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Found 281 results
  1. News Article
    Some acute trusts have failed to report large numbers of hospital-acquired covid infections as patient safety incidents, despite NHS England describing this as ‘fundamental’. HSJ examined the numbers of “infection control” patient safety incidents reported to the national reporting and learning system in 2020-21, and compared this to separate NHS England data on covid infections most likely to have been acquired in hospital. The number of incidents reported to the NRLS in the 12-month period should in theory be higher, as it covers all types of hospital-acquired infections, while th
  2. Content Article
    Structured judgement review blends opinion-based review methods with a standard format that involves staff: making safety and quality judgements over phases of care making explicit written comments about care scoring care in each phase. This provides a rich set of information about each case in a form that can also be aggregated to produce knowledge about clinical services and systems of care. The purpose of the review process is not to point to individuals, but to ask questions about the system in which people work, both when care goes well and when it is unsati
  3. Event
    until
    The duty of candour is a central to patient safety – the idea that, when things go wrong, healthcare professionals should be open and honest about this with patients and colleagues. But while incident reporting is a central plank to patient safety, the evidence still suggests that adverse outcomes and near misses are under-reported. This even before the challenges of the pandemic – which has left staff understandably exhausted, overstretched and under pressure – is taken into account. So how, in an environment as challenging as the service currently finds itself in, can candour in he
  4. News Article
    A care home in Birmingham has been heavily criticised by the care watchdog after it found physical and verbal abuse of residents with learning disabilities and autism had become “normal”. The Care Quality Commission (CQC) said it had put urgent restrictions on Summerfield House, in Birmingham, to stop any more people being admitted there. The home was looking after four residents with disabilities in August when CQC inspectors found a string of concerns. Records revealed episodes of physical, verbal and emotional abuse of the residents with staff making threats to cancel activities o
  5. News Article
    The backlog of serious clinical incidents that need investigating is building up throughout the NHS, due to the impact of coronavirus and emergency service pressures. Concerns have been raised by commissioners in some areas over the delays. Meanwhile, patients and families who have been harmed are waiting longer to see their cases resolved and the organisations involved are not learning the lessons taught by care failures as quickly as they should. Staff redeployment or absences due to COVID-19 are among the reasons why many investigations are being delayed. As result, trusts are at
  6. Content Article
    Nursing Matters: Patient safety – learning from our mistakes on Apple Podcasts Patient safety – learning from our mistakes - Nursing Matters | Podcast on Spotify
  7. News Article
    A mental health hospital in Suffolk has been closed after inspectors found it was failing to protect patients from harm and abuse. St John's House in Palgrave, near Diss, was previously rated inadequate by the Care Quality Commission (CQC). A further inspection of the 49-bed hospital found the care was "unacceptable" and "insufficient progress had been made regarding patient safety". The company that runs the hospital, Partnerships in Care, part of the Priory Group, has now decided to close the site. Stuart Dunn, CQC head of inspection for mental health and community services, s
  8. News Article
    Young people cared for by an NHS mental health service "came to harm" because of its failings, inspectors said. The care provided by Essex Partnership University NHS Foundation Trust (EPUT) has been rated "inadequate" by the Care Quality Commission (CQC). It has now been stopped from admitting new patients after inspectors found "serious concerns" in the children and adolescent mental health services. EPUT said it had increased staffing levels and had been coaching staff. The inspection was prompted by a serious incident and concerning information received about safety and quali
  9. Content Article
    The analysis used a robust, scientific approach and identified the following three recurring patient safety themes: access to care and transitions of care (when patients move between care providers or care settings) communication and decision making checking at the point of care. These three themes represent the most significant threats to patient safety that HSIB has found, based on its investigations, so far. This analysis also looked at the 85 safety recommendations made in the 22 investigations. These safety recommendations were grouped into one or more of si
  10. News Article
    Doctors at a hospital in Birmingham mistakenly terminated a healthy unborn baby in a procedure instead of its sickly twin. The unidentified mother decided to abort one of the fetuses because it was suffering from restrictive growth, which increases the chances of stillbirth and puts the healthy baby at risk. During the procedure at Birmingham Women's and Children's NHS Foundation, surgeons accidentally terminated the wrong twin. The 2019 incident emerged in a Freedom of Information Act survey of hospital blunders. Dr Fiona Reynolds, chief medical officer at Birmingham Women's an
  11. Content Article
    "Several concerns have been raised about the risk of overdose and death from oral morphine sulphate solution over the past few years, but they have gone unheard." In light of coroners reports of deaths related to abuse, or accidental overuse of Oramorph or oral morphine sulphate solution. the author argues for increased regulation. Commenting: "In the absence of any action from ministers, it seems that healthcare professionals are going to have to take the care of vulnerable patients into their own hands." My reflections on this are: Is this a signal for increased regulation or
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