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Showing results for tags 'Patient harmed'.
Found 1,335 results
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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.
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Content ArticlePatient safety incidents are any unintended or unexpected incident which could have, or did, lead to harm for one or more patients receiving healthcare. Reporting them supports the NHS to learn from mistakes and to take action to keep patients safe. Both healthcare staff and the general public are encouraged to report any incidents, whether they result in harm or not, to the National Reporting and Learning System (NRLS). You can find out how to do this from the link below.
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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 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.
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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. -
News ArticleAn NHS hospital has admitted it failed to properly anaesthetise a patient who was operated on while conscious – leaving her with post-traumatic stress disorder (PTSD) and recurring nightmares. The woman, who has chosen to remain anonymous, said she screamed out as the gynaecological surgery at Yeovil District Hospital began to operate, but could not be heard through her oxygen mask as the surgeon cut into her belly button. Medical negligence lawyers said she was given a spinal rather than general anaesthetic during the procedure at the hospital in Somerset last year. She remained conscious while a laparoscope – a long camera tube – was placed inside her, and her abdomen was filled with gas. Her law firm Irwin Mitchell said that an increase in blood pressure had alerted staff to her discomfort, but that the procedure was continued. The woman, who is in her 30s, said: “While nothing will change what has happened to me, I just hope that lessons can be learned so no one else faces similar problems in the future." A spokeswoman for Yeovil Hospital said the incident was the result of “a breakdown of communication” which “led to the use of a different anaesthetic to that normally required for such an operation”. Read full story Source: The Independent, 10 December 2019
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Content ArticleSTOMP stands for stopping over medication of people with a learning disability, autism or both with psychotropic medicines. It is a national project involving many different organisations which are helping to stop the over use of these medicines. STOMP is about helping people to stay well and have a good quality of life. Psychotropic medicines affect how the brain works and include medicines for psychosis, depression, anxiety, sleep problems and epilepsy. Sometimes they are also given to people because their behaviour is seen as challenging. People with a learning disability, autism or both are more likely to be given these medicines than other people. These medicines are right for some people. They can help people stay safe and well. Sometimes there are other ways of helping people so they need less medicine or none at all.
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Content ArticleSTOMP stands for stopping over medication of people with a learning disability, autism or both with psychotropic medicines. It is a national project involving many different organisations which are helping to stop the over use of these medicines. STOMP is about helping people to stay well and have a good quality of life.
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News Article
Nearly 70,000 patients injured in Ontario’s hospitals each year, auditor says
Patient Safety Learning posted a news article in News
Nearly 70,000 patients are injured while receiving care in Ontario's hospitals each year, the province's auditor general said Wednesday, calling for immediate government action to help reduce that number. In her 2019 annual report, Bonnie Lysyk said her team's audits of acute-care centres found that six in every 100 patients treated and discharged from provincial hospitals were harmed during care. "Each year, Ontario hospitals discharge one million people," Lysyk said. "Of those, about 67,000 people were harmed during their hospital stay." The audit found that hospitals are currently not required to report to the Ministry of Health so-called "never-events" — a medical error that should never happen, such as leaving a foreign object inside a patient. Lysyk said her team visited six of the 13 hospitals that track "never-events," and found that 214 such incidents had occurred since 2015. Ontario's rates of patient harm are the second-highest in Canada, after Nova Scotia. Read full story Source: Niagara Falls Review, 5 December 2019 -
News Article
Patients harmed after doctors ‘failed to respond’ to nurse concerns
Patient Safety Learning posted a news article in News
Two patients at a hospital in West Lancashire came to “avoidable harm” after medical staff failed to act on concerns raised by nurses, according to a health watchdog. The issue was highlighted by the Care Quality Commission (CQC) following an inspection of children and young people’s services at Ormskirk Hospital in July and August. In there report CQC stated: “In children and young people’s services we found evidence that there had been occasions when medical staff had not responded to nursing concerns, which led to avoidable harm occurring to two patients.” The document added that the two serious incidents, which had both been reported by staff, were "relating to babies". Read full story Source: The Nursing Times, 3 December 2019 -
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. -
News ArticleNHS bosses have been accused of using a 2013 report to “maintain a false narrative” about maternity services in Shropshire, which meant poor practices and conditions went unchallenged for years. The Independent has obtained a 2013 report, commissioned by NHS managers in Shropshire, which concluded maternity services at the Shrewsbury and Telford Hospital Trust were “safe”, of “good quality”, and “delivered in a learning organisation”. The report, written by rheumatologist Dr Josh Dixey (now high sheriff of Shropshire), delivered a glowing assessment of the care given to women and babies and appeared to gloss over hints of deeper problems within the service. Sources within the Shropshire and Telford clinical commissioning groups (CCGs), which paid £60,000 for the report, said since it was written it had been “proven to be wrong, inaccurate and to have come to the wrong conclusions and recommendations”, but also stressed it was based on the information received from the trust at the time. A leaked report last month revealed dozens of mothers and babies had died at the Shrewsbury and Telford Hospital Trust, with incidents of poor care stretching over four decades, due to repeated failures to learn from mistakes. Read full story Source: The Independent, 4 December 2019
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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.
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News Article
Hundreds of families come forward in Shropshire maternity scandal
Patient Safety Learning posted a news article in News
More than 200 new families have contacted an inquiry into mother and baby deaths at a hospital trust in Shropshire. Investigators were already looking at more than 600 cases where newborns and mothers died or were left injured while in the care of the Shrewsbury and Telford Hospital Trust. One expert says the scandal, spanning decades, may be the tip of the iceberg. Dr Bill Kirkup says it suggests failure might be more widespread in the NHS. The surge in new cases follows the leak of an interim report last week. Read full story Source: BBC News, 27 November 2019 -
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
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 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.
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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.
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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 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 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.
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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 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.
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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.
