The
Trust’s bulletin on risk management came through on email today.
There
was a lot to take in:
Page 01 - Don't miss vital information
Page 02 - Confidence in Confidentiality
Page 03 - Cases of unnecessary exposure to
radiation due to errors in the radiology referral process Referrer’s
responsibilities under the Ionising Radiation (Medical Exposure) Regulations –
IR(ME)R 2000
Page 04 Clinical MHLAs bariatric training sessions
Page 04 - Health and safety alert Prompt management
of spillages
Page 06 - Do you know about Deprivation of Liberty
Safeguards (2007)? The CQC hope you do
Page 07 - Incidents and Datix Guidance
Page 08 - News from the Sepsis Collaborative
Page 09 - Learning from Serious Incident
Investigations:
Page
09 - Never events
Page
09 - Case 1-Never event, wrong ankle surgery
Page
10 - Case 2 - Never event, misplace naso-gastric tube prior use
Page
11 - Case 3 - Diagnostic conundrum and sequence of problems leads to maternal
death
Page
12 - Case 4 - Delayed diagnosis of thoracic spinal cord compression leading to
paralysis
Page
13 - Case 5 - Treatment for acute coronary syndrome exacerbates bleeding in
splenectomy patient
Page
14 - Case 6 - Colorectal rapid access pathway, not so rapid
Page S1 – SPECIAL EDITION - Teams Improving Patient
Safety.
I’m
usually rather negative about these semi-regular newsletters. This one was
quite interesting.
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