Clinical risk最新文献

{"title":"Delayed diagnosis of appendicitis not negligent","authors":"J. Mead","doi":"10.1177/1356262215575955b","DOIUrl":"https://doi.org/10.1177/1356262215575955b","url":null,"abstract":"fact that the trust admitted various breaches of duty meant that it was on the back foot in this action, but its expert evidence was to the effect that even with an appropriate level of care, the patient would have died anyway. The judge was persuaded that the fact that Mrs Gardner survived three heart attacks between 10:22 and 11:02 meant that she would on the balance of probabilities have remained alive had timely action been taken by trust clinicians. However, even if that had happened, she would have been seriously disabled by amputations and therefore the ‘‘best’’ outcome for her would have been a life of serious disability.","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"1 1","pages":"132 - 133"},"PeriodicalIF":0.0,"publicationDate":"2014-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262215575955b","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65477153","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Time to revisit root cause?","authors":"H. Merrett","doi":"10.1177/1356262215574654","DOIUrl":"https://doi.org/10.1177/1356262215574654","url":null,"abstract":"It seems highly likely that the new ‘‘Zero Harm’’ bill will be pushed through parliament and become law in due course. This bill puts an obligation on the health secretary ‘‘to secure that services provided in the carrying on of regulated activities cause no avoidable harm’’. The Health and Social Care (Safety and Quality) Bill is a private members bill and is one of the many sequelae of the response to the inquiry into events at Mid Staffordshire Foundation NHS Trust. Clinical Risk will return to this topic in more detail in a later issue. If the bill becomes law, the regulator (i.e. the Care Quality Commission) will be responsible for ensuring compliance. So what does compliance mean? What is ‘‘avoidable harm’’? This question has been addressed by numerous patient safety experts and Department of Health initiatives and, of course, in the legal context as well. The studies into iatrogenic harm have shown fairly consistently that about 50% of adverse events can be considered preventable, in the sense that the provision of care according to accepted standards of practice would have prevented the event. The approach the CQC would take to fulfilling this new role will be important. One would expect organisations to have to demonstrate a range of activity addressing harm, from both proactive and retrospective points of view. Application of approaches such as the Global Trigger Tool and Root Cause Analysis of incidents would normally be regarded as an example of a positive safety culture. These look retrospectively at care and harm, informing the organisation about the effectiveness of safe practice and indicating where further action might be necessary. If the CQC were to take on a role in determining whether harm caused by serious incidents were avoidable or not, some interesting challenges emerge. One of the fundamental tenets of investigation practice is that there is unlikely to be one single root cause for serious incidents and harm. There may be an unsafe act or omission which directly caused harm (e.g. administration of wrong drug) but behind this act will be a range of contributing factors. The value of systematic investigation techniques is to identify these underlying issues and address them, rather than the unsafe act itself – i.e. the symptom. We have considerable knowledge about the reasons why and when agreed standards of safe practice are not maintained; where systems become less reliable and failures more likely. It is to be hoped that implementation of the Bill’s duties involves looking at how providers respond to their known weaknesses and underlying themes. This in itself is a key element of the process of good governance, already included in CQC and Monitor inspection regimes Anecdotally, however, there is still an expectation at senior level in some organisations that investigations must identify a single cause or – even less palatably – a single individual, to blame for events. Early reports before the publication of Sir Robert ","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"20 1","pages":"127 - 127"},"PeriodicalIF":0.0,"publicationDate":"2014-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262215574654","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65476806","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Francis’s “Freedom to Speak Up” review: An openness and transparency revolution or just another report?","authors":"P. Walsh","doi":"10.1177/1356262215575958","DOIUrl":"https://doi.org/10.1177/1356262215575958","url":null,"abstract":"","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"20 1","pages":"128 - 128"},"PeriodicalIF":0.0,"publicationDate":"2014-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262215575958","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65477164","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Obstetrics – Fourth degree tear not negligent","authors":"J. Mead","doi":"10.1177/1356262215575955","DOIUrl":"https://doi.org/10.1177/1356262215575955","url":null,"abstract":"The Claimant went into labour during the afternoon of 6 March 2007 and labour progressed steadily. By 03:00 on 7 March, the midwife noted foetal heart decelerations and called for a medical opinion. A registrar, Dr Gauthaman, attended at 03:15. She noted that the patient was fully dilated and asked her to push. After half an hour there was little progress and Dr Gauthaman therefore decided that an instrumental delivery using Neville Barnes forceps was necessary. Forceps were first applied at 03:58 and William was born at 04:01. Two pulls were used. It was the registrar’s intention to perform an episiotomy before delivery of the head. The first pull brought the baby’s head close to the vaginal entrance, and following another contraction Dr Gauthaman pulled the head to the entrance so that it was resting on the perineum. The registrar intended at this point to make the episiotomy cut and reached for her scissors. However, there was then an unexpected further contraction which pushed the baby’s head through the perineum and caused the tear. The hospital’s guidelines at the time