The second PSHO investigation found that the local NHS investigation processes were not fit for purpose, they were not sufficiently independent, inquisitive, open or transparent, properly focused on learning, or able to span organisational and hierarchical barriers, and they excluded the family and junior staff in the process.
Had the investigations been proper at the start, it would not have been necessary for the family to pursue a complaint. Rather, they would, and should, have been provided with clear and honest answers at the outset for the failures in care and would have been spared
Dena’s vigilance and persistence as a whistleblower led to an investigation by The Centres for Medicare and Medicaid Services (CMS). Based on interviews and a review of hospital records, CMS found specific events contributing to her mother’s death and issued findings in a Summary Statement of Deficiencies.
Among the key problems, Martha had not been thoroughly assessed when changes in her condition occurred. In one instance, at 10:15pm, (14 hours after the procedure), the Registered Nurse failed to perform a thorough assessment, that included vital signs and notifying the doctor. The CMS
The 2015 Montgomery ruling created practical implications for how clinicians obtain consent and support patients to make decisions about their healthcare.
The implication of the Montgomery ruling is that healthcare professionals must:
clearly outline the recommended management strategies and procedures to their patient, including the risks and implications of potential treatment options
discuss any alternative treatments
discuss the consequences of not performing any treatment or intervention
ensure patients have access to high-quality information to aid their dec
Currently, stillbirths, neonatal deaths and brain injuries occurring due to incidents in labour are investigated at a local level. The Each baby counts project team will, for the first time, bring together the results of these local investigations to understand the bigger picture and share the lessons learned.
From 2015, they began collecting and analysing data from all UK units to identify lessons learned to improve future care. They will then be able to make recommendations on how to improve practice at a national level.
This page brings together all of the information and resource
We know from our own experiences and those of others that patient safety fears are growing daily across the NHS and social care. Staff shortages and burnout are all taking their toll on patient satisfaction, safety and standards of care.
I had the pleasure of joining a webinar arranged by the Health Foundation last week where the National Director of Improvement for NHS England and NHS Improvement, Hugh McCaughey, outlined the up and coming improvement framework for the NHS. A good framework provides a skeleton on which to build. His presentation included the importance of:
Minimal Information Model:
The WHO Minimal Information Model for Patient Safety is a simple tool which contains the core data categories required for analysis, that can be used by any institution that is looking to set up, or improve, their reporting and learning system.
International Classification for Patient Safety:
The Conceptual Framework for the International Classification for Patient Safety, developed in 2009, defines and harmonises patient safety concepts into an internationally agreed classification.
From 2005 to 2009, between 400 and 600 more patients died at the Mid Staffs Foundation Trust than would have been expected. The high mortality data being a red flag to go and check. To actually open a door, enter a ward and see and hear the patients and their family’s experiences. Cost cutting and prioritising of targets and obtaining foundation trust status sadly resulted in the patients and families becoming lost and not always a priority in a care system that had, in parts, become immune to the sound of pain.
The Public Inquiry heard from 250 witnesses and over a million pages of docum
Key learning points
What happened, where and when? Give a brief history of the incident.
What is it that made the incident ‘critical’?
What were your immediate thoughts and responses?
What are your thoughts now? What has changed/developed your thinking?
What have you learned about (your) practice from this?
How might your practice change and develop as a result of this analysis and learning?
What will I learn?
An understanding of Just Culture as a framework to employ root cause analysis at your own sites
An understanding on root cause analysis as a tool for evaluation of clinical and administrative quality issues
When you should do a root cause analysis
How to engage leadership
I used to work for the World Health Organization (WHO) helping to establish its patient safety programme over 20 years ago. Last week I was invited back to attend a three day WHO meeting on behalf of Patient Safety Learning to contribute to the development of its Global Patient Safety Action Plan for 2020-2030. Heading into this event, I had several key questions at the front of my mind:
What have we learned about patient safety in the last twenty years?
Why does harm remain so persistent?
What impact has the global commitment to patient safety had in reducing harm?