Search the hub
Showing results for tags 'Patient harmed'.
Found 1,334 results
-
Content ArticleLinda Millband is the national practice lead for medical negligence at Thompsons Solicitors. She led the team responsible for fighting, and winning, a legal battle on behalf of 650 ex-patients of disgraced breast surgeon Ian Paterson. Ahead of the publication of the Independent Inquiry into Ian Paterson, Linda reflects on how it should be used as a catalyst for positive change in private hospitals.
-
Content ArticleAn alarming statistic shared by countless people is based on a highly problematic bit of data extrapolation and has been used to paint all of medicine as untrustworthy. In this article, Jonathan Jarry explores the evidence.
-
Content ArticleExtravasation is the unintentional leakage of vesicant fluids or medications from the vein into the surrounding tissue. This can cause harm and lead to complications for the patient. This guide, produced by the Royal Children's Hospital Melbourne, includes: Introduction Aim Definition of terms Risk factors Assessment Management Irrigation Procedure Follow-up/Review Special considerations Evidence Table Companion documents References
-
Content Article'What the HealthTech?' is a podcast from Radar Healthcare. A platform for professionals in health and social care to have open discussions on creating change, tackling challenges and making an impact on people’s lives. Each week Radar Healthcare talk to industry leaders, organisations making a difference and their team of experts to share ideas and learnings with you.
-
Content ArticleIn this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on some of the key patient safety issues and developments over the past 12 months and looks ahead to 2023.
- Posted
- 4 comments
-
3
-
- (and 8 more)
-
Content ArticleThis report provides an overview of the findings of Ireland's Health Information and Quality Authority (HIQA)’s monitoring programme against the national standards in emergency departments in 2022. Throughout 2022, HIQA commenced a new monitoring programme of inspections in healthcare services against the National Standards for Safer Better Healthcare. As part of the initial phase, HIQA’s core assessment in emergency departments focused on key standards relating to governance, leadership and management, workforce, person-centred care and safe and effective care. The report highlights, HIQA has identified key areas for both immediate and longer-term attention to address safety issues in our emergency departments.
-
Content ArticleFor decades, western Europe’s national healthcare systems have been widely touted as among the best in the world. But an ageing population, more long-term illnesses, a continuing recruitment and retainment crisis plus post-Covid exhaustion have combined, this winter, to create a perfect healthcare storm that is likely to get worse before it gets better, writes Jon Henley (Berlin), Kate Connolly (Berlin), Sam Jones (Madrid) and Angela Giuffrida (Rome) in this Guardian article.
-
Content ArticleThis policy paper, published by the Department of Health and Social Care, provides an update on the UK Government’s progress in implementing the recommendations of the Independent Medicines and Medical Devices Safety (IMMDS) Review, sometimes referred to as the Cumberlege Review.
- Posted
- 3 comments
-
- (and 6 more)
-
Content ArticlePatient safety incident investigations (PSII) are system-based responses to a patient safety incident for learning and improvement. Typically, a PSII includes four phases: planning, information gathering, synthesis, and interpreting and improving. More meaningful involvement can help reduce the risk of compounded harm for patients, families and staff, and can improve organisational learning, by listening to and valuing different perspectives.
-
Content ArticleThis article provides an overview of the National Patient Safety Board Act of 2022; legislation which has been introduced in the USA to establish an independent federal agency dedicated to preventing and reducing healthcare-related harms.
-
Content ArticleThis is an Adjournment Debate from the House of Commons on Wednesday 7 December 2022 on fatalities relating to foetal valproate spectrum disorder.
-
Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) explores the issues associated with the assessment of risk factors for venous thrombosis in pregnancy and the first six weeks after birth. Venous thrombosis occurs when a blood clot forms and causes a blockage in a person’s vein. This can lead to venous thromboembolism (VTE), when part of the clot breaks off and travels through the bloodstream, blocking a blood vessel elsewhere in the body. Pregnant women and pregnant people are at greater risk of developing a venous thrombosis than those who are of the same age and not pregnant. Because of the increased risk, healthcare staff assess a pregnant woman’s risk factors for VTE at key stages before and after the birth, so that they can be given preventative treatment if necessary. While rare, in the UK venous thrombosis and VTE is the leading direct cause of death of pregnant women during pregnancy or up to six weeks after the end of pregnancy. Reference event The reference event for this investigation was the case of Alice, who was 26 years old and was pregnant with her second child. A VTE risk assessment was completed for Alice at her first antenatal appointment, when she was admitted to hospital for the birth of her child, and 24 hours after admission. Her score was zero each time, meaning no risk factors were identified for VTE. During her pregnancy Alice reported experiencing some pain in her calf; she was examined by a doctor who referred her for a scan. This ruled out a deep vein thrombosis (DVT). After giving birth by caesarean section, Alice's risk assessment was repeated, and as it indicated that medication was required, a preventative dose of low-molecular-weight heparin was prescribed and Alice was discharged. Eleven days after the birth of her baby, Alice was taken by ambulance to the emergency department with chest pain, shortness of breath and leg cramps. She was diagnosed with a pulmonary embolism (PE) and was started on a treatment dose of blood-thinning injections. Following investigation, it was found that Alice may not have received an appropriate preventative dose of low-molecular-weight heparin to help prevent the VTE.
