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Found 1,336 results
  1. Content Article
    In January 2017, I read an article in Outpatient Surgery involving an elderly patient in the US who suffered multiple burns following the use of chlorohexidine bottled alcoholic prep. The Oregon woman filed a million-dollar lawsuit against the Oregon Outpatient Surgery Center in Tigard, Ore., saying she suffered severe burns when her face caught on fire during an electrocautery procedure. Having read this tragic story and escalated it to my theatre manager and colleagues, I decided to design and evaluate a FRAS (Fire Risk Assessment Score) and use it as part of the WHO Surgical Checklist at "time out" to raise awareness of fires in operating theatres.
  2. Content Article
    FallStop is a quality improvement programme from the Falls Prevention Team at the East Kent Hospitals University NHS Foundation Trust. It was developed in 2016 when they found there was a high rate of falls at one of their hospitals and a failure to learn from incidents. A FallStop Practitioner co-ordinates the programme and delivers training.
  3. Content Article
    NHS Resolution has reported on the first year of its innovative scheme to drive improvements in maternity and neonatal services and to ensure that families are better supported whose babies suffer rare, but tragic, avoidable brain injuries at birth.
  4. Content Article
    On 17 September 2019, we contributed to the first-ever World Patient Safety Day by releasing three short videos, with information about our thinking and proposed action to address unsafe care. Leadership for patient safety Patient safety is a purpose of health and social care Shared learning for patient safety
  5. Content Article
    Helen Haskell, co-chair of the WHO Patients for Patient Safety Advisory Group, brings the patient leader perspective to her take on World Patient Safety Day in this essay published in the BMJ.
  6. Content Article
    This report by NHS Resolution provides an in-depth examination of these rare but tragic incidents and the investigations that follow them. For the purposes of this study they focused on 50 cases of cerebral palsy where the incidents occurred between 2012 and 2016 and a legal liability has been established. Working in partnership with other organisations, including the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, NHS England and NHS Improvement, NHS Resolution have highlighted areas for improvement and made clear recommendations to help trusts prevent further incidents. The study draws upon the unique data set NHS Resolution holds to address two key areas for improvement: training to prevent future incidents and the quality of serious incident investigations.
  7. Content Article
    This case story highlights the missed opportunities that could have prevented a cardiac arrest and subsequent severe hypoxic brain injury in an intensive care patient. 
  8. Content Article
    No one should be harmed while receiving healthcare. And yet globally, at least five patients die every minute because of unsafe care. The World Health Organization (WHO) will focus global attention on patient safety and launch a campaign in solidarity with patients on the very first World Patient Safety Day on 17 September 2019. Watch the WHO Director General’s statement calling for patients, healthcare workers, policy makers to “Speak up for Patient Safety!”.
  9. Content Article
    Julie Carman was involved in a road traffic accident whilst on a cycling holiday, suffering injuries to her face, jaw and legs. After making a good initial recovery and expecting to be back at work within three months – three years later she is still having treatment having experienced two further emergency admissions to hospital due to acute cellulitis and sepsis.
  10. Content Article
    Communicating after harm in healthcare was developed by the Canadian Patient Safety Institute to assist organisations throughout the process of communicating after patient safety incidents that resulted in harm. 
  11. Content Article
    Dr Clare Dollery reflects on a retained swab 'never event' in Churchill Hospital theatres. Incidents, such as operating on the wrong body part or leaving instruments inside patients are categorised by the Department of Health as 'never events'. Dr Dollery is Oxford University Hospital's Deputy Medical Director. The Surgical Grand Rounds lecture series, hosted by the Nuffield Department of Surgical Sciences at Oxford University, is the key educational meeting for consultants, juniors and medical students. Presentations revolve around clinical cases.
  12. Content Article
    Never Events are patient safety incidents that are considered preventable when national guidance or safety recommendations that provide strong systemic protective barriers are implemented by healthcare providers. 
  13. Content Article
    Interesting article, by the Patient Safety Network, around how patients can be involved in the solution and the cause of some patient safety incidents.
  14. Content Article
    In this thought paper published by The Health Foundation, Dr Rebecca Lawton and Dr Gerry Armitage look at ways to involve patients in clinical safety and the readiness of patients and health professionals to adopt new roles. They discuss the importance of involving patients in the development of patient engagement and involvement strategies. Genuine patient involvement in their own care requires a fundamental cultural shift in the relationship between patients and clinicians. 
  15. Content Article
    This guide published by the Agency for Healthcare Research & Quality (AHRQ) is a tested, evidence-based resource to help hospitals in the United States work as partners with patients and families to improve quality and safety.
  16. Content Article
    The Patient Safety Network (PSNet) discuss a case of a 65 year old who went in for one operation, but ended up having a completely different operation.
  17. Content Article
    Kathryn recalls her personal experience of temporary paralysis and respiratory arrest after residual anaesthetic drugs were not flushed from her lines and cannulae following surgery. The video supports the Patient Safety Alert 'Confirming removal or flushing of lines and cannulae after procedures' issued by NHS Improvement in November 2017. More recently, the Healthcare Safety Investigation Branch (HSIB) have carried out an investigation looking at the risks to patients when intravenous (IV) drugs are retained in cannulae and extension lines and made a series of recommendations.
  18. Content Article
    Alison Phillips tells HSJ her story and why she's campaigning for the deteriorating patient and safety.
  19. Content Article
    This case study written by Matthew Doyle and published by PSNet, Agency for Healthcare Research and Quality, describes a case of a patient in the US who was given a drug they were allergic to, the implications of this and how to mitigate future events.
  20. Content Article
    This document sets out the General Medical Council's (GMC) expectation that all doctors will, whatever their role, take appropriate action to raise and act on concerns about patient care, dignity and safety. 
  21. Content Article
    The Black Country Partnership NHS Foundation Trust's medication error policy and pathway describes the procedure that must be followed when a medication error occurs.
  22. Content Article
    This Care Quality Commission (CQC) report focuses on why avoidable harm remains a persistent problem within healthcare.
  23. Content Article
    The Health Foundation’s Evidence into Practice Programme sponsored the production of a 3 minute animation led by Thomas Jun and Patrick Waterson at Human Factors and Complex Systems Research Group, Loughborough University. This highly engaging and insightful animation can provide a systems thinking reminder to any serious incident investigation in healthcare.
  24. Content Article
    Each Baby Counts is the Royal College of Obstetricians and Gynaecologists (ROCG's) national quality improvement programme to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour.
  25. Content Article
    Presentation from the BMJ/IHI 2012 conference in Paris.
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