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Found 1,334 results
  1. Content Article
    A 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. 
  2. Content Article
    In this Editorial in the BMJ, Albert Wu introduced the phrase ‘second victim’ in an attempt to highlight the emotional effects for staff involved in a medical error and the need for emotional support to help their recovery.
  3. 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.
  4. 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.
  5. Content Article
    Presentation from the BMJ/IHI 2012 conference in Paris.
  6. Content Article
    Both national and maternity investigations are showing a high level of family engagement through an inclusive and innovative model that ensures families have a voice throughout investigations. Here the Healthcare Safety Investigation Branch (HSIB) demonstrate how they involve families in their investigations.
  7. Content Article
    Although many initiatives have been implemented and great strides have been achieved in improving patient safety and reducing preventable medical errors, progress towards achieving "zero" avoidable harm continues to be slow. This video presentation will address common medical errors, their recognition, potential for harm and the psychological and financial costs. The concepts of human factors, system design and the high reliability organisation will be reviewed. New approaches in reducing harm and restoring trust will be described along with the opportunity for physician leadership.
  8. Content Article
    This directive alert has been issued on the need to confirm intravenous (IV) lines and cannulae have been effectively flushed or removed at the end of the procedure.
  9. News Article
    Regina Stepherson needed surgery for rectocele, a prolapse of the wall between the rectum and the vagina. Her surgeons said that her bladder also needed to be lifted and did so with vaginal mesh, a surgical mesh used to reinforce the bladder. Following the surgery in 2010, Stepherson, then 48. said she suffered debilitating symptoms for two years. An active woman who rode horses, Stepherson said she had constant pain, trouble walking, fevers off and on, weight loss, nausea and lethargy after the surgery. She spent days sitting on the couch, she said. In August 2012, Stepherson and her daughter saw an ad relating to vaginal mesh that mentioned 10 symptoms and said that if you had them, to call a lawyer. Vaginal mesh, used to repair and improve weakened pelvic tissues, is implanted in the vaginal wall. It was initially — in 1998 — thought to be a safe and easy solution for women suffering from stress urinary incontinence. But over time, complications were reported, including chronic inflammation, and mesh that shrinks and becomes encased in scar tissue causing pain, infection and protrusion through the vaginal wall. More than 100,000 lawsuits have been filed against makers of mesh, according to ConsumerSafety.org, making it “one of the largest mass torts in history.” Read full story Source: Washington Post, 20 January 2019
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