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Showing results for tags 'Patient harmed'.
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Content Article
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This report from the Department of Health and Social Care sets out the Government's response to the recommendations of the Independent Medicines and Medical Devices Safety (IMMDS) Review, sometimes referred to as the Cumberlege Review. -
Content Article
Jacqui Shaw, 54, underwent surgery for pelvic organ prolapse during which surgical mesh was inserted. She assumed the operation would improve her quality of life. Instead, her days are now blighted by agonising pain and despair. In this video, published on the Mail+, Jacqui bravely shares her story, and her uncertainty for the future. She describes how she found the support group Sling the Mesh, and subsequently many others who were also experiencing devastating consequences of surgical mesh. -
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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Women's Hour: Baroness Cumberlege (12 July 2021)
PatientSafetyLearning Team posted an article in Women's health
Baroness Julia Cumberlege, produced the First Do No Harm report that looked into two drugs and a medical device which caused women or their babies harm. In this episode of Women's Hour, she joins host Emma Barnett to talk about her anger and frustration at the lack of progress made since the report was published a year ago. The report made a list of nine recommendations to support victims and prevent future, avoidable damage. Eight of these have seen no action. Listen from 31:20 -
Content ArticleThis is the transcript of a backbench debate in the House of Commons regarding the implementation of the recommendations of First Do No Harm report, published by the Independent Medicines and Medical Devices Safety Review on the 8 July 2020, chaired by Baroness Cumberlege (also known as the Cumberlege Review).
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Content ArticleDiagnostic errors can result in avoidable harm when undiagnosed conditions remain untreated or when patients undergo unnecessary (or harmful) tests. This study seeks to estimate the incidence and origins of avoidable harm from diagnostic errors in English general practice. It defines diagnostic errors as missed opportunities to make a correct or timely diagnosis based on the evidence available. The authors conclude that although missed diagnostic opportunities (MDOs) occurred in fewer of 5% of the investigation consultations they analysed, high numbers of primary care contacts nationally suggest that several million patients are potentially at risk of avoidable harm from MDOs each year.
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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 ArticleThis article describes how the Care Quality Commission has charged The Dudley Group Foundation Trust with the deaths of Kaysie-Jane Robinson (14) and Natalie Billingham (33) who were found to have died as a result of safety failures. The Dudley Group Foundation Trust pleaded guilty to the charges in court on 2 July 2021, however, only the death of Ms Robinson was accepted by the trust as a result of their care failures.
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In this blog, Consultant Neurologist Jane Alty, talks about a patient with Parkinson's who was cared for in their trust for a period of time, during which there were frequent occasions on which his Parkinson's medications were delayed or not given. This sadly contributed to a deterioration in his swallowing and overall condition, and lengthened his time in hospital. Inspired by a letter from his wife, Jane and colleagues started the 'Improving care of patients with Parkinson’s quality improvement project' at Leeds Teaching Hospitals NHS Trust. Here she talks about the journey, the successes and challenges, and the value of involving staff from across the organisation and carers to make services better. -
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Sodium Valproate: The Fetal Valproate Syndrome Tragedy
Patient-Safety-Learning posted an article in Women's health
In this article, Sodium Valproate: The Fetal Valproate Syndrome Tragedy, Sharon Hartles, member of the Open University’s Harm and Evidence Research Collaborative, reflects upon the use of Sodium Valporate, marketed as Epilim, to treat patients at risk of epilepsy and the subsequent harms in fetal development and birth defects that arose from its use. -
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 ArticleA "Fair and Just Culture" supports learning from unsafe acts that result in potential or real harm as a way to prevent future errors. A fair and just culture strikes a balance between a punitive culture and a blame free culture. Differentiating acceptable from unacceptable behaviour associated with harmful events requires a consistent approach to determine culpability of individuals against system flaws that contribute to unsafe acts. More than one unsafe act by more than one individual can contribute to an event. For optimal learning and fair treatment of staff, each act should be considered individually using the same structured approach.
