Pub Date : 2015-02-13DOI: 10.1177/1356262215570948
P. O’Connor, A. Fearfull
Building improvement capacity and capability skills that enable staff to keep patients safe and improve care is essential to today’s health care environments. The Scottish Patient Safety Fellowship is an educational programme designed to build clinical leadership skills to build, improve and enhance patient care and the patient experience. The Scottish Patient Safety Fellowship is unique as it is an embedded component of the National Health Service Education for Scotland's (NES) capacity and capability plan for clinicians to be leading health care improvement. This research evaluation used mixed methods to examine the experience of the fellows in Cohorts 1–5 (2008–2013) (n = 76), alongside the view of the fellows’ organisational sponsors – the chief executive officers (n = 12) and the senior leaders (n = 9) of the Scottish Patient Safety Fellowship Programme. This research was supported by Healthcare Improvement Scotland (HIS) and NHS Education for Scotland.
{"title":"Evaluation of the Scottish Patient Safety Fellowship programme 2008–2013","authors":"P. O’Connor, A. Fearfull","doi":"10.1177/1356262215570948","DOIUrl":"https://doi.org/10.1177/1356262215570948","url":null,"abstract":"Building improvement capacity and capability skills that enable staff to keep patients safe and improve care is essential to today’s health care environments. The Scottish Patient Safety Fellowship is an educational programme designed to build clinical leadership skills to build, improve and enhance patient care and the patient experience. The Scottish Patient Safety Fellowship is unique as it is an embedded component of the National Health Service Education for Scotland's (NES) capacity and capability plan for clinicians to be leading health care improvement. This research evaluation used mixed methods to examine the experience of the fellows in Cohorts 1–5 (2008–2013) (n = 76), alongside the view of the fellows’ organisational sponsors – the chief executive officers (n = 12) and the senior leaders (n = 9) of the Scottish Patient Safety Fellowship Programme. This research was supported by Healthcare Improvement Scotland (HIS) and NHS Education for Scotland.","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"21 1","pages":"22 - 30"},"PeriodicalIF":0.0,"publicationDate":"2015-02-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262215570948","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65476755","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 : 2015-01-01DOI: 10.1177/1356262215572264
S. Corcoran
Central Manchester University Hospitals NHS Foundation Trust, like many Trusts, asked itself a number of searching questions in the wake of the reports into appalling standards of care in a number of UK care settings between 2006 and 2009. In order to seek assurance on the quality of care being provided and to be very clear about where improvements were needed, the Board of Directors commissioned a comprehensive peer review into standards of care provided. The resulting exercise involved over 200 staff being trained in review techniques and participating in a comprehensive Trust wide quality improvement programme. The output of this exercise was a detailed plan to improve quality of care, increased recognition of excellence, shared learning across multiple specialties, and increased staff engagement and expertise.
{"title":"The quality review – asking staff and patients to inform quality strategy in Central Manchester","authors":"S. Corcoran","doi":"10.1177/1356262215572264","DOIUrl":"https://doi.org/10.1177/1356262215572264","url":null,"abstract":"Central Manchester University Hospitals NHS Foundation Trust, like many Trusts, asked itself a number of searching questions in the wake of the reports into appalling standards of care in a number of UK care settings between 2006 and 2009. In order to seek assurance on the quality of care being provided and to be very clear about where improvements were needed, the Board of Directors commissioned a comprehensive peer review into standards of care provided. The resulting exercise involved over 200 staff being trained in review techniques and participating in a comprehensive Trust wide quality improvement programme. The output of this exercise was a detailed plan to improve quality of care, increased recognition of excellence, shared learning across multiple specialties, and increased staff engagement and expertise.","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"21 1","pages":"3 - 6"},"PeriodicalIF":0.0,"publicationDate":"2015-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262215572264","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65476766","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 : 2015-01-01DOI: 10.1177/1356262215584706c
S. White
The defendant’s primary case was that the claimant relied upon witnessing the consequence of the negligence, not the negligence itself. The material negligent event(s) were the antenatal appointments up to and including the appointment on 10 March. Either Mr Wild had not been present at those events or those events had not been sufficiently shocking so as to give rise to any psychiatric injury. A number of other lines of defence were raised, for example that Mr Wild’s psychiatric injury was caused by the realisation of baby Matthew’s death, not as a result of witnessing his death in utero with his own senses.
