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Found 313 results
  1. Content Article
    Brooke was admitted to Chadwick Lodge on 15 April 2019 and had been diagnosed with Emotionally Unstable Personality Disorder and Autism Spectrum Disorder; she initially failed to engage and was violent to staff and self-harming. By the middle of May 2019 she had made progress. On 5th June 2019 she was found with a ligature around her neck, which was suspended from the door of her room. Following this incident consideration should have been given to a formal risk assessment to include consideration of her level of observation. The details of the incident should have been fully disclosed to
  2. News Article
    On 25 March2022, a Tennessee jury convicted RaDonda Vaught, a nurse at Vanderbilt University Medical Center, of criminally negligent homicide and impaired adult abuse in a 2017 medication administration error that tragically resulted in a patient death. The Washington State Nurses Association have issued a joint statement adamantly opposed to criminalization of patient care errors. "Focusing on blame and punishment solves nothing. It can only discourage reporting and drive errors underground. It not only undermines patient safety; it fosters an environment of fear and lack of respect for
  3. News Article
    RaDonda Vaught's conviction for a fatal medical error has already damaged patient safety and should serve as a wake-up call for health system leaders to improve harm prevention efforts, the Institute for Healthcare Improvement has said. Ms. Vaught was convicted 25 March of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 while working as a nurse at Vanderbilt University Medical Center in Nashville, Tenn. "We know from decades of work in hospitals and other care settings that most medical errors result from flawed sys
  4. Content Article
    Thirty-seven employees described sixty-six adaptations in their transfusion practices, showing clear differences between what has been characterised as work-as-imagined (WAI) and work-as-done (WAD). An analysis of the adaptations using the Systems Engineering Initiative for Patient Safety 2.0 (SEIPS 2.0) shows that triggers for adaptations were mostly staff-related or driven by poor information technology systems, but the resultant adaptations were usually amendments to tasks and processes. The majority of adaptations (83%) were forced – ideal solutions are not possible, so workarounds an
  5. News Article
    An inspection of a county's urgent and emergency services found delays were caused by a lack of empty beds and prolonged waiting times. The Care Quality Commission (CQC) inspected Gloucestershire emergency care services in November and December. The report found staff worked well in challenging circumstances but the CQC said pressures on workers across the system needed addressing. Dr Jeremy Welch said: "The system is being stretched and we need to adapt." CQC deputy chief inspector for hospitals, Nigel Acheson, said: "We found the system to be complicated. As a result, sta
  6. Content Article
    Presentations from the webinar: Patient engagement tool: “5 Moments for Medication Safety”, Nagwa Metwally and Helen Haskell Patients, families and health workers partnering for medication safety, Dr Irina Papieva Developing programmes for patient and family engagement - Canadian experience, Ioana Popescu and Maryann Murray View presentations from the first webinar in the series.
  7. Content Article
    Sharps injuries pose a significant global risk to staff and patient safety, and many of these injuries are caused by incorrect disposal. The Royal College of Nursing (RCN) estimates that there are 100,000 sharps injuries in healthcare in the UK every year,[1] and research by both the RCN and The European Biosafety Network highlights that the situation has worsened under the pressure of the Covid-19 pandemic.[2][3] There is also evidence that sharps injuries are underreported, meaning the number of incidents could be much higher.[2] The Safer Healthcare and Biosafety Network recently launched a
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