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Showing results for tags 'Patient harmed'.
Found 1,336 results
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Content Article
Creating a safety culture
Claire Cox posted an article in Other countries and national agencies
A safety culture is built on trust. It empowers staff to report errors, near misses, and recognise unsafe behaviours and conditions that can put patients at risk, all of which drive improvement. This video by the Joint Commission Centre for Transforming Healthcare explains how they are engaging staff and the importance of speaking up. -
Content ArticleThis report summarises the themes that emerged from a restorative process to hear from New Zealand men and women affected by surgical mesh. Restorative justice approaches and practices were used to respond to harm from surgical mesh. This innovation differs to medicolegal action and inquiry approaches in other countries. A restorative approach intended to create a safe space to explore multiple experiences and perspectives of harm.
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Content Article
Consent: The Montgomery Ruling (2015)
Claire Cox posted an article in Consent issues
The Montgomery case in 2015 was a landmark for informed consent in the UK. Nadine Montgomery, a diabetic woman and of small stature, delivered her son vaginally; her son experienced complications owing to shoulder dystocia, resulting in hypoxic insult with consequent cerebral palsy. Her obstetrician had not disclosed the increased risk of this complication in vaginal delivery, despite Montgomery asking if the baby's size was a potential problem. Montgomery sued for negligence, arguing that, if she had known of the increased risk, she would have requested a caesarean section The Supreme Court of the UK announced judgement in her favour in March 2015. It established that, rather than being a matter for clinical judgment to be assessed by professional medical opinion, a patient should be told whatever they want to know, not what the doctor thinks they should be told. This ruling means that patients can expect a more active and informed role in treatment decisions, with a corresponding shift in emphasis on various values, including autonomy, in medical ethics -
Content Article
Put an end to cannula site infections!
Claire Cox posted an article in Other hospital-based clinical areas
This presentation written by Dr Gordon Caldwell, a Consultant Physician at Lorn and Islands Hospital, Oban, Argyll, Scotland, highlights the importance of surveillance and actions to be taken around prevention of infection of cannlula sites. -
Content ArticleIn his article for KevinMD.com, Ashish Jha looks at the metrics associated with hospital acquired conditions (HACs) in the US. He discusses the imperfections of HAC scored and argues that we need better measures in order to make further progress in the field of patient safety.
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Content Article
Safe practices for drug allergies using CDS and health IT (2019)
Claire Cox posted an article in Allergies
The Partnership for Health IT Patient Safety, a national collaborative convened by ECRI Institute, has released a new report on drug allergy interactions and how clinical decision support (CDS) and health information technology (IT) can be used to improve safety. Drug allergy alerts, a feature of clinical decision support (CDS), incorporated within the electronic health record (EHR), act as a safeguard against prescribing or dispensing a medication to which a patient has a documented allergy that could cause an adverse event for a patient. Drug allergy interactions are an important patient safety concern. Inadequate communication and display of drug allergy interaction information may result in incorrect treatment, delay care, or result in additional or prolonged care for a patient. -
Content ArticleTransport of patients from the intensive care unit (ICU) to another area of the hospital can pose serious risks if the patient has not been assessed prior to transport. The Department of Critical Care Medicine, Calgary Health Region, experienced two adverse events during transport. A subgroup of the Department's Patient Safety and Adverse Events team developed an ICU patient transport decision scorecard. This tool was tested through Plan-Do-Study-Act cycles and further revised using human factors principles. Staff, especially novice nurses, found the tool extremely useful in determining patient preparedness for transport.
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Content ArticleWhen patients are harmed as a result of the care they receive through Alberta Health Services (AHS), the organisation has a responsibility to understand how the harm happened and, where appropriate, respond to improve the healthcare system. This handbook has been developed to assist and support AHS staff and medical staff to retrospectively review clinical adverse events, hazards and close calls using Systems Analysis Methodologies (SAM). It is not an administrative review of individual healthcare provider performance. Using these methodologies, the complex interactions of all the components within the health system are considered, not the individual contributions of healthcare providers that have or may have led to harm. This creates opportunities to identify vulnerabilities in structures, processes and practices that can be improved and ultimately make care safer.
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Content ArticleThe National Patient Safety Agency developed the Incident Decision Tree to help NHS managers in the UK to determine a fair and consistent course of action toward staff involved in patient safety incidents. Research shows that systems failures are the root cause of the majority of safety incidents. Despite this, when an adverse incident occurs, the most common response is to suspend the clinician(s) involved, pending investigation, in the belief that this serves the interests of patient safety. The Incident Decision Tree supports the aim of creating an open culture, where employees feel able to report patient safety incidents without undue fear of the consequences. The tool comprises an algorithm with accompanying guidelines and poses a series of structured questions to help managers decide whether suspension is essential or whether alternatives might be feasible.
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Content ArticleA report from the Public Administration Select Committee looking at the investigation process, how it impacts those involved and how risk can be reduced through learning.
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Content ArticleDrawing together academic evidence and practical experience to produce a framework for safety measurement and monitoring.
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Content ArticlePublished by the Canadian Patient Safety Institute, this paper describes an investigation into engaging with patients and families that have been harmed and recommends best practices for organisations to enable such collaboration.
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Content ArticleAbout one in ten patients are harmed during health care. Published on the OECD Library website, this paper estimates the health, financial and economic costs of this harm. Results indicate that patient harm exerts a considerable global health burden. The financial cost on health systems is also considerable and if the flow-on economic consequences such as lost productivity and income are included the costs of harm run into trillions of dollars annually. Because many of the incidents that cause harm can be prevented, these failures represent a considerable waste of healthcare resources, and the cost of failure dwarfs the investment required to implement effective prevention.
