TMLEP’s Patient Safety Reports and Clinical Learning Updates provide healthcare providers with intelligence and recommendations (derived from analysis of TMLEP’s healthcare data) to directly improve healthcare standards and patient safety.
TMLEP Clinical Updates
TMLEP’s Clinical Updates are provided in order to raise awareness of clinical risk issues and to reduce incidence recurrence and improve patient safety. Facts have been anonymised to maintain data confidentiality, however learning points remain applicable.
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This case demonstrates the potentially fatal risks that are associated with unnecessarily taking aspirin in conjunction with anticoagulation medication, especially when considered in the context of invasive surgery.
The Patient attended Accident and Emergency in the early hours of the morning, two days after sustaining an injury to the left hand, suffering cuts to both the index and middle finger.
A 40-year-old woman had been suffering from symptoms of mid-cycle pain for some 13 years, therefore her GP subsequently referred her for gynaecology review. On review, she was diagnosed with cysts on both ovaries.
Tourniquet use is commonplace in surgery to create a bloodless field and facilitate the procedure. Unfortunately, tourniquet related injuries can sometimes occur ranging from temporary skin abrasions or bruising, through to full thickness burns and skin loss.
A complaint was raised that there was a failure to recognise a fistula in the patient’s oesophagus, resulting in food particles spilling over into the chest cavity causing the patient’s death.
A 65-year-old woman brought a claim against her Consultant Ophthalmologist for a failure to diagnose and treat acute angle closure attack appropriately, which resulted in progression of the condition to glaucoma that consequently lead to loss of vision in the left eye.
A 30-year-old woman who had had a previous caesarean section brought a claim against her Obstetrician & Gynaecologist for damaging her bladder, during her 2nd caesarean section.
Knee arthroscopy is one of the common procedures performed in orthopaedic for a variety of pathologies. It is a safe day case procedure with relatively few complications.