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Showing results for tags 'Patient harmed'.
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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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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 ArticleA surgical fire is potentially devastating for a patient. Fire has been recognised as a potential complication of surgery for many years. Surgical fires continue to happen with alarming frequency. Yardley and Donaldson present a review of the literature and an examination of possible solutions to this problem.
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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.
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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 ArticleIn 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.
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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 ArticleSir Liam Donaldson's presentation slide at the High Level Forum, Africa Patient Safety Initiative, Cape Town, South Africa 24- 25 October 2019.
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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 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.
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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 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 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 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.
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Content ArticleFallStop 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.
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The real second victims
Patient Safety Learning posted an article in Second victim
In many professions, specific terms – both old and new – are often established and accepted unquestioningly, from the inside. In some cases, such terms may create and perpetuate inequity and injustice, even when introduced with good intentions. One example is the term ‘second victim’. The term ‘second victim’ was coined by Albert W Wu in his paper ‘Medical error: the second victim’. Wu wrote the following: “although patients are the first and obvious victims of medical mistakes, doctors are wounded by the same errors: they are the second victims”. In his blog, Stephen Shorrick discusses the term second victim, what patients and families think of this term, and proposes that healthcare professionals are perhaps the 'third victims'. -
Content ArticleNHS 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.
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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 ArticleRob Hackett, Patient Safe Network, in the video below discusses the danger of Indistinct chlorhexidine which can easily be mistaken for other colourless solutions. He highlights the story of Grace Wang, who in 2010 had antiseptic solution injected into her epidural. She nearly died and was left paralysed. Indistinct chlorhexidine was mistaken for saline. The investigation recommended all skin antiseptic solutions to be coloured in a way that distinguished them. Sadly this recommendation isn't followed. Accidental chlorhexidine injections continue to occur and there are many more examples. This same error continues to play out again and again throughout the world. There’s no need for these indistinct solutions and safer distinct versions and those enclosed in swab sticks are already in use in many hospitals without problem and at no extra cost.
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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 ArticleHelen 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.
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Content ArticleThis 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.
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Content ArticleThis case story highlights the missed opportunities that could have prevented a cardiac arrest and subsequent severe hypoxic brain injury in an intensive care patient.
