This report investigated maternity services at Furness General Hospital from January 2004 to June 2013, and concludes the maternity unit was dysfunctional and that serious failures of clinical care led to unnecessary deaths of mothers and babies. It makes a series of recommendations for the wider NHS as well as Morecambe Bay.
This quality standard covers assessment after a fall and preventing further falls (secondary prevention) in older people living in the community and during a hospital stay. Secondary prevention focuses on interventions targeted at older people with a history of falls. Older people are those aged 65 years and over.
The Social Care Institute for Excellence (SCIE) was established to improve social care services for adults and children in the United Kingdom. This report discusses nutrition and hydration from the perspective of social care with the emphasis on simple practice points which could be implemented to improve the nutrition of the frail elderly population.
A short film produced by Health Education England to support healthcare professionals in training and staff at all levels to report and respond to concerns about patient safety.
Produced by the Canadian Patient Safety Institute, this report includes a literature review on effective teamwork and communication in healthcare, a needs assessment of Canadian healthcare organisations, a review of teamwork and communication training programmes, and a consultation with national and international experts in teamwork and communication.
An interview with Dr Kim Holt, Consultant Paediatrician who ‘blew the whistle’ on the Baby P case in Haringey. She also founded Patients First, which is a support group for whistle-blowers.
She discusses her experience and those of other health professionals who have been “whistle-blowers”.
She discusses the need to change the system so that clinical staff feel empowered to speak up.
This paper describes the use of the “trigger tool”, a relatively low cost and “low tech” technique for capturing medication related harm. The adapted technique appears to increase the rate of adverse drug event detection approximately 50-fold over traditional reporting methodologies.