Search the hub
Showing results for tags 'Patient harmed'.
Found 1,336 results
-
Content ArticleThis paper, published by Science Daily, highlights how a multidisciplinary group of leaders established consensus-driven research agenda designed to create a path forward to inform approaches that better support harmed patients and families.
-
Content ArticleConsider these actual patient experiences: A patient is admitted to the hospital for a bowel obstruction from a known malignancy. She calls her cancer specialist about this complication, but he is unavailable. A covering provider reading from her file says ‘your cancer is untreatable’. This is the first time she has heard this. A patient dies in the hospital and the next day the funeral home collects a body from the hospital morgue. After embalming the body, the funeral home is notified by the hospital that they were given the wrong body. Because of this error, it may not be possible to process the correct body in time for the wake the following day. Despite being simultaneously dreadful and familiar to healthcare professionals, cases like these are not systematically identified or addressed in hospital quality improvement programmes. As a result, we have no good way of preventing them and patients inevitably continue to suffer from these unnecessary emotional harms. The authors of this paper, published in BMJ Quality & Safety, argue these cases are examples of preventable harm that are deserving of formal capture, classification and action by the healthcare system.
-
Content ArticleSidney Dekker says when there has been an incident of harm, we need to know "who is hurt, what do they need, and whose obligation is it to meet that need?" In this blog, commissioned by Patient Safety Learning, Joanne Hughes, hub topic lead, develops our understanding of the needs of patients, families and staff when things go wrong. Using Joanne's expertise and informed by her personal experience and engagement with many others who have suffered second harm, this blog discusses the care needs for harmed patients, their families and for staff when things go wrong. It aims to highlight the chasm between what is needed and what is currently delivered.
- Posted
- 5 comments
-
3
-
- (and 9 more)
-
Content ArticleElisabeth Poorman argues that becoming a doctor means learning that mistakes are not acceptable. From study through to practice, doctors are told in ways big and small, the only way to be a good doctor is to be a perfect doctor. The pressure only intensifies when real harm is on the line. The encouraged response is to study harder, sleep less, and never admit fear.
-
Content ArticleThis comprehensive systematic review, produced by the General Medical Council) examined the prevalence, severity and key types of preventable patient harm.
-
Content ArticleChildren admitted to paediatric and neonatal intensive care units may be at high risk from medication errors (MEs) and preventable adverse drug events. In this systematic review published in Drug Safety, Alghamdi et al., reviewed empirical studies examining the prevalence and nature of MEs and preventable adverse drug events in paediatric and neonatal intensive care units. They found that medication errors occur frequently in critically ill children admitted to paediatric and neonatal intensive care units and may lead to patient harm. Important targets such as dosing errors and anti-infective medications were identified to guide the development of remedial interventions.
-
Content ArticleBabies and young children (under five years) can suffer serious injury if they ingest coin/button batteries or poke them into their nostrils or ears. While the larger lithium batteries have the greatest potential to cause harm, including death, the smaller zinc–air batteries, used in hearing aids, cochlear implants, bone-anchored hearing aids (BAHA) and similar equipment, still present a significant risk. This National Patient Safety Alert requires all organisations supplying NHS-funded hearing aids to ensure those issued to babies and children under five years of age have secure battery compartments. Where hearing aids are issued to older children and adults, organisations are required to consider the need for a secure battery compartment for anyone living with young children and babies, or with a person with additional risk factors, such as those with a significant learning disability, dementia or other cognitive or sensory impairment.
-
Content Article
Patient safety in dentistry (November 2017)
PatientSafetyLearning Team posted an article in Dentist
The aim of this article, published in Dental Update, is to inform and update the reader on NHS England patient safety initiatives applicable to dentistry, specifically the development of an example Local Safety Standards for Invasive Procedures (LocSSIPs) for wrong site extraction. -
Content ArticleAn ideal surveillance system for medical device safety would comprehensively collect data on adverse events across the life span of a device, discusses Salazar and Redberg in an Editorial in JAMA Internal Medicine. They suggest that the system should be integrated into electronic health records to allow seamless identification, tracking, and real-time reporting of device-associated adverse events. It would be able to take adverse events and detect substantial safety signals and underperforming devices. Such a system would also allow implementation of corrective actions quickly.