{"title":"Comment regarding other clinical negligence claims","authors":"S. White","doi":"10.1177/1356262215584706c","DOIUrl":"https://doi.org/10.1177/1356262215584706c","url":null,"abstract":"The defendant’s primary case was that the claimant relied upon witnessing the consequence of the negligence, not the negligence itself. The material negligent event(s) were the antenatal appointments up to and including the appointment on 10 March. Either Mr Wild had not been present at those events or those events had not been sufficiently shocking so as to give rise to any psychiatric injury. A number of other lines of defence were raised, for example that Mr Wild’s psychiatric injury was caused by the realisation of baby Matthew’s death, not as a result of witnessing his death in utero with his own senses.","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"21 1","pages":"17 - 18"},"PeriodicalIF":0.0,"publicationDate":"2015-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262215584706c","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65477199","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 : 2015-01-01DOI: 10.1177/1356262215583598
P. Walsh
{"title":"Is access to justice becoming a lost cause?","authors":"P. Walsh","doi":"10.1177/1356262215583598","DOIUrl":"https://doi.org/10.1177/1356262215583598","url":null,"abstract":"","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"21 1","pages":"1 - 2"},"PeriodicalIF":0.0,"publicationDate":"2015-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262215583598","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65476793","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 : 2015-01-01DOI: 10.1177/1356262215584706B
Sejal Mehta
ably an equitable ruling because the claimant has actually lost nothing and suffered nothing as a consequence of the technical breach. The position is, however, very different if the claimant would not have been detained but for the error. In such cases, it is entirely appropriate that damages will be substantial because the claimant will have lost liberty and possibly suffered financially as a consequence of being unlawfully detained.
{"title":"Secondary victim claim fails: Wild v Southend University Hospitals NHS Foundation Trust","authors":"Sejal Mehta","doi":"10.1177/1356262215584706B","DOIUrl":"https://doi.org/10.1177/1356262215584706B","url":null,"abstract":"ably an equitable ruling because the claimant has actually lost nothing and suffered nothing as a consequence of the technical breach. The position is, however, very different if the claimant would not have been detained but for the error. In such cases, it is entirely appropriate that damages will be substantial because the claimant will have lost liberty and possibly suffered financially as a consequence of being unlawfully detained.","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"21 1","pages":"16 - 17"},"PeriodicalIF":0.0,"publicationDate":"2015-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262215584706B","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65477647","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 : 2015-01-01DOI: 10.1177/1356262215574203
Mark Sujan, Dominic Furniss
Reporting and learning systems are key organisational tools for the management and prevention of clinical risk. However, current approaches, such as incident reporting, are struggling to meet expectations of turning health systems like the UK National Health Service (NHS) into learning organisations. This article aims to open up debate on the potential for novel reporting and learning systems in healthcare, by reflecting on experiences from two recent projects: Proactive Risk Monitoring in Healthcare (PRIMO) and Errordiary in Healthcare. These two approaches demonstrate how paying attention to ordinary, everyday clinical work can derive useful learning and active discussion about clinical risk. We argue that innovations in reporting and learning systems might come from both inside and outside of the box. 'Inside' being along traditional paths of controlled organisational innovation. 'Outside' in the sense that inspiration comes outside of the healthcare domain, or more extremely, outside official channels through external websites and social media (e.g. patient forums, public review sites, whistleblower blogs and Twitter streams). Reporting routes that bypass official channels could empower staff and patient activism, and turn out to be a driver to challenge organisational processes, assumptions and priorities where the organisation is failing and has become unresponsive.
{"title":"Organisational reporting and learning systems: Innovating inside and outside of the box.","authors":"Mark Sujan, Dominic Furniss","doi":"10.1177/1356262215574203","DOIUrl":"https://doi.org/10.1177/1356262215574203","url":null,"abstract":"<p><p>Reporting and learning systems are key organisational tools for the management and prevention of clinical risk. However, current approaches, such as incident reporting, are struggling to meet expectations of turning health systems like the UK National Health Service (NHS) into learning organisations. This article aims to open up debate on the potential for novel reporting and learning systems in healthcare, by reflecting on experiences from two recent projects: Proactive Risk Monitoring in Healthcare (PRIMO) and Errordiary in Healthcare. These two approaches demonstrate how paying attention to ordinary, everyday clinical work can derive useful learning and active discussion about clinical risk. We argue that innovations in reporting and learning systems might come from both inside and outside of the box. 'Inside' being along traditional paths of controlled organisational innovation. 'Outside' in the sense that inspiration comes outside of the healthcare domain, or more extremely, outside official channels through external websites and social media (e.g. patient forums, public review sites, whistleblower blogs and Twitter streams). Reporting routes that bypass official channels could empower staff and patient activism, and turn out to be a driver to challenge organisational processes, assumptions and priorities where the organisation is failing and has become unresponsive.</p>","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"21 1","pages":"7-12"},"PeriodicalIF":0.0,"publicationDate":"2015-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262215574203","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"33325388","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 : 2015-01-01DOI: 10.1177/1356262215584706
J. Mead
The claimant, who was aged 56 at the date of judgment, suffered from an unusual congenital condition called hypophosphatasia. As a result, he had deficient bone mineralisation and underwent various hospital admissions over many years because of his condition. Nevertheless, he was able to pursue an active lifestyle and worked as the manager of an equipment hire depot. In October 2009, he suffered significant pain and was admitted to hospital. He was discharged home on 19 October and on 22 November 2009 was admitted as an emergency. Unfortunately, despite surgical intervention, he is now paraplegic.
