Findings of this investigation included:
There is limited standardisation of handovers, ward rounds (visits to each patient in a ward to review and discuss their care) and huddles (short, focused staff briefings), in terms of which members of the multidisciplinary team are involved, and how they are conducted for maximum effectiveness.
Processes for the checking of medicines varied without evidence of what constituted the most effective process.
The environments within which staff prepared and checked medicines influenced their performance.
There are no s
I love and support the NHS. But when things go wrong for patients and service users, the system is often too slow to change or respond effectively.
I have been through complaints, the Ombudsman and Inquest processes around the poor end of life care of my late mother. Those processes took years and were almost as stressful as those last few days of my mother’s life. I would not do it again. At the time, I reported the incident in detail to the CQC (inspectors), to the CCG (commissioners), to Healthwatch (local and national), but I noted no evidence of change. In fact, the CQC continued for
The Eastern Mediterranean/African Adverse Events Study is a large scale study carried out in six Eastern Mediterranean and two African countries, to assess the number and types of incidents that can occur in their hospitals and harm patients.
To carry out this study, a collaborative model was established in which 26 hospitals from eight countries, Egypt, Jordan, Kenya, Morocco, South Africa, Sudan, Tunisia and Yemen participated.
This document contains the main findings of the Eastern Mediterranean/African Study. It presents some of the risks associated with harm in the participating
This is an independent review of the SLS:
1. To consider recommendations made by the State Coroner and by independent reviews conducted in response to the Chemotherapy Underdosing that relate to incident reporting and management.
2. To determine and describe how the SLS is used across SA Health for patient incident reporting and management including:
a. adoption and uptake;
b. data extraction;
d. incident management; and
e. open disclosure to patients and feedback to staff.
3. To identify factors that are impeding or may impede the use of S
The majority of studies typically classify patient harm as preventable if it occurs as a result of an identifiable modifiable cause and its future recurrence can be avoided by reasonable adaptation to a process or adherence to guidelines.
At least 6% of patients experienced preventable harm across the healthcare service.
13% of the identified preventable harm causes prolonged or permanent disability or leads to death.
The main types of patient safety incidents which contribute to preventable harm are medication incidents, diagnostic incidents and incidents
The new research maps the provision of safer custody telephone lines across the prison estate - dedicated phone lines which enable family members and others to pass on urgent information when they have concerns.
It finds that provision is patchy, under-resourced and even non-existent in some prisons, leaving families struggling to share their concerns with prison staff. The report reveals that:
Almost two in five (37%) prisons in England and Wales appeared to have no functioning dedicated safer custody telephone lines for families to get in touch.
Of these, nearly one in five
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.
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