-
Content ArticleIn this research paper published in the Nature journal Eye, Foot and MacEwen determine the frequency of patients suffering harm due to delay in ophthalmic care in the UK over a 12-month period. They found that patients were suffering preventable harm due to health service initiated delay leading to permanently reduced vision. This was occurring in patients of all ages, but most consistently in those with chronic conditions. Delayed follow-up or review is the cause in the majority of cases indicating a lack of capacity within the hospital eye service.
-
Content ArticleThe National Patient Safety Agency (NPSA) issued guidance on preventing delay to follow up for patients with glaucoma [NPSA/2009/RRR004]. This followed evidence of harm to patients with glaucoma suffering visual loss after delays to follow up appointments. This came to light from incidents reported by staff in the NHS relating to glaucoma. This paper provides background information and a checklist for organisations to help implement actions in the accompanying guidance to prevent harm from delayed follow-up appointments for patients with glaucoma. It presents details of incident data and litigation data. This work was supported by an interactive event in March 2009 with input from ophthalmic surgeons (and the Royal College of Ophthalmologists), nurses, service managers and patient representatives.
-
Content ArticleSHOT is the United Kingdom independent, professionally led haemovigilance scheme. Since 1996 SHOT has been collecting and analysing anonymised information on adverse events and reactions in blood transfusion from all healthcare organisations that are involved in the transfusion of blood and blood components in the United Kingdom. Where risks and problems are identified, SHOT produces recommendations to improve patient safety. The recommendations are put into its annual report which is then circulated to all the relevant organisations including the four UK Blood Services, the Departments of Health in England, Wales, Scotland and Northern Ireland and all the relevant professional bodies as well as circulating it to all of the reporting hospitals. As haemovigilance is an ongoing exercise, SHOT can also monitor the effect of the implementation of its recommendations.
-
Content Article
Electrosurgery. Managing the risk (September 2004)
Patient Safety Learning posted an article in Surgery
This poster from the National Association of Theatre Nurses (ATN) aims to give an overview of electrosurgery in the perioperative setting. It identifies and defines some of the common forms of electrosurgery used in perioperative practice and identifies some of the hazards that can be associated with these products. -
Content ArticleThe hospital environment is both unique and unusual in that electrical equipment is directly applied to the human body. From this contact either capacitive or resistive coupling may lead to current flow and harm. Surgical diathermy, patient monitoring and imaging, although universal, are often misunderstood, and many clinicians are ignorant of their principles and hazards. Electrical equipment in hospital therefore has the potential to lead to serious injury or death. This article published in Anaesthesia and Intensive Care Medicine outlines the basic physics of electricity, in particular the principles behind diathermy, the hazards posed by it and by other devices and the various measures available to reduce the risk of these.
-
Content ArticleThis report from Saaiq and colleagues, published in the Annals of Burns and Fire Disasters, highlights three cases of iatrogenic electrocautery burns with review of the relevant published literature. The aim is to prompt awareness among surgeons and theatre staff regarding this avoidable hazard associated with the equipment frequently used for the purpose of electrocautery. This may serve as a reminder to professionals to be cautious about the pitfalls that lead to such preventable injuries.
-
Content ArticleFollowing a reported death, the National Patient Safety Agency (NPSA) commissioned the Health and Safety Executive to undertake fire hazard testing with white soft paraffin on a variety of bandages, dressings and clothing. The results showed the ability to reproduce the fire hazard in a controlled environment. This risk was not previously well recognised.
-
Content ArticleIn this US-based article, Christopher Jason discusses recent evidence that highlights how electronic health records (EHRs) have the potential to cause patient harm in various ways.
