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Found 132 results
  1. News Article
    The death of a premature baby in 2001 led to a "20-year cover-up" of mistakes by health workers, an independent inquiry has found. Elizabeth Dixon, from Hampshire, died due to a blocked breathing tube shortly before her first birthday. The government, which ordered the inquiry in 2017, said the mistakes in her care were "shocking and harrowing". The inquiry report by Dr Bill Kirkup said some of those involved had been "persistently dishonest". Elizabeth, known as Lizzie, died from asphyxiation after suffering a blockage in her tracheostomy tube while under the care of a private nursing agency at home. Dr Bill Kirkup, who was appointed by the government to review the case, said her "profound disability and death could have been avoided". He said: "There were failures of care by every organisation that looked after her, none of which was admitted at the time, nor properly investigated then or later." "Instead, a cover-up began on the day that she died, propped up by denial and deception." Read full story Source: BBC News, 26 November 2020 Patient Safety Learning's statement on the Dixon Inquiry report
  2. News Article
    An acute trust’s record of eight never events in the last six months has raised concerns that quality standards have slipped since it was taken out of special measures. The never events occurred at Royal Cornwall Hospitals Trust. They included three wrong site surgeries within the same speciality and an extremely rare incident in which a 30cm (15 inch) wire was left in a cardiology patient. Kate Shields, chief executive of the trust, said the incidents have led to a “great deal of soul searching”. Prior to the incidents the trust had gone 13 months without recording a never event, and Ms Shield acknowledged that pressure created by the pandemic was likely to have been a contributing factor behind the cluster of never events. She stressed that none of the patients affected had suffered physical harm. Read full story (paywalled) Source: HSJ, 12 November 2020
  3. Content Article
    According to the responses we received, the four themes that became most obvious - the four things you think staff most need to be safe - are: Compassionate leaders and role models who prioritise their staff’s wellbeing A respectful, supportive team with good communication and united by a common purpose A safe and just culture that invites staff to speak up Psychological safety, protecting staff form burnout
  4. Content Article
    This article from the Natasha Allergy Research Foundation (NARF) notes that the updated guidance came in response to the inquest into Shante Turay-Thomas, who died in north London just 18 years old, from anaphylaxis after eating hazelnut. The Coroner found that she had not been properly advised that the reason for carrying two AAIs was that in the event of a severe food allergy. A second dose of adrenaline can be a life preserving measure whilst waiting for emergency medical treatment. The coroner warned that action is needed to ensure that people with severe food allergies are aware that two AAIs must be carried at all times and they must be properly trained in how to use them. This would help to prevent further, avoidable deaths from severe food allergies. Follow the link below to read the full article from NARF. The full updated NICE guidance is also attached below.
  5. Content Article
    Summary of recommendations Taking the learning from good practice, the CQC want to see tangible progress on four key areas. Below is a summary of the CQC's recommendations. People with a learning disability and or autistic people who may also have a mental health condition should be supported to live in their communities. This means prompt diagnosis, local support services and effective crisis intervention.People who are being cared for in hospital in the meantime must receive high-quality, person-centred, specialised care in small units. This means the right staff who are trained to support their needs supporting them along a journey to leave hospital.There must be renewed attempts to reduce restrictive practice by all health and social care providers, commissioners and others. We have seen too many examples of inappropriate restrictions that could have been avoided. We know in absolute emergencies this may be necessary, but we want to be clear – it should not be seen as a way to care for someone.There must be increased oversight and accountability for people with a learning disability, and or autistic people who may also have a mental health problem. There must be a single point of accountability to oversee progress in this policy area.
  6. News Article
    A hospital that was at the centre of a major inquiry into unsafe maternity care five years ago is facing new questions over its safety after bosses admitted a baby boy would have survived if not for mistakes by hospital staff. Jenny Feasey, from Heysham in Lancashire, is still coming to terms with the loss of her son Toby who was stillborn at the Royal Lancaster Infirmary, part of the University Hospitals of Morecambe Bay Foundation Trust in January 2017 after a series of mistakes by staff who did not act on signs she had pre-eclampsia. Jenny, 33, has backed The Independent’s campaign for improved maternity safety and called on midwives to learn lessons after what happened to her family. She added: “This was an easily avoidable situation. They just didn’t piece it together, all they had to do was carry out a test and I lost my son because of it." Read full story Source: The Independent, 25 October 2020
  7. Content Article
    Seven features of safety in maternity units 1. Commitment to safety and improvement at all levels, with everyone involved 2. Technical competence, supported by formal training and informal learning 3. Teamwork, cooperation, and positive working relationships 4. Constant reinforcing of safe, ethical, and respectful behaviours 5. Multiple problem-sensing systems, used as basis of action 6. Systems and processes designed for safety, and regularly reviewed and optimised 7. Effective coordination and ability to mobilise quickly
  8. Content Article
    Follow the link below for more information and an illustrative example from the Royal College of Obstetricians and Gynaecologists.
  9. Content Article
    Key points This framework highlights the following five dimensions, which the authors believe should be included in any safety and monitoring approach in order to give a comprehensive and rounded picture of an organisation’s safety: Past harm: this encompasses both psychological and physical measures. Reliability: this is defined as ‘failure free operation over time’ and applies to measures of behaviour, processes and systems. Sensitivity to operations: the information and capacity to monitor safety on an hourly or daily basis. Anticipation and preparedness: the ability to anticipate, and be prepared for, problems. Integration and learning: the ability to respond to, and improve from, safety information.
  10. Content Article
    Key highlights Empirical description of safety case development at service level in healthcare. Safety cases can support adoption of proactive and rigorous safety management. Adaptation to purpose and use of safety cases might be required in healthcare. Education should be provided to practitioners and regulators.
  11. Content Article
    This leaflet includes patient information on: why is patient safety important how you can help your medicine recognising acute illness what happens if your Early Warning Score increases? what should relatives or friends do if they are worried that your health is worsening or not improving? blood clots safe surgery infections falls prevention advice preventing pressure ulcers.
  12. Content Article
    The report also confirms that the NHS serves as a ‘safety net’ for the private sector with around 6,000 people a year transferred to NHS hospitals following treatment in private hospitals. Read the press release and coverage on BBC News, the Telegraph and Health Service Journal Read a blog on patient safety from Peter Walsh Sources of further information on patient safety private hospitals Read a blog from Colin Leys exploring the issues in the report.
  13. Content Article
    2020 National Patient Safety Goals (NPSGs) for specific programmes include chapters on: ambulatory healthcare behavioural healthcare critical access hospital home care hospital laboratory nursing care centre office-based surgery.
  14. News Article
    Five years after launching a plan to improve treatment of black and minority ethnic staff, NHS England data shows their experiences have got worse. Almost a third of black and minority ethnic staff in the health service have been bullied, harassed or abused by their own colleagues in the past year, according to “shameful” new data. Minority ethnic staff in the NHS have reported a worsening experience as employees across four key areas, in a blow to bosses at NHS England, five years after they launched a drive to improve race equality. Critics warned the experiences reported by BME staff raised questions over whether the health service was “institutionally racist” as experts criticised the NHS “tick box” approach and “showy but pointless interventions”. Read full story Source: The Independent, 18 February 2020
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