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Found 113 results
  1. Content Article
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    In this blog Helen discusses how Patient Safety Learning is working with Tim Edwards to raise awareness of the findings of his report, and its associated nine calls for action, to help improve pulmonary embolism outcomes. Read the full blog on the National Voices website. Related reading Independent review of pulmonary embolism fatalities in England & Wales – recent trends, excess deaths, their causes and risk management concerns (December 2022, Tim Edwards) Jenny, and why we must learn from her misdiagnosis of pulmonary embolism Pulmonary embolism misdiagnosis
  4. Content Article
    A systemic problem Pulmonary embolism misdiagnosis unfortunately appears a systemic issue to our nation. The recent Healthcare Safety Investigation Branch (HSIB) report [1] details that clinical best practice for pulmonary embolism diagnosis is out of step with European standards [2] and, alarmingly, is often not being followed. A Royal College of Radiologists briefing [3] indicates there is a lack of available scanning equipment required to assess the extent of blood clots, in a safe fashion. The NHS’ own Getting it Right First Time (GIRFT) initiative [4]– aimed at reducing variatio
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    As many as 250,000 people die every year because they are misdiagnosed in the emergency room, with doctors failing to identify serious medical conditions like stroke, sepsis and pneumonia, according to a new analysis from the US federal government. The study by the Agency for Healthcare Research and Quality estimates roughly 7.4 million people are inaccurately diagnosed of the 130 million annual visits to hospital emergency departments in the United States. Some 370,000 patients may suffer serious harm as a result. Researchers from Johns Hopkins University analysed data from two deca
  8. Content Article
    Although estimated ED error rates are low (and comparable to those found in other clinical settings), the number of patients potentially impacted is large. Not all diagnostic errors or harms are preventable, but wide variability in diagnostic error rates across diseases, symptoms, and hospitals suggests improvement is possible. With 130 million U.S. ED visits, estimated rates for diagnostic error (5.7%), misdiagnosis-related harms (2.0%), and serious misdiagnosis-related harms (0.3%) could translate to more than 7 million errors, 2.5 million harms, and 350,000 patients suffering potentially pr
  9. News Article
    The family of a boy who died of an invasive form of strep A have said they sought medical help three times before he was admitted to hospital. Jax Albert Jefferys, who attended Morelands Primary School in Waterlooville, Hampshire, died on 1 December, aged five. His family said they were initially told he had flu. Since September, UK Health Security Agency figures show 15 UK children have died after invasive strep A infections. Paying tribute to their "darling son", Jax's family said they had sought medical advice on three occasions during the four days leading up to his dea
  10. Content Article
    Jenny, my mother Jenny was a much-admired mother, grandmother and friend. She had a strong determination and an uplifting zest for life; she was loyal and we, her family, miss her. Her passions were many, from her love of travel to places of geographic interest, to line-dancing and amassing a curious Tupperware collection. Jenny attended university in the 1960s, a time when women from her background were discouraged from attending further education. Having graduated, Jenny then worked for British Leyland and later moved to Germany with my father where she taught English. During which
  11. Content Article
    Key findings from the report: There were 400 excess deaths attributable to pulmonary embolism misdiagnosis from March 2021 to April 2022 in England and Wales. In parts of England and Wales the number of deaths due to pulmonary embolism were almost 3 times the national average. The clinical guidelines and diagnostic processes used in England and Wales are out of step with our European counterparts and, in Jenny’s case, were not used correctly. Clinical teams too often lack the training, expertise and/or equipment to deliver safe and effective pulmonary embolism care.
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    Safety observation It may be beneficial for NHS care providers to explore options for the translation of written appointment communications, including pre-attendance guidance, for patients whose preferred written language is not English.
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    National investigation findings In March 2020, demand on the NHS 111 system increased. Demand exceeded the system’s capacity, and around half of calls were answered at that time. Evidence from families indicated that aspects of NHS 111 telephone triage, such as routing all Covid-19-related calls to the Covid-19 Response Service (CRS), did not function as intended. Strong national messaging advised people with suspected Covid-19 to stay at home. This may have impacted on patients’ willingness to seek medical advice from elsewhere, even if their condition deteriorated. T
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    The Measure Dx Guide is organised into four sections that outline a series of steps to begin and sustain measurement of diagnostic safety: Part I outlines ways to engage people in the organisation to ensure adequate resources to implement measurement and learning activities. Part II contains a self-assessment checklist to gauge readiness for implementation, as well as guidance for choosing a measurement strategy that fits with your organisation's resources. Part III describes four different strategies (systematic approaches to measurement) based on different types of data s
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  25. News Article
    The Leapfrog Group will add a section to its annual survey in 2024 asking US hospitals to report their progress on evidence-based practices designed to prevent and reduce patient injury and death from diagnostic error and delay. This Autumn, Leapfrog will pilot test survey questions about a range of diagnostic practices from holding leaders accountable for diagnostic safety to openly communicating diagnostic errors to patients and optimising electronic records to support accurate and timely diagnosis. Results of the Leapfrog Hospital Survey — completed voluntarily each year by more t
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