-
Content Article
Did you know? Extravasation (November 2022)
Patient_Safety_Learning posted an article in Extravasation
Extravasation is the accidental leakage of any liquid from a vein into the surrounding tissues, which can cause serious harm to the patient (NHS England, 2017). From 1 April 2011 until 31 March 2021 the NHS paid £15.6 million in damages relating to extravasation. This leaflet, published by NHS Resolution, aims to share learning from those claims. -
Content ArticleAn expert review of the clinical records of 44 deceased patients who had been under the care of neurologist Dr Michael Watt has found there were “significant failures” in their treatment and care. Dr Watt, a former Belfast Health and Social Care Trust consultant neurologist, was at the centre of Northern Ireland’s largest ever recall of patients, which began in 2018, after concerns were raised about his clinical work. More than 4,000 of his former patients attended recall appointments. At the direction of the Department of Health, in August 2021, the Regulation and Quality Improvement Authority (RQIA) commissioned the Royal College of Physicians to undertake an expert review of the clinical records of certain deceased patients who had been under the care of Dr Watt, with the intention to understand his clinical practice, to ensure learning for others and to help make care better and safer in the future.
-
Content ArticleA recently published report highlights the shortcomings in care provided by the NHS. Peter Walsh, Joanne Hughes and James Titcombe emphasise how millions could be saved if people were empowered early on to have their needs met without the need to turn to litigation
-
Content ArticleThis open letter from patient safety campaigner Richard von Abendorff calls for patients, their families and safety campaigners to help improve patient investigation and patient inclusive systems. Richard highlights a new role coming up at the new Health Services Safety Investigations Body (HSSIB).
- Posted
- 1 comment
-
- (and 2 more)
-
Content ArticleThe third leading cause of death in the US is its own healthcare system—medical errors lead to as many as 440,000 preventable deaths every year. To Err Is Human is an in-depth documentary about this silent epidemic and those working quietly behind the scenes to create a new age of patient safety. Through interviews with leaders in healthcare, footage of real-world efforts leading to safer care, and one family’s compelling journey from being victims of medical error to empowerment, the film provides a unique look at the US healthcare system’s ongoing fight against preventable harm.
-
Content ArticleThis article in Time reviews the documentary film 'To Err is Human', which explores the tragic outcomes of medical errors and the medical culture that allows them to persist. The film follows the Sheridans, a family from Boise, Idaho on their journey to understand how two major medical errors befell their family: one that contributed to a case of cerebral palsy, and another that involved a delayed cancer diagnosis and ended in death.
-
Content ArticleKeeping patients safe during their care and treatment should be at the heart of any health system, including the NHS. Yet avoidable harm still occurs every day, around the world. There have been major efforts to prioritise patient safety in England, but the pandemic has shone a light on areas of care where progress has stalled, or safety has deteriorated. This report by Imperial College London's Institute of Global Health Innovation, commissioned by Patient Safety Watch, brings together publicly available data to present a national picture of patient safety in England.
- Posted
- 1 comment
-
- (and 9 more)
-
Content ArticleA complaint from a patient was made to the Scottish Public Services Ombudsman (SPSO) about the care and treatment provided during the period January 2018 to September 2021. In January 2018 the patient underwent emergency surgery for a perforated sigmoid diverticulum (a complication of diverticulitis, an infection or inflammation of pouches that can form in the intestines). An emergency Hartmann's procedure (a surgical procedure for the removal of a section of the bowel and the formation of a stoma - an opening in the bowel) was performed. In April 2018, the patient was seen in an outpatient clinic and informed it would be possible to have a stoma reversal. The patient complained that the Board had continually delayed the stoma reversal surgery which they required, which as of September 2021 had not taken place. The patient also complained that Covid-19 could not account for the delays between the Board informing patient they were ready for surgery around December 2018 and the start of the pandemic in March 2020. The patient noted that as a consequence they had developed significant complications: a large hernia. The patient added that this had severely impacted their personal life and self-esteem, and left them unable to work and reliant on welfare benefits.