{"title":"No liability in paraplegia case despite failings: Barnett v Medway NHS Foundation Trust","authors":"J. Mead","doi":"10.1177/1356262215584706","DOIUrl":"https://doi.org/10.1177/1356262215584706","url":null,"abstract":"The claimant, who was aged 56 at the date of judgment, suffered from an unusual congenital condition called hypophosphatasia. As a result, he had deficient bone mineralisation and underwent various hospital admissions over many years because of his condition. Nevertheless, he was able to pursue an active lifestyle and worked as the manager of an equipment hire depot. In October 2009, he suffered significant pain and was admitted to hospital. He was discharged home on 19 October and on 22 November 2009 was admitted as an emergency. Unfortunately, despite surgical intervention, he is now paraplegic.","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"21 1","pages":"13 - 15"},"PeriodicalIF":0.0,"publicationDate":"2015-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262215584706","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65476837","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 : 2014-11-01DOI: 10.1177/1356262215575955a
J. Mead
ing in the delivery of William which ought to have caused her to modify that plan. The child’s head delivered suddenly with unexpected maternal effort and led to a fourth degree tear, which was a serious but recognised non-negligent complication of child birth. Accordingly, the claim failed. Jonathan Hand (Instructed by Barratt Goff & Tomlinson) appeared for the claimant. Bradley Martin (Instructed by Browne Jacobson) appeared for the Trust.
{"title":"Trust liable in case of Necrotising Fasciitis","authors":"J. Mead","doi":"10.1177/1356262215575955a","DOIUrl":"https://doi.org/10.1177/1356262215575955a","url":null,"abstract":"ing in the delivery of William which ought to have caused her to modify that plan. The child’s head delivered suddenly with unexpected maternal effort and led to a fourth degree tear, which was a serious but recognised non-negligent complication of child birth. Accordingly, the claim failed. Jonathan Hand (Instructed by Barratt Goff & Tomlinson) appeared for the claimant. Bradley Martin (Instructed by Browne Jacobson) appeared for the Trust.","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"20 1","pages":"130 - 132"},"PeriodicalIF":0.0,"publicationDate":"2014-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262215575955a","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65477112","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 : 2014-11-01DOI: 10.1177/1356262214562916
Susan E Mackie, D. Baldie, E. McKenna, P. O'Connor
Pressure ulcer prevention is core to nursing practice and as such is often overlooked as a safety risk. A multifaceted quality improvement initiative guided by both Felgen’s Model and the Model for Improvement delivered implemented in a systematic way led to significant improvements in the prevalence and incidence of pressure ulcers. Prevalence of all ulcers was reduced from 21% to 7% and to 3.1% when grade 1 ulcers are removed from analysis. Incidence (i.e. ulcers acquired in hospital) was reduced from 6.6% to 2.4% and 1.4% when grade 1 ulcers are removed from the analysis. Furthermore, improvements have been sustained for more than 2 years. This paper presents a case study of framework for change developed across a healthcare region NHS Tayside in Scotland.
{"title":"Using quality improvement science to reduce the risk of pressure ulcer occurrence – a case study in NHS Tayside","authors":"Susan E Mackie, D. Baldie, E. McKenna, P. O'Connor","doi":"10.1177/1356262214562916","DOIUrl":"https://doi.org/10.1177/1356262214562916","url":null,"abstract":"Pressure ulcer prevention is core to nursing practice and as such is often overlooked as a safety risk. A multifaceted quality improvement initiative guided by both Felgen’s Model and the Model for Improvement delivered implemented in a systematic way led to significant improvements in the prevalence and incidence of pressure ulcers. Prevalence of all ulcers was reduced from 21% to 7% and to 3.1% when grade 1 ulcers are removed from analysis. Incidence (i.e. ulcers acquired in hospital) was reduced from 6.6% to 2.4% and 1.4% when grade 1 ulcers are removed from the analysis. Furthermore, improvements have been sustained for more than 2 years. This paper presents a case study of framework for change developed across a healthcare region NHS Tayside in Scotland.","PeriodicalId":89664,"journal":{"name":"Clinical risk","volume":"20 1","pages":"134 - 143"},"PeriodicalIF":0.0,"publicationDate":"2014-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1356262214562916","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65477140","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}
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