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Found 132 results
  1. Content Article
  2. Content Article
  3. 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
  4. 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 even
  5. 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
  6. 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 t
  7. 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 campaig
  8. 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
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    Follow the link below for more information and an illustrative example from the Royal College of Obstetricians and Gynaecologists.
  11. 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 abi
  12. Content Article
  13. 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.
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    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.
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    The aim of this study, published in Human Factors journal, was to examine the effects of interruptions and retention interval on prospective memory for deferred tasks in simulated air traffic control. This can be translated into a healthcare environment.
  23. Content Article
    Difficult to know where to start with this blog. Like the rest of the world, I’m anxious. We don’t know what is happening, we have not experienced anything like this before. When COVID-19 first arrived in late February (it felt like it snuck up on us, but I’m not sure that is the case), there was talk about some people having to work from home. This really suited me as I could easily do this in my role at Patient Safety Learning and it would mean I would be around more for my two boys. My boys are 12 and 14. Trying to parent boys of this age I find challenging at present. They
  24. Content Article
    Key findings 59.7% think their organisation treats staff who are involved in an error, near miss or incident fairly. This is a 1 percentage point improvement since 2018 (58.3%) and continues a positive trend since 2015 (52.2%). 71.1% think their organisation takes action to ensure that reported errors, near misses or incidents do not happen again. 73.8 think their organisation acts on concerns raised by patients / service users (2018: 73.4%). 61.1% gives them feedback about changes made in response to reported errors, near misses and incidents (q17d) This is a 1 perce
  25. Content Article
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