Pub Date : 2014-05-01DOI: 10.1177/1356262214528840
P. Walsh
The dust is finally beginning to settle following the Government’s response to the Francis report, and we are beginning to see what is actually going to change as a result. A few things still need to be bottomed out of course – not least the question of whether England introduces a full statutory Duty of Candour or some pale shadow of it, which could actually make things worse. This was discussed in some detail in a previous issue. At the time of writing, an announcement has yet to be made about this. However, whilst we eagerly await the Government’s decision – arguably the most central and important potential outcome from the inquiry – some things are becoming clearer. The Government has made much of accepting the ‘vast majority’ of Francis’ recommendations. However, a closer look shows that many of these are accepted ‘in principle’, but the Government is actually going to do something rather different from what was recommended, if anything at all. Perhaps, the most noticeable changes have come in the approach to regulation, the need for which was so graphically exposed by the inquiry. Whilst some of the details of the recommendations such as merger of Monitor with the Care Quality Commission (CQC) were not accepted, the main thrust at least was taken to heart. We are already beginning to see a completely different approach from the CQC. A beefed-up inspection regime; a willingness to engage with and act on intelligence from patients and whistleblowers; and a much more open and principled style of leadership. Some of the disappointments were the refusal to accept recommendations about introducing guidance on minimum staffing levels or to bring in regulation of healthcare assistants. These are decisions which I fear may come back to haunt ministers. Questions about staffing levels and skill mix, and indeed the effect of 12-hour shift patterns are, I fear, going to remain a huge issue. Even more so due to the strain on resources. The issues are commonly a red hot topic of debate in Wales, which has been facing its own Stafford-style scandals. More of that later. Action against Medical Accidents (AvMA)
随着政府对弗朗西斯报告的回应，尘埃终于开始落定，我们开始看到实际的变化。当然，仍有一些事情需要彻底解决——尤其是英国是否引入了一项完整的法定“坦率义务”(Duty of Candour)，或者是它的一些苍白的影子，这实际上可能会让事情变得更糟。在前一期中对此进行了详细讨论。在撰写本文时，尚未就此发布公告。然而，在我们急切地等待政府的决定- -可以说是调查最核心和最重要的潜在结果- -的同时，有些事情正在变得更加清楚。政府已经接受了方济各“绝大多数”的建议。然而，仔细观察就会发现，其中许多是“原则上”被接受的，但政府实际上要做的事情与建议的完全不同，如果有的话。或许，最引人注目的变化出现在监管方式上，此次调查生动地揭示了监管的必要性。虽然建议的一些细节，如Monitor与护理质量委员会(CQC)的合并没有被接受，但主要的主旨至少被铭记于心。我们已经开始看到一种与CQC完全不同的方法。加强检查制度;愿意与患者和举报人接触并根据他们的情报采取行动;以及更加开放和有原则的领导风格。一些令人失望的是，拒绝接受关于引入最低人员配备水平指导或引入医疗助理监管的建议。我担心这些决定可能会反过来困扰部长们。我担心，有关人员配备水平和技能组合的问题，以及12小时轮班模式的影响，仍将是一个大问题。由于资源紧张，更是如此。这些问题通常是威尔士辩论的热门话题，威尔士也面临着自己的斯坦福式丑闻。稍后会详细介绍。防止医疗意外行动(AvMA)
{"title":"How much will Mid Staffordshire Public Inquiry change things?","authors":"P. Walsh","doi":"10.1177/1356262214528840","DOIUrl":"https://doi.org/10.1177/1356262214528840","url":null,"abstract":"The dust is finally beginning to settle following the Government’s response to the Francis report, and we are beginning to see what is actually going to change as a result. A few things still need to be bottomed out of course – not least the question of whether England introduces a full statutory Duty of Candour or some pale shadow of it, which could actually make things worse. This was discussed in some detail in a previous issue. At the time of writing, an announcement has yet to be made about this. However, whilst we eagerly await the Government’s decision – arguably the most central and important potential outcome from the inquiry – some things are becoming clearer. The Government has made much of accepting the ‘vast majority’ of Francis’ recommendations. However, a closer look shows that many of these are accepted ‘in principle’, but the Government is actually going to do something rather different from what was recommended, if anything at all. Perhaps, the most noticeable changes have come in the approach to regulation, the need for which was so graphically exposed by the inquiry. Whilst some of the details of the recommendations such as merger of Monitor with the Care Quality Commission (CQC) were not accepted, the main thrust at least was taken to heart. We are already beginning to see a completely different approach from the CQC. A beefed-up inspection regime; a willingness to engage with and act on intelligence from patients and whistleblowers; and a much more open and principled style of leadership. Some of the disappointments were the refusal to accept recommendations about introducing guidance on minimum staffing levels or to bring in regulation of healthcare assistants. These are decisions which I fear may come back to haunt ministers. Questions about staffing levels and skill mix, and indeed the effect of 12-hour shift patterns are, I fear, going to remain a huge issue. Even more so due to the strain on resources. The issues are commonly a red hot topic of debate in Wales, which has been facing its own Stafford-style scandals. More of that later. Action against Medical Accidents (AvMA)","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"20 1","pages":"58 - 58"},"PeriodicalIF":0.0,"publicationDate":"2014-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262214528840","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65476542","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}
