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Showing results for tags 'Investigation'.
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Content Article
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. -
Content Article
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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Content Article
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.
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Content ArticleHealthcare Safety Investigation Branch (HSIB) looked into the suitability of equipment and technology used within maternity departments to conduct continuous fetal heart rate monitoring during labour and birth. Although there are multiple methods used to monitor fetal heart rate, the main equipment used is a continuous fetal heart rate monitoring is the cardiotocograph (CTG) machine. There has been some common safety issues identified with availability of equipment and functionality, staff understanding of the equipment and its purpose and an inability to understand and interpret the fetal heart rate. HSIB conducted an investigation into how cardiograph machines are used, any problems staff experienced while using them and problems that staff using them and how the equipment was purchased experienced, and how staff are trained and assessed as being competent to use them.
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Content ArticleThis video, produced in conjunction with Royds Withy King Solicitors, provides a quick overview of AvMA’s services and how volunteers help them to deliver the vital support people need after experiencing medical harm.
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Content ArticleThis is the report of an inquiry conducted by the Health and Social Care Select Committee in 2020/21 which examined the ongoing safety concerns with maternity services and the action needed to improve safety for mothers and babies. It suggests that improvements to maternity services have been too slow to date and recommends several changes, including increasing in the budget for maternity services and reforming existing to litigation processes.
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Content ArticleNever Events are defined by the NHS as patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers. This study considers how effective using of the absolute number of Never Events that take place at English hospital trusts, without accounting for hospital workload, is for judging their underlying safety performance and safety culture. In its conclusions the authors suggest that there are flaws in the current approach regulators take to using Never Events data to judge hospital performance.
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Content ArticleIn this blog, published on the Learning from Excellence website, author AP introduces the philosophical theory of determinism and the implications for patient safety investigations.
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Content ArticleThis video, from the Healthcare Safety Investigation Branch (HSIB), will help clinical staff to understand what to expect when asked to take part in an HSIB maternity investigation interview. You will meet some of the HSIB maternity investigation team, who'll talk you through the interview. You will also hear from NHS staff, who will talk you through their experience of being involved in a maternity investigation.
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Content ArticleIn order to obtain compensation for harm arising out of medical treatment received within the NHS in Scotland, the elements needed to establish negligence under the law of delict must be satisfied. The Scottish government has expressed the view that a no-fault compensation scheme in relation to clinical negligence claims made against the NHS in Scotland could be simpler than the existing litigation system and could support the development of the concept of a mutual NHS, as well as a positive feedback and learning culture. With this in mind, the government considers that such a scheme is the favoured way forward for the NHS in Scotland. This report reviews and analyses existing no-fault schemes in a number of countries/jurisdictions: New Zealand (NZ); Nordic countries (Sweden, Finland, Denmark, Norway); and the schemes operating in Virginia and Florida (United States) for birth-related neurological injury.
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Content Article
JCP Solicitors: NHS Redress Scheme
Patient Safety Learning posted an article in Legal matters
The NHS Redress Scheme, also known as the “Putting Things Right Scheme,” is a method of handling and investigating complaints about the NHS service within Wales. In NHS Redress claims, redress may consist of an apology, or a financial award of compensation of up to £25,000.00 (The limit for the NHS Redress Compensation claims). JCP Solicitors explains the Redress Scheme and how to claim under the scheme. -
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation looked at the risks involved in the correct identification of patients in outpatient departments. Correct identification is crucial to make sure they receive the right clinical procedure. In the last 10 years the number of patients treated in outpatient clinics has nearly doubled. Many minor surgical procedures can now be carried out in an outpatient clinic, whereas in the past they would have been carried out in an inpatient theatre setting. The high number of patients treated in an outpatient clinic requires efficient management. Clinical consultation and delivery of the required intervention often needs to be completed within a 15-20-minute appointment. In a single outpatient waiting area there may be patients arriving for different clinical interventions. Staff need to make sure that all patients are seen in the right place, at the right time and (if required) receive the right procedure. Outpatients are not provided with any physical means that staff can use to identify them. This is different to inpatients where a wristband is worn following an initial check of the patient’s identity. Checking the identity of a patient in an outpatient department typically relies on staff speaking to patients. There is a risk of patients being missed or misunderstood due to the environment, work demands, language or cultural barriers.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) held a webinar on 12 May to discuss asthma management in children, to support the launch of their recent publication: Management of chronic asthma in children aged 16 years and under. For those of you who missed the event, HSIB have made available the webinar recording, presentation slides and Q&As.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) has analysed its first 22 HSIB national investigations to identify the recurring patient safety themes and to explore the impact so far of the 85 recommendations they have made to address them.
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Content ArticleThe Patient Safety Incident Response Framework (PSIRF) sets out the NHS's approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety It is intended to support one of the key aims of the NHS Patient Safety Strategy, to help the NHS improve its understanding of safety by drawing insight from patient safety incidents. This will replace the Serious Incident Framework with organisations expected to transition to PSIRF within 12 months of its publication, by Autumn 2023.
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Content ArticleThis investigation from the Healthcare Safety Investigation Branch, focuses on the design and implementation of patient safety alerts. It follows a reference event where an 85-year old woman was connected to the piped medical air supply, instead of the oxygen supply, whilst she was receiving hospital treatment after a fall at home.
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Content ArticleProviders led by GPs of an ethnic minority background have raised with the Care Quality Commission (CQC) concerns that they do not receive the same regulatory outcomes from CQC as providers led by GPs of a non-ethnic minority background. To investigate and respond to these concerns, CQC started a programme of work in February 2021. The focus of this has been on how CQC's regulatory approach affects ethnic minority-led GP practices and how it can improve its methods to address any inequalities identified.
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Content ArticleSurekha Shivalkar was a 78-year-old woman who was scheduled for elective total hip replacement revision surgery. Following surgery she suffered a cardiac arrest and subsequently died. The conclusion of the inquest was that died from multi-organ failure and complications arising during anaesthesia and hip revision surgery, which led to hypotension and hypoperfusion in a woman with ischaemic heart and chronic obstructive pulmonary disease. In his report, the Coroner raises concerns about the lack of a use of a formal risk assessment tool prior to her surgery, communication failures between the orthopaedic surgical team and the anaesthetist and the departure of the Senior Consultant surgeon prior to the surgeries conclusion.
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Content Article
Bleed Out: HBO documentary (2018)
Patient Safety Learning posted an article in Investigations and complaints
Medical error is the third leading cause of death in the U.S. After a routine partial hip replacement operation leaves the mother of filmmaker and comedian Steve Burrows in a coma with permanent brain damage, what starts as a personal video diary becomes a citizen’s investigation into the state of American healthcare.
