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 [...]
The number of stillbirths and neonatal deaths every year in the UK is more than twice the number of deaths on UK roads. While road safety attracts a huge amount of attention, resources and legislation, perinatal mortality still tends to be regarded as an unhappy fact of life about which little can be done.
But [...]
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 [...]
One of the important features of our baby’s death was something called a sub-aponeurotic haemorrhage. On the face of it, this is a relatively rare complication of vacuum assisted delivery - an invaluable technique in difficult births for delivering babies. As far as the hospital where our baby was born is concerned, this [...]
Yet more pressure on NHS Maternity Units today.
This time in Milton Keynes, where the local Coroner reported the Trust involved to the Department of Health, asking for an investigation into why a senior midwife’s views had been disregarded. Apparently, a registrar, after discussion with a consultant on the phone, had ignored the [...]
This is an extract from a report on healthcare professionals’ views about safety in maternity services, published in 2008. The report identifies, along with various staffing and management issues, that learning lessons from mistakes and near-misses is one of the key problems in maternity.
Learning from adverse incidents is one of the key components of [...]
Group B Strep (GBS) is a common, asymptomatic bacteria in adults, which occasionally seriously affects newborns because their immune systems are not well developed. It is the most common cause of life-threatening infection in newborns in the developed world.
We were told, following the death of our baby in which early onset GBS had been [...]
When things get really bad at a hospital, sometimes the staff just can’t cope anymore.
Things at Birmingham Children’s Hospital were under such stress by early November 2008, that the hospital’s own paediatric consultants went over the heads of the hospital’s management and called in the Healthcare Commission to draw attention to their own poor health [...]
