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 [...]
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 [...]
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 [...]
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 [...]
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 [...]
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 [...]
Group B Strep (GBS) is a bacterial infection that results in significant mortality and morbidity in newborns. While a significant proportion of mothers (25 to 30 %) carry GBS at the time of delivery, only a relatively small fraction of them will pass it on to their baby during birth (~ 1 in 200). [...]
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 [...]
