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Found 187 results
  1. Content Article
    ‘Work as done’ Because healthcare is constantly evolving and complex, by looking more closely at everyday work and finding out what actually happens, it allows an understanding of what it is, that frontline clinicians do to ensure successful outcomes. This is termed as looking at 'work as done' and informs us about the nuances, the adjustments, the compromises, the workarounds, the actions and the decision making that is taken to meet the needs of the patients they are caring for. ‘Work as done’ is a combination of expertise, clinical decisions, experience and tacit knowledge. It is
  2. 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
  3. Content Article
    Background In 2018, SIM was selected for national scaling and spread across the Academic Health Science Networks (AHSNs). The High Intensity Network (HIN) has been working with the three south London Secondary Mental Health Trusts: The South London and Maudsley NHS Foundation Trust, Oxleas NHS Foundation Trust and South West London and St George’s Mental Health NHS Trust, and the Metropolitan Police, London Ambulance Service, A&E, CCG commissioners, and the innovator and Network Director of the High Intensity Network. The model can be summarised as: A more integrated, infor
  4. Content Article
    Stuck in a lift This series of blogs has been characterised by writers of great wit and wisdom, with references to Socrates, Oscar Wilde and more. As the latest incumbent, I feel a great trust has been placed upon me to maintain the standard. That I plan to completely abuse by telling you about the time I was stuck in a lift in my underpants. For the sake of probity, I should point out that they were highly respectable underpants. The sort of multi-purpose item that is sold in high-end camping shops as suitable for underwear/swimming/signal flags. That information is entirely irreleva
  5. Event
    Dr Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, is joined by Thankam Gomez, Founder & CEO, Cygnia Healthcare, Mark Graban, Author of "Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement”, Management Consultant, Coach, Professional Speaker, Podcaster, Senior Advisor to KaiNexus, and Beth Beswick, Retired Vice President, Human Resources, Carteret Healthcare to discuss the background of accountability in healthcare, the history of healthcare culture, and the current organisational barriers to implementing an environment of shared lear
  6. News Article
    Hospitals and care homes are failing to properly investigate incidents before referring nurses to their regulator, fuelling a blame culture and repeat failures, the head of the nursing watchdog has told The Independent. In her first national interview, Andrea Sutcliffe, head of the Nursing and Midwifery Council (NMC) said some employers were referring nurses without any investigation at all, while half of initial enquiries to the NMC were rejected or required further work. She told The Independent this emphasis on blaming the individual meant underlying causes of safety errors were b
  7. Content Article
    In the early days of my career, I worked with clinical teams while managing a hospital and later a network of hospitals. I must say, the experience I gathered in these different roles shaped me into what I am today. I can fit into healthcare conversations easily because of these early relationships and interactions with clinical experts. When I look back to my experience as a hospital administrator, a particular incident keeps coming back to mind; I sometimes link this to my later involvement in patient safety but most times I feel it is my conscience speaking to me. There was a patient w
  8. News Article
    The family of a man who bled to death during kidney dialysis treatment at Royal Shrewsbury Hospital have said they believe lessons have been learned. Mohammed Ismael Zaman, known as Bolly, died after hospital staff failed to check the connection on his dialysis machine, despite it sounding an alarm after the catheter had become disconnected. During Mr Zaman’s treatment at the Royal Shrewsbury Hospital on October 18, 2019, his dialysis machine set off a venous pressure alarm. An unidentified member of staff reset the alarm without checking that the connection was still secure. As
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