Jump to content

Search the hub

Showing results for tags 'Omissions'.


More search options

  • Search By Tags

    Start to type the tag you want to use, then select from the list.

  • Search By Author

Content Type


Forums

  • All
    • Commissioning, service provision and innovation in health and care
    • Coronavirus (COVID-19)
    • Culture
    • Improving patient safety
    • Investigations, risk management and legal issues
    • Leadership for patient safety
    • Organisations linked to patient safety (UK and beyond)
    • Patient engagement
    • Patient safety in health and care
    • Patient Safety Learning
    • Professionalising patient safety
    • Research, data and insight
    • Miscellaneous

Categories

  • Commissioning, service provision and innovation in health and care
    • Commissioning and funding patient safety
    • Digital health and care service provision
    • Health records and plans
    • Innovation programmes in health and care
  • Coronavirus (COVID-19)
    • Blogs
    • Data, research and statistics
    • Frontline insights during the pandemic
    • Good practice and useful resources
    • Guidance
    • Mental health
    • Exit strategies
    • Patient recovery
  • Culture
    • Bullying and fear
    • Good practice
    • Occupational health and safety
    • Safety culture programmes
    • Second victim
    • Speak Up Guardians
    • Staff safety
    • Whistle blowing
  • Improving patient safety
    • Clinical governance and audits
    • Design for safety
    • Disasters averted/near misses
    • Equipment and facilities
    • Error traps
    • Health inequalities
    • Human factors (improving human performance in care delivery)
    • Improving systems of care
    • Implementation of improvements
    • International development and humanitarian
    • Safety stories
    • Stories from the front line
    • Workforce and resources
  • Investigations, risk management and legal issues
    • Investigations and complaints
    • Risk management and legal issues
  • Leadership for patient safety
    • Business case for patient safety
    • Boards
    • Clinical leadership
    • Exec teams
    • Inquiries
    • International reports
    • National/Governmental
    • Quality and safety reports
    • Techniques
    • Other
  • Organisations linked to patient safety (UK and beyond)
    • Government and ALB direction and guidance
    • International patient safety
    • Regulators and their regulations
  • Patient engagement
    • Consent and privacy
    • Harmed care patient pathways/post-incident pathways
    • How to engage for patient safety
    • Keeping patients safe
    • Patient-centred care
    • Patient stories
  • Patient safety in health and care
    • Care settings
    • Conditions
    • Diagnosis
    • High risk areas
    • Learning disabilities
    • Medication
    • Mental health
    • Men's health
    • Patient management
    • Social care
    • Transitions of care
    • Women's health
  • Patient Safety Learning
    • Patient Safety Learning campaigns
    • Patient Safety Learning documents
    • Patient Safety Learning news archive
    • 2-minute Tuesdays
    • Patient Safety Learning Annual Conference 2019
    • Patient Safety Learning Annual Conference 2018
    • Patient Safety Learning Awards 2019
    • Patient Safety Learning Interviews
    • Patient Safety Learning webinars
  • Professionalising patient safety
    • Accreditation for patient safety
    • Competency framework
    • Medical students
    • Patient safety standards
    • Training
  • Research, data and insight
    • Data and insight
    • Research
  • Miscellaneous
    • Health care
    • Social care
    • Jobs and voluntary positions
    • Suggested resources

News

  • News

Find results in...

Find results that contain...


Date Created

  • Start
    End

Last updated

  • Start
    End

Filter by number of...

Joined

  • Start

    End


Group


First name


Last name


Country


Join a private group (if appropriate)


