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  • Patient Safety Commissioner: 100 Days Report (2 February 2023)

    Patient Safety Learning
    • UK
    • Reports and articles
    • Pre-existing
    • Original author
    • No
    • Patients Association
    • 02/02/23
    • Everyone


    In this report, Dr Henrietta Hughes, Patient Safety Commissioner for England, reflects on her first 100 days in this new role. She sets out what she has heard, what she has done and her priorities for the year ahead.


    The Patient Safety Commissioner outlines the range of different stakeholders she has met within her first 100 days in office, including patients, healthcare staff, patient safety specialists and healthcare providers. She also details the number of different areas of concern that have been raised with her in this period, including:

    • pelvic mesh complications
    • isotretinoin side effects
    • painful gynaecological investigations
    • Covid vaccination concerns
    • mental health difficulties
    • fluoroquinolone side effects
    • Yellow Card scheme reporting
    • concerns about electroconvulsive therapy.

    The report then sets out in more detail her reflections on patient safety concerns relating to the three medical interventions covered by the Independent Medicines and Medical Devices Safety Review: pelvic mesh, Sodium valproate and Primodos. She also highlights some positive areas of patient safety work she has encountered in her first 100 days in office, including the Scan 4 Safety initiative, NHS Resolution’s work on consent resources and how the new Patient Safety Incident Response Framework (PSIRF) is seeking to ensure that patients’ voices are included in incident investigations.

    The report concludes by setting out her top three priorities:

    1.     Culture Change

    The Patient Safety Commissioner plans to:

    • hold a public consultation on the Principles of Better Patient Safety for the Patient Safety Commissioner
    • work with healthcare leaders to put patient voice at the core of their activity and reporting
    • amplify patients’ voices in all parts of the health system to ensure they are heard
    • identify and highlight where patient voice is neglected
    • challenge organisations to identify a named patient voice on all Boards and to place patient stories at the top of their meeting agendas
    • campaign to improve the use of Yellow Card reporting
    • campaign to see the NHS number used as the default and unique identifier
    • ·work to ensure patients are engaged in the development of all national specifications
    • develop the Patient Safety Commissioner website as a hub of best practice in championing patient voice.

    2.     Pelvic mesh

    The Patient Safety Commissioner plans to:

    • co-produce resources for patients and GPs about side effects from pelvic mesh surgery
    • work with NHS England to provide patients choice of access to specialist mesh centres
    • work with the health system to ensure that information is available to all patients on national registries.

    3.     Sodium valproate

    The Patient Safety Commissioner plans to:

    • support the health system to include the views of all stakeholders including patients to reduce harm from sodium valproate to the lowest possible level
    • work with health leaders to ensure that all relevant patients are on a Pregnancy Prevention Plan (PPP) and given the necessary information
    • collaborate with partners to ensure annual reviews are carried out by specialist prescribers
    • work with partners across health to eliminate dispensing of sodium valproate in unlabelled white boxes
    • work with professional regulators to streamline the advice to their registrants on sodium valproate and contraception
    • raise patient awareness through charity collaboration.
    Patient Safety Commissioner: 100 Days Report (2 February 2023) https://www.patients-association.org.uk/Handlers/Download.ashx?IDMF=abf20ccc-cc86-4ee6-a9fc-38c58af50424
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