Pub Date : 2014-05-01DOI: 10.1177/1356262214535734
Wrg Perry, E. Kelley
The WHO Surgical Safety Checklist has become a high-profile symbol for patient safety efforts in surgery. Since the landmark study by Haynes et al. 1 documenting its success at reducing peri-operative morbidity and mortality in a diversity of settings, others have gone on to show positive effects of the checklist on teamwork, communication, and patient outcomes. The widespread dissemination of the checklist has now allowed for a more global analysis of its role in surgery, and has highlighted two key points: first, the success of the checklist relies on effective and appropriate implementation; and second, the checklist needs to be introduced as part of a broader patient safety movement. Beyond universal challenges with implementation, some questions have been asked about its applicability to low- and middle-income countries. WHO acknowledges that checklist implementation in such settings needs to be well considered; limited availability of resources and less structure around patient safety provides a different context for effective use. Further research needs to be undertaken to better understand what if any modifications need to be made. WHO also hope to better coordinate patient safety efforts with the global surgery movement to maximize the effect of the checklist and improve surgical safety in low- and middle-income countries.
{"title":"Checklists, global health and surgery: a five-year checkup of the WHO Surgical Safety checklist programme","authors":"Wrg Perry, E. Kelley","doi":"10.1177/1356262214535734","DOIUrl":"https://doi.org/10.1177/1356262214535734","url":null,"abstract":"The WHO Surgical Safety Checklist has become a high-profile symbol for patient safety efforts in surgery. Since the landmark study by Haynes et al. 1 documenting its success at reducing peri-operative morbidity and mortality in a diversity of settings, others have gone on to show positive effects of the checklist on teamwork, communication, and patient outcomes. The widespread dissemination of the checklist has now allowed for a more global analysis of its role in surgery, and has highlighted two key points: first, the success of the checklist relies on effective and appropriate implementation; and second, the checklist needs to be introduced as part of a broader patient safety movement. Beyond universal challenges with implementation, some questions have been asked about its applicability to low- and middle-income countries. WHO acknowledges that checklist implementation in such settings needs to be well considered; limited availability of resources and less structure around patient safety provides a different context for effective use. Further research needs to be undertaken to better understand what if any modifications need to be made. WHO also hope to better coordinate patient safety efforts with the global surgery movement to maximize the effect of the checklist and improve surgical safety in low- and middle-income countries.","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"20 1","pages":"59 - 63"},"PeriodicalIF":0.0,"publicationDate":"2014-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262214535734","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65476684","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}
Pub Date : 2014-05-01DOI: 10.1177/1356262214529692
J. Mead
{"title":"Healthcare and Law Digest","authors":"J. Mead","doi":"10.1177/1356262214529692","DOIUrl":"https://doi.org/10.1177/1356262214529692","url":null,"abstract":"","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"20 1","pages":"76 - 80"},"PeriodicalIF":0.0,"publicationDate":"2014-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262214529692","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65476555","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}
Pub Date : 2014-05-01DOI: 10.1177/1356262213514214
Antonia J. Jones
Negligent delay in the diagnosis and treatment of infected cervical discitis leading to a permanent and partial C5 tetraplegia. Settlement: 8 March 2012. Christopher Wilson-Smith QC and Caroline Hallissey of Outer Temple Chambers, instructed by Antonia Jones of Stewarts Law LLP for the claimant. Sarah Pritchard of Kings Chambers, instructed by Vanessa Splaine of Weightmans LLP for the defendant.
