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Found 206 results
  1. Content Article
    Let’s start with a story I was once told… There once was a very successful farmer who hired many people to work on his farm; at a glance, you could see countless heads of men and women tilling the ground. He grew very rich. The wealthier he became the more people he hired. His farmland kept increasing every year until it got to the boundary of a river. Although there were many workers, the farmer knew everyone by name and was able to account for them on a daily basis. However, over time, he noticed some workers who came to work could not be accounted for – they went missing. The farme
  2. Content Article
    The Coroner notes that, although he was assessed at home by the midwifery team at aged 5 days, no basic observation assessments were taken, such as temperature, heart rate and respiration rate, from the deceased or his mother to confirm their wellbeing. There is no national guidance for such checks, however, University Hospital Dorset NHS Foundation Trust (UHD) have since changed their local policies to embed better safety nets. The local policy now provides guidance that at each visit up to day 10 post birth, a full set of baby and maternal observations are to be taken. The Coroner also
  3. Content Article
    In the two weeks before his death Robbie was seen seven times by five different GPs. The child was seen by three different GPs four times in the last three days when he was so weak and dehydrated he was bedbound and unable to stand unassisted. Only one GP read the medical records, six days before death, and was aware of the suspicion of Addison's disease, the need for the ACTH test and the instruction to immediately admit the child back to hospital if he became unwell. The GP informed the Powells that he would refer Robbie back to hospital immediately that day but did not inform them that
  4. News Article
    Thousands of similar errors contributing to patient deaths are being repeated by hospitals despite warnings from coroners, according to new research. An analysis of four years of official reports by coroners, issued after the conclusion of inquests into patient deaths, has revealed the impact of the NHS struggling with a lack of resources and staff. Coroners found similar mistakes across hundreds of inquests. Professor Alison Leary, chair of healthcare a workforce modelling at London South Bank University, and who led the study, told The Independent: “We are missing opportunities to
  5. Content Article
    The aim of this study from Leary et al. was to examine the feasibility of extracting data from these reports and to evaluate if learning was possible from any common themes. In total 710 reports were examined, with 3469 concerns being raised. Thirty-six reports expressed concern about having to issue repeat PFDs to the same organisation for the same or similar concerns. Thematic analysis reliability was high (κ 0.89 unweighted) with five emerging primary themes: deficit in skill or knowledge, missed, delayed or uncoordinated care, communication and cultural issues, systems issues and lack
  6. Content Article
    It’s been a really difficult time for all of us this past year. When I say ‘we’, I mean every single person on the planet. I am yet to find anyone who hasn’t had to deal with stress, mental health problems, anxiety, illness, disappointment or bereavement of some nature over the past year. Collectively, we are all going to need a period to heal. I fear that the healthcare system will have no time to heal and that we are only on the tip of what more there is to come. Not only has the healthcare system had to deal with a pandemic, we have had to deal with the consequences from that. The
  7. Content Article
    HSIB's national learning reports can be used by healthcare leaders, policymakers, and the public to: Aid their knowledge of systemic patient safety risks. Understand the underlying contributing factors. Inform decision making to improve patient safety.
  8. Content Article
    Over the past twelve years, I have helped dozens of organisations in the NHS, higher education and in corporate contexts start using AAR to improve the quality of learning after events. Yet despite the proven value of AAR to patient safety and team performance,[1] AAR is still not making the impact it can and should. This short article explains some of the barriers to implementation that I have encountered during this time so that you can mitigate for them in your own context. In 2009, I joined a team at University College London Hospitals (UCLH) that had adapted the AAR concept from the
  9. Content Article
    Key points Learning from Excellence (LfE) is a system for capturing examples of good practice in healthcare as a complementary approach to traditional incident reporting. The LfE philosophy proposes that learning from what works well in a system enables improvements in the quality and safety of the work, and the morale of staff performing it. LfE systems comprise simple reporting forms for peer-to-peer positive feedback with sharing of examples to enable wider learning. LfE reporting identifies excellence and learning opportunities in both process and outcome.
  10. Content Article
    Healthcare is inherently a messy business. It is complex and filled with hazards. If I asked you to list the things that could potentially go wrong, I suspect you would be there for a while... So, how do you even begin to bring some consistency and safety into a system such as healthcare? How do you ‘head off’ incidents at ‘the pass’ before they occur? My experience of healthcare in the last 30 years, and of investigating complaints, incidents and errors in the last 10 years, is that we often immediately check if the appropriate policy has been followed. The ‘horror of horrors’
  11. Content Article
    The CQC strategy is built on four themes that together determine the changes they want to make. Running through each theme is CQC's ambition to improve people’s care by looking at how well health and care systems are working and how they’re acting to reduce inequalities. It is not enough to look at how one service operates in isolation. It is how services work together that has a real impact on people’s experiences and outcomes. The four themes in our draft strategy are: People and communities: CQC want their regulations to be driven by people’s experiences and what they expect and
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