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Showing results for tags 'Patient death'.
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Content ArticleIn this podcast from The Health Foundation, Chief Executive Dr Jennifer Dixon talks to Jeremy Hunt about his tenure as the longest-serving health secretary. Jeremy speaks about his passion for patient safety, a topic which became his professional focus following the Mid-Staffs investigations. He highlights the importance of the patient safety agenda and the need to learn from past experiences. With the challenges of the COVID-19 pandemic holding the world’s attention, what would Hunt have done differently? And what are the key lessons for government as we enter a new phase of the pandemic?
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Content ArticleAs a second wave of COVID-19 infections is underway in the UK, Sarah Scobie answers some key questions on how mortality figures are collected and measured during the pandemic. How do the numbers relate to the daily figures reported, and are all the extra deaths due to the coronavirus?
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Content ArticleA report by Fiona Ritchie OBE, Chair on behalf of Oliver’s Independent Panel for NHS England and NHS Improvement, has been published following an investigation into Bristol, North Somerset and South Gloucestershire clinical commissioning group’s Learning Disability Mortality Review (LeDeR) review into the death of Oliver McGowan.
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Content ArticleThis report, written in collaboration with the Royal College of Nursing (RCN), sets out proposals to reduce the number of preventable natural deaths in prisons. It identifies how natural deaths occurring in prison might be prevented, where possible, and end-of-life care managed with dignity and compassion.
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Content ArticleThe number of publicly reported deaths from coronavirus disease 2019 (COVID-19) may underestimate the pandemic’s death toll. Such estimates rely on provisional data that are often incomplete and may omit undocumented deaths from COVID-19. Moreover, restrictions imposed by the pandemic (eg, stay-at-home orders) could claim lives indirectly through delayed care for acute emergencies, exacerbations of chronic diseases, and psychological distress (eg, drug overdoses). This study from Woolf et al. estimated excess deaths in the early weeks of the pandemic and the relative contribution of COVID-19 and other causes.
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Content ArticleThe COVID-19 pandemic will impact the health of many people in England and unfortunately many people will lose their lives. This paper from the Department of Health and Social Care, Office for National Statistics, Government Actuary’s Department and Home Office, provides a summary of research and analysis, discussing and estimating the health impacts (both excess deaths and morbidity) from the pandemic.
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Content ArticleThis is a video recording of a formal meeting (oral evidence session) of the Health and Social Care Select Committee on Tuesday 29 September 2020, as part of their inquiry looking at the Safety of maternity services in England.
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Content ArticleThe Patient Association's response to the PHSO: Complaint Standards Framework. Summary of core expectations for NHS organisations and staff. See also Patient Safety Learning's response to the framework.
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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 ArticleThis report represents the findings of the fourth perinatal confidential enquiry carried out as part of the MBRRACE-UK programme of work and focuses on stillbirths and neonatal deaths in twin pregnancies. It contains illustrative vignettes which are taken from real life events. The vignettes are used to illustrate single aspects of care and are not intended to describe all the care provided to individual mothers and their babies. The vignettes are often a combination of events from the care of more than one mother and her babies and are described such that it is not possible to identify the individuals involved. The report sets out many key findings and recommendations based on different stages and aspects of care.
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Content ArticleThis blog, published on the Maternity Experience website, is written by Gill Phillips Director of Nutshell Communications Ltd and creator of the Whose Shoes?® concept and principles. Through her facilitation work, Gill helps people get to the heart of what is important in communication and co-production. Instead of wrapping things up in jargon and complicated language, messages are honest, direct and simple, sourced from what real people are saying. In this blog, Gill talks about the networks that have come together over the past year to explore baby loss and how this work is enabling diverse conversations, rich discussions and a shared commitment to continue improving services for families who experience bereavement.
