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Found 13 results
  1. News Article
    Inquest finds Susan Warby, 57, received insulin she did not need after blood test mistakes. Hospital errors contributed to her death five weeks after bowel surgery, an inquest into her death has concluded. Susan Warby, 57, who died at West Suffolk hospital in Bury St Edmunds, was incorrectly given glucose instead of saline through an arterial line that remained in place for 36 hours and resulted in inaccurate blood test readings. She was subsequently given insulin she did not need, causing bouts of extremely low blood sugar (hypoglycemia) and the development of “a brain injury of uncertain severity”, recorded Suffolk’s senior coroner, Nigel Parsley. Speaking after the inquest was adjourned in January, Susan's husband, Jon Warby, said he was “knocked sideways completely” when he received an anonymous letter two months after her death highlighting blunders in her treatment. Doctors at the hospital were reportedly asked for fingerprints as part of the hospital’s investigation into the letter, a move described by a Unison trade union official as a “witch-hunt” designed to identify the whistleblower. Following January’s adjournment, Parsley instructed an independent expert to review the care that Warby received. Warby’s medical cause of death was recorded as multi-organ failure, with contributory causes including septicaemia, pneumonia and perforated diverticular disease, affecting the bowel. Recording a narrative conclusion, Parsley wrote: “Susan Warby died as the result of the progression of a naturally occurring illness, contributed to by unnecessary insulin treatment caused by erroneous blood test results. This, in combination with her other comorbidities, reduced her physiological reserves to fight her naturally occurring illness.” Jon Warby said in a statement: “The past two years have been incredibly difficult since losing Sue, and it is still a real struggle to come to terms with her no longer being here. The inquest has been a highly distressing time for our family, having to relive how Sue died, but we are grateful that it is over and we now have some answers as to what happened." “After learning of the errors in Sue’s care, I wanted to know how these occurred and what action was being taken to prevent any similar incidents in the future. The trust has now made a number of changes which I am pleased about.” Read full story Source: The Guardian, 7 September 2020
  2. News Article
    Inspectors raise ‘serious concerns’ about medical wards and emergency care at Shropshire NHS trust A patient bled to death on a ward at Shrewsbury and Telford Hospitals Trust after a device used to access his bloodstream became inexplicably disconnected, The Independent has learnt. The incident came to light as new concerns arose about quality of care at the Shropshire trust, with the Care Quality Commission (CQC) warning of “serious concerns” about its medical wards and emergency department following an inspection last month. Although the report from the inspection has not yet been published, it is understood that the trust has been served with a legal notice by the regulator to comply with more than a dozen conditions. It remains in special measures following the inspection and is rated inadequate overall. See full article in The Independent here
  3. Content Article
    As in previous years, it is certain that under-reporting is significant. Reporting rates in some of the higher usage Trusts/Health Boards vary twentyfold. Given the cultural, resource and procedural similarities of these organisations, it is highly unlikely that the error and mishap rate varies by anything like this much, so reporting rates are likely to play a large part. One area where this is likely to have greatest impact is in the reporting of near misses, the most fertile learning area. The leading causes of transfusion-related incidents are, again this year, ‘human factors’ related, with procedural failures and flawed decision-making contributing in large measure. While decision support tools and information technology have gained some traction, and continue to help us progress in these areas, their universal adoption remains some way off. Until these are more widespread, we continue to rely on education and peer pressure to encourage best practice. A ‘human factors’ approach is key to understanding why errors and accidents continue to occur, despite, in many cases, adequate training, knowledge, expertise and currency. Those areas of hospitals which are under greatest stress and pressure, for example, emergency departments, continue to report a year on year increase in errors. Despite this, transfusion remains very safe indeed,with the risk of serious harm being 1 in 17,884 and death 1 in 135,705 transfused components in the UK.
  4. News Article
    This is the independent public statutory inquiry into the use of infected blood. The timetable and factsheet to provide information for those attending the hearings in London on 24-28 February have just been published. Go to this link for more information >> https://www.infectedbloodinquiry.org.uk/news
  5. News Article
    Hundreds of people with haemophilia in England and Wales could have avoided infection from HIV and hepatitis if officials had accepted help from Scotland, newly released documents suggest. A letter dated January 1990 said Scotland’s blood transfusion service could have supplied the NHS in England and Wales with the blood product factor VIII, but officials rejected the offer repeatedly. Large volumes of factor VIII were imported from the US instead, but it was far more contaminated with the HIV and hepatitis C viruses because US supplies often came from infected prison inmates, sex workers and drug addicts who were paid to give blood but not screened. The death of scores of people with haemophilia and blood transfusion patients and the infection of thousands of others across the UK in the contaminated blood scandal has been described as the worst health disaster to hit the NHS. The latest document was released under the Freedom of Information Act to campaigner Jason Evans, whose father died in 1993 having contracted hepatitis and HIV. In it, Prof John Cash, a former director of the Scottish Blood Transfusion Service, said the decision not to use Scotland's spare capacity to produce Factor VIII for England was "a grave error of judgement". Read full story Source: The Guardian, 3 January 2020
  6. Content Article
    This guideline includes recommendations on: hand decontamination use of personal protective equipment safe use and disposal of sharps waste disposal long-term urinary catheters enteral feeding vascular access devices. Who is it for? commissioners and providers healthcare professionals working in primary and community care settings, including ambulance services, schools and prisons children, young people and adults receiving healthcare for which standard infection-control precautions apply in primary and community care, and their families and carers.
  7. Content Article
    National data from SHOT (Serious Hazards of Transfusion) indicates there were 792 ‘wrong blood in tube’ near misses (where the error was spotted in time and no patient suffered harm) relating to blood transfusion samples, in 2018 across England. This doesn’t account for blood samples taken for any other purpose. The HSIB report showed why these incidents happen and most importantly what can be done to reduce the risk of it happening again. The investigation looked at all the factors involved and found evidence to show that electronic systems could help staff in busy environments, by making the processes easier and more efficient, to manage and reduce the risk to patients.
  8. Content Article
    Based on quality improvement initiatives undertaken at the University of California, San Diego Medical Center and Emory University Hospitals, this guide assists quality improvement practitioners in leading an effort to improve prevention of hospital-acquired venous thromboembolism.
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