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Found 315 results
  1. Content Article
    Turning "To err is human, but to really screw up, you need a computer" on its head, in 1999 the Institute of Medicine's To Err Is Human: Building a Safer Health Care System recommended that healthcare professionals focusing on patient safety should increase their understanding of how information technology could be applied to deliver safer care. This recommendation was made as part of the approach to reducing errors in the delivery of care leading to the death of as many as 98,000 US citizens annually. Much of the subsequent response to that challenge has focused on increasing the capabil
  2. Content Article
    Key messages The total number of NHS hospital beds in England has more than halved over the past 30 years, from around 299,000 in 1987/88 to 141,000 in 2019/20, while the number of patients treated has increased significantly. Most other advanced health care systems have also reduced bed numbers in recent years. However, the UK has fewer acute beds relative to its population than many comparable health systems. Since 1987/88, the largest percentage reductions in bed numbers have occurred in mental illness and learning disability beds as a result of long-term policies to move
  3. Content Article
    The report provides information on the patient involved and background to the adverse incident, analyses the reasons for the incident and provides recommendations for the administration of intrathecal chemotherapy to prevent a similar incident occurring in the future: Recommendations include: changes to operational practices in pharmacy and ward settings changes to protocols in pharmacy and ward settings the provision of separate prescri0ption charts for intrathecal drugs formal, appropriate training on practical chemotherapy administration for senior house offi
  4. News Article
    The family of a man who bled to death during kidney dialysis treatment at Royal Shrewsbury Hospital have said they believe lessons have been learned. Mohammed Ismael Zaman, known as Bolly, died after hospital staff failed to check the connection on his dialysis machine, despite it sounding an alarm after the catheter had become disconnected. During Mr Zaman’s treatment at the Royal Shrewsbury Hospital on October 18, 2019, his dialysis machine set off a venous pressure alarm. An unidentified member of staff reset the alarm without checking that the connection was still secure. As
  5. Content Article
    ‘Work as done’ Because healthcare is constantly evolving and complex, by looking more closely at everyday work and finding out what actually happens, it allows an understanding of what it is, that frontline clinicians do to ensure successful outcomes. This is termed as looking at 'work as done' and informs us about the nuances, the adjustments, the compromises, the workarounds, the actions and the decision making that is taken to meet the needs of the patients they are caring for. ‘Work as done’ is a combination of expertise, clinical decisions, experience and tacit knowledge. It is
  6. News Article
    The NHS 111 helpline for urgent medical care is facing calls for an investigation after poor decision-making was linked to more than 20 deaths. Experts say that inexperienced call handlers and the software used to highlight life-threatening emergencies may not always be safe for young children. At least five have died in potentially avoidable incidents. Professor Carrie MacEwen, Chairwoman of the Academy of Medical Royal Colleges, said: “These distressing reports suggest that existing processes did not safeguard the needs of the children in these instances.” Since 2014 coroners
  7. Content Article
    This study highlights that people with complex concerns with a history of placement breakdowns and past institutionalisation can be settled successfully and safely in local communities. However, it is difficult for many of them to achieve a satisfactory quality of life long term. The obligation for this lies with service providers to provide adequate support to overcome that difficulty.
  8. Content Article
    Building on its successful predecessors, the third edition of The Field Guide to Understanding ‘Human Error’ will help you understand a new way of dealing with a perceived 'human error' problem in your organisation. It will help you trace how your organisation juggles inherent trade-offs between safety and other pressures and expectations, suggesting that you are not the custodian of an already safe system. It will encourage you to start looking more closely at the performance that others may still call 'human error', allowing you to discover how your people create safety through practice, at
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