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Showing results for tags 'Investigation'.
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Content ArticleIn this Byline Times blog, Stephen Colegrave looks into the case of NHS whistleblower Paul, who was let down by his hospital trust and worse still by the NHS regulators there to protect the public.
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Content ArticleRob Hackett, Patient Safe Network, in the video below discusses the danger of Indistinct chlorhexidine which can easily be mistaken for other colourless solutions. He highlights the story of Grace Wang, who in 2010 had antiseptic solution injected into her epidural. She nearly died and was left paralysed. Indistinct chlorhexidine was mistaken for saline. The investigation recommended all skin antiseptic solutions to be coloured in a way that distinguished them. Sadly this recommendation isn't followed. Accidental chlorhexidine injections continue to occur and there are many more examples. This same error continues to play out again and again throughout the world. There’s no need for these indistinct solutions and safer distinct versions and those enclosed in swab sticks are already in use in many hospitals without problem and at no extra cost.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) report sets out a case where a medication error with warfarin contributed to the death of a 79-year-old man. The patient had suffered a fall at home and had been admitted to hospital. An error on his chart whilst he was on the ward led to him receiving four or five doses of warfarin, which he did not normally take, before the error was spotted by a ward-based clinical pharmacist. The patient developed internal bleeding and deteriorated (due to several health reasons) and died 21 days after his first admission. Research published this year suggests that medication errors may directly cause around 712 deaths per year and indirectly contribute to 1,708. The report highlights the growing ageing population and that pharmaceutical care of older people can be complex. They are often taking multiple medications and are at the greatest risk of harm due to medicine-related errors.
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Content ArticleAt the First Do No Harm All Party Parliamentary Group (APPG) meeting on 26 January 2021 with the Minister for Patient Safety, Nadine Dorries MP, attendees asked a large number of questions, not all of which could be answered by the Minister due to time constraints. The unanswered questions were submitted to the Minister’s office at the Department for Health and Social Care for a written response. The Department has now provided answers.
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Content ArticleRoot cause analysis (RCA) is a widely used method deployed following adverse events in health care. Using a range of information-gathering and analytical tools (such as interviews, the "five whys" technique, fishbone diagrams, change analysis, and others), RCA seeks to understand what happened and why and to identify how to prevent future incidents. In this PSNet Case and Commentary, Mohammad Farhad Peerally and Mary Dixon-Woods discuss a case where a hospital planned to perform a root cause analysis (RCA) to investigate an adverse event which resulted in an individual blamed and no interventions to prevent similar errors or address systems issues were ever implemented.
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Content ArticleAfter two weeks of evidence by experts in medical ethics the Infected Blood Inquiry finishes its review of Newcastle, reviews a single case from Cardiff and moves onto its first evidence from those involved with the Haemophilia Society. Professor Brian Edwards reflects on the evidence in this NHSManagers.Net article. See also the weekly updates on the inquiry from The Haemophilia Society.
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Content ArticleThe UK-wide inquiry is looking into what has been described as the worst treatment disaster in the history of the NHS. Thousands of patients across the UK were infected with HIV and hepatitis C via contaminated blood products in the 1970s and 1980s. The Haemophilia Society updates give a weekly summary of inquiry news when public hearings take place.
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Patient referrals and waiting lists: A ticking time bomb
Jerome P posted an article in By health and care staff
Jerome, a patient safety manager, discusses the impact the pandemic is having on patient referrals and waiting lists, and the subsequent increases in serious incidents and never events that will arise. With an already overstretched and exhausted workforce, how will these be investigated, how will this be managed? Jerome urges NHS England to give guidance.- Posted
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Content ArticleIn Part 8 of the 'Why investigate' blog series, Martin Langham takes a look at the hub's error trap gallery and explains why when we conclude it's an error trap we are missing the bigger picture.
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We need to talk about Francis ....
PatientSafetyLearning Team posted an article in Inquiries
In this article, Valerie Iles, argues that we should hesitate before deciding to implement the recommendations of the Francis Inquiry. Instead, she states that we should consider whether Francis and his Inquiry are part of the system, part of the mindset, that is the problem. -
Content ArticleAction Against Medical Accidents (AvMA) have created a set of guides to help patients raise concerns about a healthcare worker. Health professionals fitness to practise Raising concerns about doctors Raising concerns about nurses, midwives and nursing associates Raising concerns about dental professionals. Follow the link below to find out more.
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Content ArticleMothers and families whose baby was born at an NHS hospital after 1st April 2017 and who may be concerned that their baby sustained a brain injury at birth may be going through an investigation process. This guide, from Action Against Medical Accidents (AvMA), provides mothers and families with information about the process.
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Content ArticleAvMA’s self-help guides have been written by experts to help guide you through the process of taking action following a medical injury. In clear and straightforward language, they set out the procedures you will need to follow, and legal rights and obligations, and contain useful contact details for regulatory bodies, advice services and other organisations that may be of help.
