Rocco Friebel and Laia Maynou examined the prevalence of five avoidable in-hospital patient safety incidents (adverse drug reactions, hospital-acquired infections, pressure ulcers, postoperative pulmonary embolism or deep vein thrombosis, and postoperative sepsis) for four developmental disability groups (people with intellectual disability, chromosomal abnormalities, pervasive developmental disorders, and congenital malformation syndrome) in the NHS during the period April 2017–March 2019.
The authors found that the likelihood of experiencing harm in disability groups was up to 2.7-fold
This guideline written by Mid and South Essex Hospitals is designed to help maternity staff to identify, counsel and put the women who need antenatal and postpartum thromboprophylaxis on the correct pathway of care.
The NICE 2010 guidance (CG92) requires that all adult hospital inpatients undergo a VTE risk assessment (RA) using a standardised national VTE RA template – upon admission, again 48 hours later, and whenever the patient’s clinical condition changes.
Based on the national template, clinicians at Colchester Hospital University NHS Foundation Trust (CHUFT) pioneered an electronic VTE RA tool that enables the assessment to be completed in 30 seconds. This tool has the added benefits of calculating the risk of VTE and recommending appropriate prophylaxis using a pharmacological and/or mechanic
In her report, the coroner highlights two matters of concern in this case:
Initial delay in seeing a doctor
Mr Collinson was not seen by a Doctor until eight hours after he arrived at hospital. The reason given for this was that the department was highly pressured on this date, and although a junior doctor had assigned the case to them by "clicking", that doctor had not in fact been able to see Mr Collinson. He did not "unclick" the patient and therefore other doctors who may have had capacity were not aware that Mr Collinson had not been seen.
The coroner expressed concerns that
HSIB makes the following safety recommendation:
It is recommended that the Intercollegiate Stroke Working Party with support from the Joint Stroke Medicine Committee and NHS England and NHS Improvement develop a stroke specific venous thromboembolism (VTE) assessment tool and system for ordering the associated treatment for patients who have suffered a stroke. HSIB recommend that the Intercollegiate Stroke Working Party supports development of a tool that ensures that important information is recorded and reviewed at appropriate
intervals. The following points should be considered in