-
Content ArticleWhen medical errors result in adverse patient outcomes, many healthcare professionals are concerned about malpractice litigation. Fear of malpractice has been associated with excessive health care use through defensive medicine, which involves doctors ordering additional testing or making extra referrals to protect themselves from malpractice accusations. The authors of this study in JAMA Network Open aimed to examine the perspectives of doctors on patient harm and malpractice litigation. They conducted an online survey targeting all emergency department attending physicians and advanced practice clinicians (APCs) in acute care hospitals across Massachusetts from January to September 2020. The results showed that although clinicians feared legal action, they feared harming patients to a greater degree regardless of specialty, experience or sex.
-
Content ArticleRadar Healthcare has published its 'Incident Reporting in Secondary Care' whitepaper – an in-depth analysis of reporting within secondary care and its effects on patient safety. It has taken a look into the current state of incident reporting: the good work being done, the concerns across the sector, and how we can all aim to improve the situation. The report was conducted using a panel provided by SERMO from its database of UK Nurses and includes the views from 100 nursing staff members working in hospital wards across the UK. Those surveyed work with hospital in-patients daily and are responsible for reporting safety and regulatory incidents involving patients to senior colleagues.
-
News Article
‘It feels very unsafe’: the NHS staff bracing for winter as cuts loom
Patient Safety Learning posted a news article in News
Further funding cuts to the NHS will unavoidably endanger patient safety, an NHS leader warned last week after the chancellor’s promise of spending cuts of “eye-watering difficulty”. Matthew Taylor, the chief executive of the NHS Confederation, said his members were issuing the “starkest warning” about “the huge and growing gulf between what the NHS is being asked to deliver and the funding and capacity it has available”. The warning came as figures showed that paramedics in England had been unavailable to attend almost one in six incidents in September due to being stuck outside hospitals with patients. Service leaders say wait times for A&E and other care are being exacerbated by an acute lack of nurses, with a record 46,828 nursing roles – more than one in 10 – unfilled across the NHS. "Patients are presenting more unwell," says a GP from South Wales, "Wait times in A&E have become unmanageable, so we’re seeing patients who have waited so long to be seen they’re bouncing back to us. Things we can’t deal with, like injuries and chest pain. We tell them they have to go back to A&E. "Abuse of surgery reception and admin staff began last year and it’s just scaled up from there. We’ve had staff members who have been verbally and physically threatened and we’re struggling to recruit and retain staff – people are hired and quit in a couple days. A lot of people are going off sick with stress." Five healthcare workers describe the pressures they are facing, including ambulance stacking, rising A&E wait times and difficulties discharging patients. Read full story Source: The Guardian, 1 November 2022 -
News Article
Eighteen deaths following Tees health trusts' safety lapses
Patient Safety Learning posted a news article in News
Eighteen people died at two Teesside hospital trusts following patient safety lapses over a 12-month period. Sixteen such deaths were recorded at the South Tees Hospitals NHS Foundation Trust, with two at the North Tees and Hartlepool NHS Foundation Trust. Examples of patient safety lapses include a failure to provide or monitor care, a breakdown in communication, an out-of-control infection in a hospital, insufficient staffing or a missed diagnosis. NHS England figures show that, between April 2021 and March this year, there were 16,557 incidents at the South Tees Trust, which operates James Cook University Hospital in Middlesbrough, and Northallerton's Friarage Hospital. Thirty-four resulted in "severe" harm. Middlesbrough MP Andy McDonald told the Local Democracy Reporting Service the figures were a concern and that he planned to take them up with the South Tees Trust's chief executive. He said NHS staff worked under "the most demanding of conditions" but added: "Every person going into hospital rightly expects to receive the best treatment. Patient safety is paramount and no family wants to see a loved one suffer." Dr Mike Stewart, the trust's chief medical officer, said: "We encourage an open and transparent culture and promote the reporting of all patient safety incidents, even when there is uncertainty over a direct link between any problems in care and incidents of severe harm or death. "In the last year there were no deaths graded as definitely preventable due to a problem in the care delivered by the trust. "While our reporting has increased consistently over the last three years, the number of serious incidents has not risen, which is strong evidence of a positive safety culture." Read full story Source: BBC News, 30 October 2022 -
News ArticleMinisters have been urged to launch a public inquiry into the care of mental health patients after The Independent revealed allegations that patients had suffered “systemic abuse” in inpatient units. A joint investigation with Sky News found that teenagers at facilities run by The Huntercombe Group had been left with post-traumatic stress disorder by their treatment despite hundreds of warnings to regulators and the NHS. Now the government is facing calls to review all mental health care services over fears that these cases are “the tip of the iceberg”. Labour’s shadow mental health minister Dr Rosena Allin-Khan has called for a “rapid review” by the government into inpatient mental health services, while Deborah Coles, the chief executive of charity Inquest, has called on the new health secretary Steve Barclay to launch a statutory public inquiry. Read full story Source: The Independent, 28 October 2022