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ECRI: Wrong-site surgery (14 December 2020)
Patient Safety Learning posted an article in Surgery
Wrong-site surgery is a broad, generic term that encompasses all surgical procedures performed on the wrong patient, the wrong body part, or the wrong side of the body; it can also describe performing the wrong procedure on, or performing on the wrong part of, a correctly identified anatomic site. This guidance from ECRI reviews the various types of wrong-site surgery; discusses the incidence, risk factors, and causes of wrong-site surgery; examines barriers to effective risk reduction; highlights Joint Commission’s elements of performance for the Universal Protocol and other accreditation and regulatory issues; and offers guidance for implementing strategies to prevent the occurrence of wrong-site surgery -
Content ArticleThis study, published in BMJ Quality and Safety, aimed to quantify the prevalence and nature of adverse events in acute Irish hospitals in 2015 and to assess the impact of the National Clinical Programmes and the National Clinical Guidelines on the prevalence of adverse events by comparing these results with the previously published data from 2009.Key findings:an estimated 54,000 patient safety or adverse incidents occurred in Irish public hospitals in 2015 this cost the health service an estimated €190m in additional costs for extended hospital stays and treatmentthe volume of adverse incidents in hospitals "remained stable" between 2009 and 201514% of all hospital admissions in 2015 involved an adverse incident compared to 12.2% in 2009.
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Content ArticlePeople are given this Guide when someone close to them has died and their death has been reported to the coroner or if they have been called as a witness at an inquest. The coroner is involved in the death because the coroner needs to make enquiries to find out what happened and how the person died. For most people, the inquest process is new. Preparing for an inquest can be difficult, and some find it hard to find their way through the legal processes on top of the distress caused by the death. This guide, from the Ministry of Justice, is designed to help bereaved families understand the coroner process.
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Medicines and prescribing are highly risky areas of health care. It is estimated that more than 200 million medication errors occur in NHS every year, and that avoidable adverse drug reactions (ADRs) cause 712 deaths per year, at a financial cost of at least £98.5 million every year.[1] Many medicines and prescribing issues have been highlighted in reports and investigations into patient deaths over the years, yet the issues around prescribing competency are yet to be fully addressed. It is time this omission was rectified. This blog explains why I believe patients, the public and healthcare practitioners, need to be aware of the Prescribing Competency Framework.[2] It outlines why the framework must be applied in practice, used in clinical supervision and CPD, and why we must all speak out of it is not being followed. The benefits of this will include prevention of unnecessary medicines being prescribed, avoidance of drug related harm, and lives saved.- Posted
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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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Content ArticleThe purpose of this study from Kleven et al. was to provide a national estimate of the number of healthcare-associated infections (HAI) and deaths in United States hospitals.
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Patient Safety Movement: Story of Pat Denton
Patient Safety Learning posted an article in By patients and public
The story of Pat Denton who died from a surgery site infection after surgery. -
Content ArticleThis report, the seventh MBRRACE-UK annual report of the Confidential Enquiry into Maternal Deaths and Morbidity, includes surveillance data on women who died during or up to one year after pregnancy between 2016 and 2018 in the UK. In addition, it also includes Confidential Enquiries into the care of women who died between 2016 and 2018 in the UK and Ireland from epilepsy and stroke, general medical and surgical disorders, anaesthetic causes, haemorrhage, amniotic fluid embolism and sepsis. The report also includes a Morbidity Confidential Enquiry into the care of women with pulmonary embolism.
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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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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.
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Content ArticleSarah Scobie, Deputy Director of Research at the Nuffield Trust, looks at the continued high numbers of people dying at home, even as hospital deaths return to close-to-average levels, and discusses what reasons might lie behind the continued high numbers of home deaths since the onset of the pandemic. Whatever the reasons for the greater number of deaths at home, a third more people are now dying at home than prior to the pandemic. Although it is widely thought that many people prefer to die at home, this shift presents a significant challenge for community health and care services to deliver high quality care for patients, and to support families at the end of life.
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Content ArticleHow many of you know the full history of duty of candour in healthcare in the UK? It was Will Powell who, after the tragic death of his son Robbie, brought to light that there was none. Even today we only have an institutional duty of candour in place, leaving clinicians with the right to lie as no specific law exists to prevent this.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) reiterates the importance of clear personal protective equipment (PPE) guidelines to reduce the risk of COVID-19 transmission when delivering care in people’s homes.
