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Found 36 results
  1. Content Article
    Case submission 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, de
  2. Content Article
    In this study, Kim et al. analysed 1,189 patient safety event reports using a safety science and resilience engineering approach, which focuses on identifying processes to discover errors before they reach the patient so these processes can be expanded. They analysed the general care processes in which wrong-patient errors occurred, the clinical process step during which the error occurred and was discovered, and whether the error reached the patient. For those errors that reached the patient, they analysed the impact on the patient, and for those that did not reach the patient, we analysed ho
  3. News Article
    Trusts are carrying out harm reviews after a ‘contamination issue’ affecting hundreds of samples resulted in some staff and patients being wrongly told they had coronavirus, HSJ can reveal. The error happened in mid-October and involved swabs from five trusts in the South East region, which were being processed by the NHS-run Berkshire and Surrey Pathology Services. HSJ understands it is thought that around 100 people across several trusts were given false positive results, and subsequently tested negative. The trusts involved are the Royal Surrey Foundation Trust, Frimley Healt
  4. News Article
    In ‘Invisible Women: Exposing Data Bias in a World Designed For Men’ author Caroline Criado Perez writes about Rachael, a woman who suffered years of severe and incapacitating pain during her period. It takes, on average, eight years for women in the UK to obtain a diagnoses of endometriosis. In fact, for over a decade, there has been no improvement in diagnostic times for women living with the debilitating condition. You might think, given the difficulty so many women experience in having their symptoms translated into a diagnosis, that endometriosis is a rare condition that doctors per
  5. Content Article
    Thomas L. Rodziewicz and John E. Hipskind explore medical error prevention in their book and conclude that: All providers (nurses, pharmacists, and physicians) must accept the inherent issues in their roles as healthcare workers that contribute to error-prone environments. Effective communication related to medical errors may foster autonomy and ultimately improve patient safety. Error reporting better serves patients and providers by mitigating their effects. Even the best clinicians make mistakes, and every practitioner should be encouraged to provide peer support to
  6. Content Article
    Take-home points Patient-related factors, cognitive errors, and systems factors are common categories of diagnostic errors, all three of which played a role in the failure to recognize that the patient in this case was in her third trimester of pregnancy and in early labor Communication among members of work teams is critical for avoiding perpetuation of cognitive errors Appropriate supervision of physician trainees is necessary to ensure high-quality patient care Diagnostic errors in the use obstetrical ultrasound can result from inadequate training and experience, and
  7. News Article
    Hospital trust ‘truly sorry that mistakes were made in care’ of Luchii Gavrilescu, who died after being sent home from hospital with undiagnosed tuberculosis. An NHS trust investigated over maternity care failings has apologised after a six-week-old child was found to have died due to mistakes at one of its hospitals. East Kent Hospitals University Trust was embroiled in a major scandal after The Independent revealed the trust had seen more than 130 babies over a four-year period suffer brain damage as a result of being starved of oxygen during birth. A report into the trust conclude
  8. Content Article
    The 6 factors: Incomplete communication during care transitions Lack of measures and feedback Limited support to help with clinical reasoning Limited time The diagnostic process is complicated Lack of funding for research
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