara Carballo continues the 'Why investigate' blog series with a cautionary tale of why within Human Factors it is necessary to ensure that ethics are in place before embarking on research. -
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HSIB: A simple overview (27 July 2021)
Patient Safety Learning posted an article in HSSIB investigations
Watch this animation and find out how the Healthcare Safety Investigation Branch (HSIB) works. -
Content ArticleThis guide, developed by the charity Action Against Medical Accidents (AvMA), aims to provide support for people seeking legal advice about a possible clinical negligence claim. It is intended to provide information about what to expect from a first meeting with a lawyer and how to prepare for this.
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Content ArticleWhen good people raise serious concerns employers can welcome them as gold dust, as "canaries in the mine" or do the opposite. This is an unfinished account of what happened when Karen Rai, Strategic Research & Innovation Manager at The Christie Hospital NHS Trust, wrote to the Trust Chair setting out concerns about governance, financial conduct, and bullying...
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) identified a patient safety risk involving the timely detection and treatment of non-malignant spinal compression (cauda equina syndrome). Cauda equina syndrome (CES) is a rare and severe type of spinal stenosis, causing all the nerves in the lower back to become suddenly and severely compressed. If CES is not diagnosed and treated in a timely way it can lead to permanent incontinence, sexual dysfunction and even paralysis. The investigation was launched after HSIB identified an event where a patient had several GP and hospital presentations before CES was diagnosed.
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Content ArticleThe Defective Medicines Report Centre (DMRC) is part of the Medicines and Healthcare products Regulatory Agency (MHRA). The role of the DMRC is to minimise the hazard to patients arising from the distribution of defective medicines by providing an emergency assessment and communication system between manufacturers, distributors, wholesalers, pharmacies, regulatory authorities and users. This guide is for patients, healthcare professionals, manufacturers and distributors for reporting, investigating and recalling suspected Defective Medicinal Products.
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HSIB maternity programme year in review 2020/21 (August 2021)
Mark Hughes posted an article in HSSIB investigations
This report provides a review of the Healthcare Safety Investigation Branch (HSIB) maternity investigation programme during 2020/21, including an overview of activity during this period, themes arising from investigations and plans for the future. It is intended for healthcare organisations, policymakers and the public to understand the work HSIB have undertaken. -
Content ArticleThis report, produced by The International Association of Oil and Gas Producers (IOGP), aims to ‘demystify’ human factors and help those involved in the investigation process gain confidence by successfully incorporating human factors into investigations.
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Content ArticleThis New Scientist article explores various safety incidents that have occurred in oil companies due to failings in their organisational structures. Lessons can be learnt and applied to safety in healthcare.