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Content Article
PHE: Become an antibiotic guardian
Claire Cox posted an article in Medicine management
The Antibiotic Guardian campaign is led by Public Health England (PHE) in collaboration with the Devolved Administrations (Scotland, Wales and Northern Ireland); the Department for Environment Food and Rural Affairs (DEFRA) and professional bodies/ organisations towards the ‘One Health’ initiative. Antibiotic resistance is one of the biggest threats facing us today. Without effective antibiotics many routine treatments will become increasingly dangerous. Setting broken bones, basic operations, even chemotherapy and animal health all rely on access to antibiotics that work. To slow resistance we need to cut the unnecessary use of antibiotics. The Antibiotic Guardian invite the public, students and educators, farmers, the veterinary and medical communities and professional organisations, to become Antibiotic Guardians. -
Content ArticleAn extensive governance review of the events leading to the closure of Tawel Fan ward in December 2013 and a review of the current governance arrangements in older people’s mental health in Betsi Cadwaldr University Health Board.
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Content ArticleThe Inquiry into the management of care of children receiving complex heart surgery at the Bristol Royal Infirmary.
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Content Article
The harms of promoting ‘Zero Harm’
Claire Cox posted an article in Research papers
In their paper 'Managing risk in hazardous conditions: improvisation is not enough', Almaberti and Vincent ask "what strategies we might adopt to protect patients when healthcare systems and organisations are under stress and simply cannot provide the standard of care they aspire to". This is clearly a critical and much overdue question, as many healthcare organisations are in an almost constant state of stress from high workload, personnel shortages, high-complexity patients, new technologies, fragmented and conflicting payment systems, over-regulation, and many other issues. These stressors put mid-level managers and front-line staff in situations where they may compromise their standards and be unable to provide the highest quality care. Such circumstances can contribute to low morale and burn-out. Eric Thomas discusses this further in his Editorial published in BMJ Safety & Quality.- Posted
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Content ArticleThe Health Foundation's response to the Department of Culture, Media and Sport and Home Office consultation on the Online Harms White Paper.
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Content ArticleAdverse events and poor health outcomes are continuing challenges for nursing home residents and staff. Research has shown that many resident harms are avoidable and may be caused by situations in which residents do not receive needed care, often called omissions of care. Omissions of care research in nursing home settings is limited and definitions of omissions of care vary. Therefore, the US Agency of Healthcare Research and Quality (AHRQ) has developed a definition of omissions of care for nursing homes intended to be meaningful to stakeholders, including residents and caregivers, and actionable for research or improving quality of care. They developed the definition through a literature review and feedback from subject matter experts and stakeholders in the US. To develop and describe the definition, project staff produced an environmental scan and final report, including resources to help nursing homes operationalise and apply the definition of omissions of care.
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Content ArticleA protocol for liaison and effective communications between the NHS, Association of Chief Police Officers (replaced in 2015 by a new body, the National Police Chiefs' Council) and Health and Safety Executive (HSE). Although now archived in The National Archives, much of the protocol is still relevant today. The protocol took effect in circumstances of unexpected death or serious untoward harm requiring investigation by the police, or the police and the HSE jointly. The protocol sets out the general principles for the NHS, police and HSE to observe when liaising with one another. It focused on investigations in NHS Trusts, although the principles and practices it promotes should apply to other locations where healthcare is provided and the NHS is required to investigate under its performance management and other duties.
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Content ArticleSmoking or a naked flame could cause patients’ dressings or clothing to catch fire when being treated with paraffin-based emollient that is in contact with the dressing or clothing. The Medicines and Healthcare products Regulatory Agency (MHRA) provided this update for healthcare professionals.
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Content Article
Bottle of Lies by Katherine Eban
Patient Safety Learning posted an article in Recommended books and literature
The troubles of Indian pharma companies abroad raise questions about the domestic drug regulator. Although Bottle of Lies, a book about the quality problems plaguing generic drugs, focuses on medicines intended for American consumers, the real and continuing victims of the failings described in the book are consumers in developing countries, including Indians. In May 2013, soon after the erstwhile Ranbaxy Laboratories admitted in an American court to selling adulterated drugs, journalist Katherine Eban published a gripping 10,000-word account of the saga in Fortune magazine. But the story left Eban wondering if Ranbaxy was an isolated case. Could there be more rotten eggs, she asked, given the United States Food & Drugs Administration’s (FDA) lax policing of overseas manufacturers? Bottle of Lies is the result of the multi-year investigation that followed. -
Content Article
Staff safety in the mental healthcare setting
Sarahjane Jones posted an article in Staff safety
I lead a team of multidisciplinary researchers who explore the power of routinely collected data for improving our understanding of patient safety. Our hope is that this insight will be translated into improvements in patient care. On this World Mental Health Day, there is an opportunity to reflect on the implications of harm to staff who deliver care to some of the most vulnerable patients in any healthcare system and what we might do to better protect them from harm. We recently published a study that focussed on staff safety in the mental healthcare setting and I'd like to discuss some of the findings in this blog. -
Content ArticleAction Against Medical Accidents (AvMa) is a UK charity for patient safety and justice. AvMA supports people affected by avoidable harm in healthcare; to help them achieve justice; and to promote better patient safety for all.
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Content ArticleThe Citizens Advice provides advice on how to take legal action to get compensation for clinical negligence.
