Incident-triggered random clinical audits.
A very interesting paper by Lee et al regarding the trial of a simple risk management process in Bristol’s Southmead NICU was published in August 2008 (Archives of Disease in Childhood - Fetal and Neonatal Edition 2009;94:F116-F119).
To quote the deputy editor’s comments;
“Over recent years, we have carried a number of papers examining rates of adverse [...]
How more might be learned about Stillbirth and Neonatal Death.
In the guidance for Serious Untoward Incidents (SUI) from different hospital trusts that I’ve seen published on the web, a common example of the kind of adverse event that might start the process off is the death of a baby. Some trusts go as far as suggesting stillbirth - even as far back as [...]
Families Of Critically Ill Patients Want To Discuss Uncertain Prognoses.
Critically ill patients frequently have uncertain prognoses, but their families overwhelmingly wish that physicians would address prognostic uncertainty candidly, according to a new study out of the University of San Francisco Medical Center.
In face-to-face interviews with 179 surrogate decision-makers for patients in four separate intensive care units (ICUs), 87 % of caregivers indicated that they [...]
Make timelines that illustrate the whole story.
People understand something by understanding its context, not by cramming the details of that thing into their brain. That is why making diagrams is such a useful technique for understanding complicated things; it puts all the details into some kind of context and helps you make sense of things.
Here is a timeline I built [...]
Serious Untoward Incident Reporting is a Matter of Life and Death.
A Serious Untoward Incident is an investigation process in hospitals that happens following the death or harm of someone due to failures in care, the type of thing that might attract media interest, litigation etc. We have been involved in one following the death of our baby.
The idea behind it is that time and [...]
Stop using second class post for correspondence.
Our hospital has used second class post to correspond with us throughout. This is very poor PR.
Second class post costs 9p per letter less than first class, and while it ‘aims’ to get there within three working days, it very often takes 10 days or more. For a bereaved family trying to make sense [...]
One concerned, all concerned.
I’m not sure where I read this, but in some intensive care facilities they adopt a very simple but effective strategy: if one member of the team has concerns, then all members of that team have to share that concern until it is demonstrated to be unfounded. In fact, I think this simple thing [...]