-
Content ArticleAvMA was originally established in 1982 as Action for the Victims of Medical Accidents following public reaction to the television play Minor Complications by AvMA’s founder Peter Ransley. The name was changed in 2003 to Action against Medical Accidents. Since its inception, AvMA has provided advice and support to over 100,000 people affected by medical accidents, and succeeded in bringing about massive changes to the way that the legal system deals with clinical negligence and in moving patient safety higher up the agenda in the UK.
-
Content Article
Why should health agencies refer to restorative justice?
Claire Cox posted an article in Second victim
‘Victim wellbeing’ is a phrase often linked to restorative justice, but what does that look like in practice? In this article, Greg Smith (restorative justice development manager at Thames Valley Restorative Justice Service (TVRJS)), Diana Batchelor (PhD researcher at Oxford University and independent evaluation researcher for TVRJS) and Becci Seaborne (assistant director for restorative justice at TVRJS) consider why, and how, restorative justice could become a default option for health service providers. -
Content Article
What is restorative justice?
Claire Cox posted an article in Harmed care patient pathways/post-incident pathways
Restorative justice brings those harmed by crime or conflict and those responsible for the harm into communication, enabling everyone affected by a particular incident to play a part in repairing the harm and finding a positive way forward. This is part of a wider field called restorative practice. Restorative practice can be used anywhere to prevent conflict, build relationships and repair harm by enabling people to communicate effectively and positively. Restorative practice is increasingly being used in schools, children’s services, workplaces, hospitals, communities and the criminal justice system. Could this be something that we could utilise as a new approach in healthcare? -
Content ArticleThis study by Charles Vincent and colleagues, published in the Archives of Disease in Childhood, looked at the nature and causes of reported patient safety incidents relating to care in the community for children dependent on long-term ventilation with the further aim of improving safety. Common problems in the delivery of care included issues with faulty equipment and the availability of equipment, and concerns around staff competency. There was a clearly stated harm to the child in 89 incidents (40%). Contributory factors included staff shortages, out of hours care, and issues with packaging and instructions for equipment. This study has identified a range of problems relating to long-term ventilation in the community, some of which raise serious safety concerns. The provision of services to support children on long-term ventilation and their families needs to improve. Priorities include training of staff, maintenance and availability of equipment, support for families and coordination of care.
-
Content ArticleWhen Julie Bailey took her mother, Bella, into Mid Staffs Hospital in September 2007 she had no idea that her life was about to change forever. Over the next eight weeks she would witness such shocking neglect and abuse of elderly, vulnerable patients that the memories would haunt her for the rest of her life. And over the next five years she would uncover a culture of deceit and denial going right to the top of the NHS. From Ward to Whitehall is the story of Julie s fight for the truth to be uncovered about the deadly failings at Mid Staffs Hospital and her struggle to ensure that the tragedy would never be repeated.
-
Content ArticleAt a time of increasing regulatory scrutiny and medico-legal risk, managing serious clinical incidents within primary care has never been more important. Failure to manage appropriately can have serious consequences both for service organisations and for individuals involved. This is the first book to provide detailed guidance on how to conduct incident investigations in primary care. The concise guide: explains how to recognise a serious clinical incident, how to conduct a root cause analysis investigation, and how and when duty of candour applies covers the technical aspects of serious incident recognition and report writing includes a wealth of practical advice and 'top tips', including how to manage the common pitfalls in writing reports offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. This book offers a master class for anyone performing root cause analysis and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices, 'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical are investigated and managed.
-
Content ArticleDr Damian Roland, Consultant and Honorary Senior Lecturer in Paediatric Emergency Medicine at the University Hospitals of Leicester and Leicester University introduces Re-ACT, the Respond to Ailing Children Tool, and the knowledge map for healthcare professionals wishing to improve the recognition and management of the deteriorating child.
-
Content ArticleThere are an estimated 200,000 severe adverse drug errors (ADRs) in Canada each year, though it is estimated that 95% of ADRs are not reported. They cost the Canadian healthcare system between $13.7 and $17.7 billion each year and kill up to 22,000 Canadians each year. Over 5,000 of these are Canadian children. ADR Canada is working to prevent this. This article explains the role of genomics in the solution to adverse drug reactions.
