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Showing results for tags 'Patient harmed'.
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Content ArticleThe Black Country Partnership NHS Foundation Trust's medication error policy and pathway describes the procedure that must be followed when a medication error occurs.
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- Medication
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Content ArticleAt a time of increasing regulatory scrutiny and medico-legal risk, managing serious clinical incidents within primary care has never been more important. Failure to manage appropriately can have serious consequences both for service organisations and for individuals involved. This is the first book to provide detailed guidance on how to conduct incident investigations in primary care. The concise guide: explains how to recognise a serious clinical incident, how to conduct a root cause analysis investigation, and how and when duty of candour applies covers the technical aspects of serious incident recognition and report writing includes a wealth of practical advice and 'top tips', including how to manage the common pitfalls in writing reports offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. This book offers a master class for anyone performing root cause analysis and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices, 'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical are investigated and managed.
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- Investigation
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Content ArticleThis Care Quality Commission (CQC) report focuses on why avoidable harm remains a persistent problem within healthcare.
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- Communication
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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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- Patient death
- Patient harmed
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Content ArticleThe 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.
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Content Article
Each Baby Counts (RCOG, 2019)
Patient Safety Learning posted an article in Maternity
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.- Posted
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- Obstetrics and gynaecology/ Maternity
- Patient death
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Content ArticlePresentation from the BMJ/IHI 2012 conference in Paris.
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Content ArticleBoth 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.
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Content ArticleAlthough 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.
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- Human factors
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Content ArticleThis 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.
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- Patient harmed
- Anaesthesia
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News ArticleRegina 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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- Medical device
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