感染性颈椎间盘炎导致永久性和部分C5四肢瘫痪的诊断和治疗疏忽。结算日期:2012年3月8日。Christopher Wilson-Smith QC和Caroline Hallissey Outer Temple Chambers律师事务所，由stewart Law LLP律师事务所的Antonia Jones代表原告。金伯斯律师事务所的莎拉·普里查德，由魏特曼律师事务所的凡妮莎·斯普莱因委托为被告辩护。
{"title":"Aldred v Western Sussex Hospitals NHS Trust*","authors":"Antonia J. Jones","doi":"10.1177/1356262213514214","DOIUrl":"https://doi.org/10.1177/1356262213514214","url":null,"abstract":"Negligent delay in the diagnosis and treatment of infected cervical discitis leading to a permanent and partial C5 tetraplegia. Settlement: 8 March 2012. Christopher Wilson-Smith QC and Caroline Hallissey of Outer Temple Chambers, instructed by Antonia Jones of Stewarts Law LLP for the claimant. Sarah Pritchard of Kings Chambers, instructed by Vanessa Splaine of Weightmans LLP for the defendant.","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"20 1","pages":"69 - 70"},"PeriodicalIF":0.0,"publicationDate":"2014-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262213514214","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65476456","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}
Pub Date : 2014-05-01DOI: 10.1177/1356262214535735
John Illingworth
The NHS excels at measuring incidences of past harm - whether it is falls or hospital-acquired infections - but research undertaken by Charles Vincent, Jane Carthey and Susan Burnett for the Health Foundation suggests past harm is only one element of what is needed to understand how safe care is. The researchers developed a framework to incorporate other necessary elements, such as anticipating and preparing for risks before they lead to harm to patients. In 2013, the Health Foundation road-tested this framework with staff in three NHS organisations and held a two-day summit with leaders from across the healthcare system to get feedback on its potential. This article presents the findings of this phase of work and sets it in the context of recent changes in the policy and regulatory landscape for patient safety in England. It concludes that the framework offers a great deal of potential for supporting organisations to understand the safety of their services. The framework could be most effective when used to identify the relative strengths and weaknesses of current safety measures, and when staff are given sufficient time, resource and support to consider the complex issues surfaced by the questions in the framework. This needs to be matched by a system of regulation which is aligned and mature, and an approach from NHS Trust Boards which welcomes information about the risks of its services.
{"title":"Developing and testing a framework to measure and monitor safety in healthcare.","authors":"John Illingworth","doi":"10.1177/1356262214535735","DOIUrl":"https://doi.org/10.1177/1356262214535735","url":null,"abstract":"<p><p>The NHS excels at measuring incidences of past harm - whether it is falls or hospital-acquired infections - but research undertaken by Charles Vincent, Jane Carthey and Susan Burnett for the Health Foundation suggests past harm is only one element of what is needed to understand how safe care is. The researchers developed a framework to incorporate other necessary elements, such as anticipating and preparing for risks before they lead to harm to patients. In 2013, the Health Foundation road-tested this framework with staff in three NHS organisations and held a two-day summit with leaders from across the healthcare system to get feedback on its potential. This article presents the findings of this phase of work and sets it in the context of recent changes in the policy and regulatory landscape for patient safety in England. It concludes that the framework offers a great deal of potential for supporting organisations to understand the safety of their services. The framework could be most effective when used to identify the relative strengths and weaknesses of current safety measures, and when staff are given sufficient time, resource and support to consider the complex issues surfaced by the questions in the framework. This needs to be matched by a system of regulation which is aligned and mature, and an approach from NHS Trust Boards which welcomes information about the risks of its services.</p>","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"20 3","pages":"64-68"},"PeriodicalIF":0.0,"publicationDate":"2014-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262214535735","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"32832819","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}
Pub Date : 2014-04-07DOI: 10.1177/1356262214530271
A. Davies
At the age of 40, the Claimant (date of birth 24 February 1964) suffered a deep vein thrombosis after which he was started on long-term warfarin. In April 2006, his general practitioner stopped the warfarin. On 10 December 2006, the Claimant experienced severe pain in his right calf. He was taken by ambulance to the University Hospital of Wales where he was diagnosed with acute ischaemia caused by an arterial occlusion. The Claimant was treated with thrombolytics along with intravenous heparin. Blood tests prior to the infusion were within normal limits. Record keeping of the administration of the heparin was poor, but it was noted that the dosage of heparin was entered twice on the chart to start at 5000 IU in 45ml sodium chloride. The syringe/bag would have been changed at approximately 05:00 and 14:50 h on 11 December 2006 and approximately 01:00 h on 12 December 2006. The activated partial thromboplastin time (clotting time) was measured at 22:35 h on 10 December 2006 and 10:00 h on 11 December 2006 and noted as within the desired range at 38 and 41 s, respectively. During the evening of 11 December 2006, the femoral sheath was checked and moderate oozing of fresh blood noted in an untimed entry. No action was taken in response to this. At about 05:00 h on 12 December 2006, the Claimant developed a headache and began vomiting. He was reviewed at 07:00 h, and a doctor suspected an intracranial haemorrhage, which was confirmed with a subsequent computed tomography scan. A blood test taken at 07:34 h showed an APTT of greater than 240 s (the norm being 22–33 s). The heparin infusion was stopped at 09:00 h, and blood tests taken at 09:34 h confirmed the prolonged APPT. It was noted ‘Heparin overdosed’. The Claimant was given fresh frozen plasma, and an external ventricular drain was inserted. Protamine was given at approximately 13:30 h.
