When submitting a case, the following information is required.
Title (please provide an appropriate title for the case).
Patient Description (describe the patient [as much as you would in a case summary] at the time of the event of interest)
Nature of Error (the nature of the error and any relevant events or contributing factors)
Impacts/Effects (describe the impact of the error on the patient and state whether the patient was harmed or required increased level of care, even if only temporarily)
How Error was Recognised (if not noted above,
Patient Safety - March 2022
Patient Safety - January 2022 Special Issue: Pharmacy Education and Practice
Patient Safety - December 2021
Patient Safety - September 2021
Patient Safety - June 2021
Patient Safety - March 2021
Patient Safety-December 2020
Patient Safety - September 2020
Patient Safety Journal - June 2020
Patient Safety March 2020
Patient Safety - December 2019
Patient Safety - September 2019
The review found that work was underway to improve the organisation’s speaking up culture, but there were long-standing issues with the trust’s speaking up culture. There was a perception among some workers that speaking up was futile. Black and minority ethnic workers – and other groups – also reported facing barriers to speaking up.
The review also found that some workers who had spoken up to national bodies had variable experiences.
The report makes recommendations for actions which national bodies and the healthcare system as whole can take to support organisations, including bri
This guide is for reviewers undertaking Structured Judgement Reviews (SJR's). A SJR is usually undertaken by an individual reviewing a patient’s death and mainly comprises two specific aspects: explicit judgement comments being made about the care quality and care quality scores being applied. These aspects are applied to both specific phases of care and to the overall care received.
The phases of care are:
admission and initial care – first 24 hours
care during a procedure
end-of-life care (or discharge care)
The use of artificial intelligence (AI) in patient care can offer significant benefits. However, there is a lack of independent evaluation considering AI in use. This paper from Sujan et al., published in BMJ Health & Care Informatics, argues that consideration should be given to how AI will be incorporated into clinical processes and services. Human factors challenges that are likely to arise at this level include cognitive aspects (automation bias and human performance), handover and communication between clinicians and AI systems, situation awareness and the impact on the interaction wi
Four key themes were identified in the study:
context of exposure
fear of punitive action
On the one hand, students recognised there was a professional obligation bestowed upon them to raise concerns if they witnessed sub-optimal practice; however, their willingness to do so was influenced by intrinsic and extrinsic factors. Students have to navigate their moral compass, taking cognisance of their own social identity and the identity of the organisations in which they are placed.
Latest case studies:
Delayed oxygenation of neonate during resuscitation when oxygen not ‘flicked’ on
Equipment falling onto critically ill patients during intrahospital transfers
Misapplication of spinal collars resulting in harm from unsecured spinal injury
Ensuring compatibility between defibrillators and associated defibrillator pads
Ensuring pregnant women with COVID-19 symptoms access appropriate care
Harm from catheterisation in patients with implanted artificial urinary sphincters
Central Manchester University Hospitals NHS Foundation Trust
Case study: Improving management of deteriorating acutely ill patients
Improve compliance with an Early Warning Score protocol
A flowchart for the escalation of deteriorating patients
Western Sussex NHS Foundation Trust
Case study: Using electronic bedside observation to target support to deteriorating patients and facilitate research and development of new triaging and scoring systems
University Hospitals Bristol NHS Foundation Trust
Case study: Empowering a clinical champion to ensure effective
Summary of findings and recommendations
People living in the poorest neighbourhoods in England will on average die seven years earlier than people living in the richest neighbourhoods.
People living in poorer areas not only die sooner, but spend more of their lives with disability – an average total difference of 17 years.
The Review highlights the social gradient of health inequalities - put simply, the lower one's social and economic status, the poorer one's health is likely to be.
Health inequalities arise from a complex interaction of many factors – housing, income,
The findings from this study, published in BMC Nursing show that advanced education and familiarity with current diabetes guidelines was related to adequate evaluations on essential areas of patient safety culture in nursing homes.
Key learning points
An abnormal antenatal cardiotocograph (CTG) may represent chronic fetal hypoxia.
Consideration should be given to the use of an antenatal CTG classification system (see example CTG sticker) and/or computerised cCTG.
Intrapartum CTG classification may not be appropriate in women who are not in established labour.
Where there are CTG concerns and fetal well-being cannot be further assessed, obtain senior review and consider expediting the birth.
Clear communication with the woman giving birth, birth partner(s) and maternity team is an essential
This editorial by Dr Michael Farquhar, published in Anaesthesia, explains the importance of taking breaks while on shift and ensuring a good sleep between shifts and the inextricable link between sleep and patient safety.
In this series of case studies, CQC highlight what providers have done to take a flexible approach to staffing. The case studies show different ways of organising services. They focus on the quality of care, patient safety, and efficiency, rather than just numbers and ratios of staff. They illustrate how providers have redesigned services to make the best use of the available range of skills and discipline or they found new ways to work with others in the local health and care system.
Safe, effective staffing is about having enough people with the right skills, in the right place, at the