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Content ArticleA conversation with John Wilkes (AstraZeneca), Clifford Berry (Takeda), Amy D. Wilson, Ph.D. (Biogen), and Jim Morris (NSF Health Sciences). This article is the second part of a two-part roundtable Q&A on the topic of human performance in pharmaceutical operations. Part 1 evaluated the underpinnings of human performance and provided advice to those individuals managing rapid production scale-up to support COVID-19 production demand. Here in Part 2, human performance in the context of investigation and CAPA programmes is considered.
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Content ArticleThis document defines the investigation framework in the event of a patient safety Serous Incident (SI) related to NHS Wales Informatics Service (NWIS) delivered or supported services, which affects one or more health body in Wales.
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Are agency healthcare practitioners adequately covered to work in private hospitals?
Anonymous posted an article in Occupational health and safety
I would like to share with you my experience of an injury I sustained when working as an agency nurse doing bank shifts in a private hospital and highlight to colleagues the importance of knowing your entitlements when working for an Agency. Please make sure you are adequately covered for injury. -
Content Article‘Never events’ are patient safety incidents that are defined as being wholly preventable. They are considered wholly preventable because guidance or safety recommendations are in place at a national level and should have been implemented by all providers in the healthcare system. This should act as a strong systemic barrier to prevent the serious incident from happening. The latest national report from the Healthcare Safety Investigation Branch (HSIB) says that 'Never Events' should not be defined as such if they don’t have strong enough barriers in place to stop them happening.It recommends that seven Never Events on a list of 15 should be removed until better barriers are in place. They are using the Safety Engineering Initiative for Patient Safety (SEIPS) model to carry out the analysis. SEIPS provides a framework for understanding structures, processes and outcomes in healthcare, and their relationships.
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Content ArticleJames Titcombe, Patient Safety Campaigner and co-founder of Harmed Patients Alliance, discusses the findings of the recent Bill Kirkup report 'The Life and Death of Elizabeth Dixon: A Catalyst for Change'.
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House of Commons Debate - Ockenden Review
Mark Hughes posted an article in Other reports and inquiries
This debate begins with a statement by the Minister for Mental Health, Suicide Prevention and Patient Safety, Nadine Dorries MP, responding to the publication of the first report by the independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust. It is followed by questions from MPs in the chamber and the Minister's responses. -
Content ArticleSerious complications and deaths resulting from maternity care have an everlasting impact on families and loved ones. The families who have contributed to the Ockenden Review want answers to understand the events surrounding their maternity experiences, and their voices to be heard, to prevent recurrence as much as possible. They are concerned by the perception that clinical teams have failed to learn lessons from serious events in the past. The learning of lessons and embedding of meaningful change at The Shrewsbury and Telford Hospital NHS Trust and in maternity care overall is essential both for families involved in this review and those who will access maternity services in the future. After reviewing 250 cases and listening to many more families, this first report identifies themes and recommendations for immediate action and change, both at The Shrewsbury and Telford Hospital NHS Trust and across every maternity service in England.
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Why investigate? Part 7 – The questions and answers
MartinL posted an article in Why investigate? Blog series
In part 1 of my blog series, I said "This will be a series of short blogs that will cover the investigation process, answer questions about humans, and shine a light on the method of forensic investigations”. It is time to answer some questions -
Content ArticleThis report from Verita, an independent consultancy, provides an independent account into the disciplinary process regarding Nurse Amin Abdullah in late 2015. It was commissioned by Imperial College Healthcare NHS Trust (‘the trust’) in 2017 to review the process that it followed in dealing with Nurse Abdullah’s case and whether fair and appropriate action was taken
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) report charts the emerging patient safety risks that can come with the introduction of ‘smart’ infusion pump technology into hospitals. Smart infusion pumps are the latest generation of programmable devices that administer medication. They are seen as a way of improving safety as the smart functionality aims to prevent underdoses or overdoses – they are equipped with features such as alerts or alarms to help detect problems. The investigation was launched after one NHS Trust recorded three incidents where a smart infusion pump delivered an overdose of fentanyl, a powerful pain medication. The patients weren’t harmed as it was swiftly picked up, however it emphasised the new risks that come with introducing new technology and the potential for serious medication errors. The investigation focused on the barriers to implementing the technology effectively across the NHS, rather than on the technology itself.
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Content ArticleCoroners have a statutory duty to issue a Prevention of Further Deaths report to any person or organisation where, in the opinion of the coroner, action should be taken to prevent future deaths. This is a coroner's report into the death of Susan Warby. The coroner's report concluded that the incorrect intravenous fluid was given and remained in place for approximately 36 hours before it was changed. As a direct result, blood tests on samples drawn from the arterial line gave incorrect results. The incorrect results were exacerbated by the poor technique being used by staff to draw blood from the arterial line transducer set when they failed to fully account for the 'dead space', which needed to be fully removed to obtain an accurate result. These erroneous blood results led to Sue being given doses of insulin medication over a two-day period that she did not need. The incorrect insulin doses caused Sue to suffer from bouts of extremely low blood sugar (hypoglycaemia) which caused her to develop a brain injury of uncertain severity.
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Content ArticleA report on the investigation into the death of Elizabeth Dixon and a series of recommendations in respect of the failures in the care she received from the NHS.