required an episiotomy with a forceps delivery. They stated: ‘‘Episiotomy is to be performed as head is brought down to perineum’’. There was a dispute between the expert obstetricians as to precisely what those words meant. Mr Jarvis, for the Claimant, said they indicated that the episiotomy should be undertaken before the head reached the perineum. He considered that this was good professional practice because to wait until the head is on the perineum risks an unexpected rapid delivery, as indeed happened in this case. The trust’s expert, Dr Erskine, considered that the words ‘‘as head is brought down to perineum’’ included the head being brought through the perineum. Her own practice was to wait until she was drawing the head through the perineum before making a cut.","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"20 1","pages":"129 - 130"},"PeriodicalIF":0.0,"publicationDate":"2014-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262215575955","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65477094","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Welsh NHS Redress arrangements – Are they putting things right for Welsh patients?","authors":"M. Rosser","doi":"10.1177/1356262214566700","DOIUrl":"https://doi.org/10.1177/1356262214566700","url":null,"abstract":"Mari Rosser examines the operation of the National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011. She comments on the intention behind the National Health Service Redress measure passed by the Welsh Government in 2008 and reviews how successful this has been in delivering an effective complaint handling process. She highlights the areas where she considers that the process is not working as it should be.","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"20 1","pages":"144 - 149"},"PeriodicalIF":0.0,"publicationDate":"2014-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262214566700","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65476714","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Replacement disc surgery which resulted in severe chronic pain syndrome","authors":"Lesley Herbertson","doi":"10.1177/1356262214563621","DOIUrl":"https://doi.org/10.1177/1356262214563621","url":null,"abstract":"","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"20 1","pages":"122 - 123"},"PeriodicalIF":0.0,"publicationDate":"2014-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262214563621","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65476696","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Section 63 Mental Health Act 1983 and the overdosing patient","authors":"A. R. Keene, H. Burnell","doi":"10.1177/1356262214557365","DOIUrl":"https://doi.org/10.1177/1356262214557365","url":null,"abstract":"Patients who overdose but resist treatment raise difficult ethical and legal issues for clinicians. It can be tempting to consider detention under the Mental Health Act 1983 and administration of treatment under section 63 Mental Health Act 1983. But how far can clinicians go? Three recent cases have helped illustrate the approach to forced life-saving treatment; this article suggests questions that clinicians should ask themselves in light of them.","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"20 1","pages":"111 - 113"},"PeriodicalIF":0.0,"publicationDate":"2014-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262214557365","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65477035","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Will the new Duty of Candour fulfil its potential to be the biggest breakthrough in patients’ rights and patient safety in history?","authors":"P. Walsh","doi":"10.1177/1356262214562737","DOIUrl":"https://doi.org/10.1177/1356262214562737","url":null,"abstract":"","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"20 1","pages":"103 - 104"},"PeriodicalIF":0.0,"publicationDate":"2014-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262214562737","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65477129","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"SH v. Bristol University Hospitals NHS Foundation Trust","authors":"A. Davies","doi":"10.1177/1356262214563622","DOIUrl":"https://doi.org/10.1177/1356262214563622","url":null,"abstract":"","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"37 1","pages":"124 - 125"},"PeriodicalIF":0.0,"publicationDate":"2014-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262214563622","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65476705","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Patient safety and interactive medical devices: Realigning work as imagined and work as done.","authors":"Ann Blandford,&nbsp;Dominic Furniss,&nbsp;Chris Vincent","doi":"10.1177/1356262214556550","DOIUrl":"https://doi.org/10.1177/1356262214556550","url":null,"abstract":"<p><p>Medical devices are essential tools for modern healthcare delivery. However, significant issues can arise if medical devices are designed for 'work as imagined' when this is misaligned with 'work as done'. This problem can be compounded as the details of device design, in terms of usability and the way a device supports or changes working practices, often receives limited attention. The ways devices are designed and used affect patient safety and quality of care: inappropriate design can provoke user error, create system vulnerabilities and divert attention from other aspects of patient care. Current regulation involves a series of pre-market checks relating to device usability, but this assumes that devices are always used under the conditions and for the purposes intended (i.e. work as imagined); there are many reasons for devices being used in ways other than those assumed at development time. Greater attention needs to be paid to learning points in actual use and user experience (i.e. work as done). This needs to inform manufacturers' designs, management procurement decisions and local decisions about how devices are used in practice to achieve co-adaptation; without these, we foster risks and inefficiencies in healthcare.</p>","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"20 5","pages":"107-110"},"PeriodicalIF":0.0,"publicationDate":"2014-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262214556550","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"33211695","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}