About me


Organisation


Role

Found 20 results
  1. Community Post
    What is your experience of having a hysterscopy? We would like to hear - good or bad so that we can help campaign for safer, harm free care. You can read Patient Safety Learning's blog about improving hysteroscopy safety here. You'll need to be a hub member to comment below, it's quick and easy to do. You can sign up here.
  2. Content Article
    Social normalisation of deviance means that people within the organisation become so much accustomed to a deviant behaviour that they don’t consider it as deviant, despite the fact they exceed their own rules for the elementary safety. People grow more accustomed to the deviant behaviour the more it occurs . To people outside of the organisation, the activities seem deviant; however, people within the organisation do not recognise the deviance because it is seen as a normal occurrence. In hindsight, people within the organisation realise that their seemingly normal behaviour was deviant.
  3. Content Article
    The PSHO found that the Trust failed to: act on the results of the ECG and chest X-ray consider Baby K’s history and symptoms ask for input from specialist staff escalate his care when his condition was getting worse. If these failings had not occurred, it is likely that the Trust would have recognised that Baby K had a problem with his heart. In these circumstances he would have received the correct treatment instead of being treated for suspected pneumonia. The PSHO found that on the balance of probabilities, his cardiac arrest would not have occurred and it is mo
  4. Content Article
    To use the tool, you just need to enter your height and weight into the online calculator, along with your height and weight 3-6 months ago. You will be given a rating that will tell you if you are at high, medium or low risk of malnutrition. You will then be able to download a dietary advice sheet that gives basic information and suggestions for improving nutritional intake. If you are worried about your weight or having difficulty eating, make sure you talk to your GP or a healthcare professional. The dietary advice sheet was developed in partnership with a number of professional o
  5. Content Article
    I believe all clinicians should read this latest report. There is so much to be learned and so many changes in clinical practice that can be made right away. Since 2018, I have been teaching using Oliver's tragic story to promote reflection on best practice in prescribing and in implementing the Mental Capacity Act. I could write a lot here; however, I believe this is a report all clinicians, and especially all prescribers, need to read in full. A summary of how I see this (or indeed how any individual sees it) it will not be adequate.
  6. Content Article
    My much loved daughter-in-law, Mariana Pinto, died on 16 October 2016. She was 32. Her tragic and unexpected death raised many questions for us about standard practice by psychiatric services and about patient safety. The evening before she died, Mariana was taken by ambulance to her local A&E department, escorted by four police officers, and handcuffed for her own safety. She was psychotic – delusional, paranoid, violent and very distressed. She had attacked her husband (my son) who had visible bite marks, scratches and bruises. It was a first episode and totally out of character.
  7. News Article
    Shrewsbury and Telford hospital NHS trust has uncovered dozens of avoidable deaths and more than 50 babies suffering permanent brain damage over the past 40 years. But how many more babies must die before NHS leaders finally tackle unsafe, disrespectful, life-wrecking services? The NHS’s worst maternity scandal raises fundamental questions about the culture and safety of our health service. Too many hospital boards complacently believe “it couldn’t happen here”. Instead of constantly testing the quality and reliability of their services, they look for evidence of success while explaining
  8. Content Article
    This regulation 28 is around testing of patient call bells in care homes. Questions: Have you got a system for checking call bells where you work? Are the call bells always in reach of the patient?
  9. Content Article
    This Inquiry examines the involvement of numerous agencies with the events at the Mid Staffordshire NHS Foundation Trust within a defined period: January 2005 to March 2009. This is the executive summary which includes 290 themed recommendations.
  10. Content Article
    In a blog in the Patient Safety Movement newsletter, James Titcombe talks about his son's death and how speaking out can save lives.
  11. Content Article
    The study used quality improvement methods to develop and test interventions to extend drinking opportunities and choice in two care homes. Initial activity included observation of the systems for delivering fluids and involving staff, residents and carers in describing and mapping the organisation of care. An interactive training programme was indicated by staff as an important priority and was therefore introduced as a first step to improve hydration care. Subsequent interventions were co-designed with care staff and tested using Plan Do Study Act (PDSA) cycles. Their efficacy was measu
  12. Content Article

    Walk on by...

    Anonymous
    It's midnight on the acute floor, just before Christmas. As I walk through the Emergency Department (ED), I can hear the ambulances reverse up to the door, people shouting, doors opening and closing, phones ringing and the general white noise of the department. You wouldn’t know it was night-time at all, the lights are beaming and it's as noisy now as it is in the day. I am a junior doctor. I’m on my fourth night shift of six. I have a patient on the acute medical admission unit that I need to check up on. I take the opportunity to seek some darkness and quiet away from the hustle and bus
  13. Content Article
    Key learning points Two approaches to the problem of human fallibility exist: the person and the system approaches. The person approach focuses on the errors of individuals, blaming them for forgetfulness, inattention, or moral weakness. The system approach concentrates on the conditions under which individuals work and tries to build defences to avert errors or mitigate their effects. High reliability organisations—which have less than their fair share of accidents—recognise that human variability is a force to harness in averting errors, but they work hard to focus that v
×