{"title":"KMJ (a patient through his son and litigation friend) v Cardiff and Vale University Health Board (formerly Cardiff and Vale NHS Trust)","authors":"A. Davies","doi":"10.1177/1356262214530271","DOIUrl":"https://doi.org/10.1177/1356262214530271","url":null,"abstract":"At the age of 40, the Claimant (date of birth 24 February 1964) suffered a deep vein thrombosis after which he was started on long-term warfarin. In April 2006, his general practitioner stopped the warfarin. On 10 December 2006, the Claimant experienced severe pain in his right calf. He was taken by ambulance to the University Hospital of Wales where he was diagnosed with acute ischaemia caused by an arterial occlusion. The Claimant was treated with thrombolytics along with intravenous heparin. Blood tests prior to the infusion were within normal limits. Record keeping of the administration of the heparin was poor, but it was noted that the dosage of heparin was entered twice on the chart to start at 5000 IU in 45ml sodium chloride. The syringe/bag would have been changed at approximately 05:00 and 14:50 h on 11 December 2006 and approximately 01:00 h on 12 December 2006. The activated partial thromboplastin time (clotting time) was measured at 22:35 h on 10 December 2006 and 10:00 h on 11 December 2006 and noted as within the desired range at 38 and 41 s, respectively. During the evening of 11 December 2006, the femoral sheath was checked and moderate oozing of fresh blood noted in an untimed entry. No action was taken in response to this. At about 05:00 h on 12 December 2006, the Claimant developed a headache and began vomiting. He was reviewed at 07:00 h, and a doctor suspected an intracranial haemorrhage, which was confirmed with a subsequent computed tomography scan. A blood test taken at 07:34 h showed an APTT of greater than 240 s (the norm being 22–33 s). The heparin infusion was stopped at 09:00 h, and blood tests taken at 09:34 h confirmed the prolonged APPT. It was noted ‘Heparin overdosed’. The Claimant was given fresh frozen plasma, and an external ventricular drain was inserted. Protamine was given at approximately 13:30 h.","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"20 1","pages":"73 - 75"},"PeriodicalIF":0.0,"publicationDate":"2014-04-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262214530271","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65476595","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}
Pub Date : 2014-01-01DOI: 10.1177/1356262213519982
C. Mellor
This article (written in April 2013) considers the observations and recommendations made in the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry as to a duty of candour and, in particular, the recommendation that there should be a statutory duty of candour imposed on healthcare providers, as well as on registered medical practitioners, nurses and other registered professionals, who believe or suspect that patient treatment or care has caused death or serious injury. The article details the Government's initial response to such recommendations, in which it indicated an intention to introduce a statutory duty for health and care providers, and sets out the contractual duty of candour that is currently included in the NHS Standard Contract for 2013/14 (SC35). There is then an analysis of the terms of the contractual duty contrasted with those of the proposed statutory duty; a look at the limitations of the contractual duty; a discussion of some of the issues that may arise in relation to when the relevant duty (either contractual or statutory) will be triggered; a consideration of the apparent novelty of a statutory duty of candour in English law; and a brief discussion in relation to the potential remedies, penalties and offences that may be adopted if such a statutory duty comes into force. In conclusion, on any basis the imposition of the contractual duty of candour and the intention to introduce some form of statutory duty heralds a new era in relation to candour in healthcare.
{"title":"A duty of candour: A change in approach","authors":"C. Mellor","doi":"10.1177/1356262213519982","DOIUrl":"https://doi.org/10.1177/1356262213519982","url":null,"abstract":"This article (written in April 2013) considers the observations and recommendations made in the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry as to a duty of candour and, in particular, the recommendation that there should be a statutory duty of candour imposed on healthcare providers, as well as on registered medical practitioners, nurses and other registered professionals, who believe or suspect that patient treatment or care has caused death or serious injury. The article details the Government's initial response to such recommendations, in which it indicated an intention to introduce a statutory duty for health and care providers, and sets out the contractual duty of candour that is currently included in the NHS Standard Contract for 2013/14 (SC35). There is then an analysis of the terms of the contractual duty contrasted with those of the proposed statutory duty; a look at the limitations of the contractual duty; a discussion of some of the issues that may arise in relation to when the relevant duty (either contractual or statutory) will be triggered; a consideration of the apparent novelty of a statutory duty of candour in English law; and a brief discussion in relation to the potential remedies, penalties and offences that may be adopted if such a statutory duty comes into force. In conclusion, on any basis the imposition of the contractual duty of candour and the intention to introduce some form of statutory duty heralds a new era in relation to candour in healthcare.","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"20 1","pages":"36 - 46"},"PeriodicalIF":0.0,"publicationDate":"2014-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262213519982","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65476307","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}
京公网安备 11010802042870号
京ICP备2023020795号-1
扫码关注我们
求助内容：
应助结果提醒方式：