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WHO Global Patient Safety Action Plan 2021–2030 (Final version)
Mark Hughes posted an article in WHO
The Global Patient Safety Action Plan aims to provide a strategic direction for concrete actions to be taken by countries, partner organisations, care facilities and World Health Organization (WHO). It sets out a vision of a “world in which no patient is harmed in healthcare, and everyone receives safe and respectful care, every time, everywhere” and a goal of achieving the maximum possible reduction in avoidable harm as a result of unsafe care. -
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 ArticleImproving the design of technology relies in part, on the reporting of performance failures in existing devices. Healthcare has low levels of formal reporting of performance and failure of medical equipment. This paper from Tase et al. examines methods of reporting in the car industry and healthcare and aims to understand differences and identify opportunities for improvement within healthcare.
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Content ArticleSue Hignett and Paul Bowie propose taking a much-needed professional approach to patient safety through an accredited learning pathway to integrate safety into clinical systems and develop healthcare safety specialists and experts
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Content ArticleThis article, published in Mayo Clinic Proceedings, looks at how outsourcing in health care has become increasingly common as health system administrators seek to enhance profitability and efficiency while maintaining clinical excellence. However, outsourcing clinical services often results in lower quality patient care, including patient harm, and compromises the values of the organisation.
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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. -
Content Article
In this personal account, hub member Sophie talks about the trauma she experienced after a painful contraceptive device (IUD) fitting, and the impact this has had on her subsequent experience of medical procedures. She argues that damaging narratives around female pain cause harm to patients in multiple ways and have consequences that reach far beyond the initial experience of pain.- Posted
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Content ArticleThis study in The Journal of Minimally Invasive Gynecology applied a structured human factors analysis to understand the factors that contribute to vaginal retained foreign objects (RFOs). Trained human factors researchers looked at 45 incidents that occurred between January 2000 and May 2019 at an academic medical centre in Sothern California. The narrative of each incident was reviewed to identify contributing factors, classified using the Human Factors Analysis and Classification System for Healthcare (HFACS-Healthcare). The authors of the study concluded that the top two contributing factors in vaginal RFO incidents were skill-based errors and communication breakdowns. Both types of errors can be addressed and improved with human factors interventions, including simulation, teamwork training, and streamlining workflow to reduce the opportunity for errors.
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Content ArticleThe Health Protection Agency has suggested that one in ten hospital patients experiences an incident that puts their safety at risk, around half of which could be prevented, and the RCN has identified the need to reduce nurses’ paperwork considerably. This article reports a successful project that set out to tackle these two issues by developing a risk-based nursing assessment system that is simple to use, reduces unnecessary paperwork and reduces the risk of harm to patients. It outlines how the initiative was introduced, as well as obstacles encountered during the process. The risk-assessment tool received positive feedback from nursing staff as it reduces paperwork while providing a risk-based assessment of care needs.
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Content Article
The bleeding edge (2018)
Patient-Safety-Learning posted an article in Medical devices (new)
This documentary takes a look at the fast-growing medical device industry and reveals how the rush to innovate can lead to devastating consequences for patients. -
Content ArticleIn this episode of BBC Panorama, Reporter Deborah Cohen investigates how medical devices can cause harm to patients, and the lack of support and redress available when things go wrong.
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Content ArticleA surgical fire is one that occurs in, on or around a patient undergoing a surgical procedure and is an internationally recognised patient safety issue. On 16 December 2021, Members of Parliament held a general debate on preventing surgical fires in Westminster Hall. In this article, the Association for Perioperative Practice (AfPP) sets out its response to issues raised in the debate.
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Content ArticleThis paper, published in the Journal of Health Services Research & Policy, examines the potential of combining insights from patient complaints and staff incident reports for a more comprehensive understanding of the causes and severity of harm. In their conclusion, the authors state that this study demonstrates the value of using patient complaints to supplement, test and challenge staff reports, including to provide greater insight on the many potential factors that may cause unsafe care.
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