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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Xanax, a drug used to treat anxiety disorders, has been placed under a nationwide recall in the USA Viatris, the maker of Xanax, recalled the medication last month because of “failed dissolution specifications,” according to a recent notice from the Food and Drug Administration. This means the pill may not break down in the body and release the drug at the right speed. If the medication doesn’t dissolve correctly, it could reduce its effectiveness. Last week, the FDA classified the recall as Class II, meaning the affected pills could cause “temporary or medically reversible adverse health consequences or where the probability of serious adverse health consequences is remote,” according to the agency. A Viatris spokesperson told The Independent, “Patient safety and the quality of our medicines are of the utmost importance to Viatris. The voluntary recall of Xanax XR in the U.S. is specific to one lot of one strength (3mg) of the brand product only, and no other batches of the Xanax XR brand product, or its generics, are impacted.” Viatris said patients don’t need to take any action in connection with the recall and that wholesalers and pharmacies have been provided with instructions on how to return the affected Xanax. The drug maker said they have not received any reports of adverse reactions from the recalled product as of Wednesday. Read full story Source: The Independent, 16 April 2026
  2. News Article
    Nearly half of Americans are somewhat skeptical of vaccines, a new poll has found. Some 46% of U.S. adults who responded to a Public First poll by Politico in March agreed that “facts on vaccines are still up for debate and it is damaging to enforce their uptake.” In contrast, only 39% said that the science on vaccines “is clear and it is damaging to question it.” The results of the survey are in line with the views of Health Secretary Robert F. Kennedy Jr., a longtime vaccine skeptic and founder of the Republican “Make America Healthy Again” movement. “What stands out is that vaccine safety and vaccine choice are no longer fringe issues,” Mary Holland, CEO of anti-vax group Children’s Health Defense, which Kennedy previously led before taking his post in government, told Politico. “People want to be able to make their own medical decisions.” Astonishingly, overall, 39% of respondents to Politico’s survey said they would allow vaccine-preventable diseases to return, rather than force people to have vaccines, in contrast to 47% who said they would rather not. During his tenure as Health Secretary, Kennedy has overseen several major changes within his department and its policies, including the attempted overhaul of the Centers for Disease Control and Prevention and the elimination of Covid-19 vaccine recommendations. Last week, it was reported that the CDC had delayed publishing a report showing the benefits of the Covid vaccine, further sparking concerns that the information conflicted with Kennedy’s views. The CDC insisted that the move followed standard procedure. Read full story Source: The Independent, 14 April 2026
  3. News Article
    Treating patients with serious conditions from the comfort of their own homes could deliver far greater benefits than previously thought, saving the NHS hundreds of millions of pounds while improving care quality and patient satisfaction, according to a major new study. The most comprehensive evaluation of the ‘Hospital at Home’ model to date has found that patients cared for through West Hertfordshire Teaching Hospitals NHS Trust’s Virtual Hospital, delivered in partnership with Central London Community Healthcare NHS Trust, overwhelmingly preferred home‑based care to traditional hospital treatment. The peer‑reviewed study, published on 8 April in Frontiers in Digital Health, analysed outcomes for 3,000 patients admitted to the Hospital at Home service between April 2023 and April 2024. The findings demonstrate not only strong clinical and patient experience benefits, but also a compelling economic case for scaling up Virtual Hospital models across the NHS. The evaluation found that Hospital at Home care significantly reduced the time patients spent receiving acute treatment. Key findings include: Early Supported Discharge patients spent 2.8 fewer days in care on average compared with similar hospital patients. Hospital at Home care costs £118.49 per bed day, compared with £569 for inpatient hospital care. Savings of £486 per Early Supported Discharge patient. Savings of £3,652 per Admission Avoidance patient. Overall, the programme delivered net savings of £1.33 million over 12 months. Patient experience was a major strength of the Virtual Hospital model. The study found that 95.8% of patients preferred Virtual Hospital care, and 98.3% of patients said they felt safe while being treated at home. Read full story Source: National Health Executive, 14 April 2026
  4. News Article
    Drugs aimed at slowing Alzheimer's disease progression "make no meaningful difference to patients" while raising the risk of brain swelling and bleeding, a new review has claimed. However, charities have swiftly challenged these findings, accusing experts of unfairly combining failed and successful drug trials. Researchers behind the review stated that the effects of these medicines on individuals with early-stage Alzheimer's and dementia were "either absent or consistently small". Edo Richard, a professor of neurology at Radboud University Medical Centre in the Netherlands, noted his team observed "results from trials over the last two decades 'are not consistent'". Charities argue that the review's authors have attempted to "paint an entire class of drugs with the same brush", potentially undermining the benefits of certain treatments. Anti-amyloid medicines work by binding to and clearing protein deposits in the brains of those with Alzheimer's, a process intended to slow cognitive decline. The treatments were not approved for use on the NHS after the National Institute for Health and Care Excellence (Nice) deemed their benefits “too small” to justify the cost. The new Cochrane review looked at 17 studies involving 20,342 patients overall. The analysis found that the effects of these drugs on cognitive function and dementia severity after 18 months was “trivial”. According to Prof Richard, the differences made by the treatments were “far below the minimal effect that’s needed to be noticeable at all for patients and caregivers”. Dr Susan Kohlhaas, executive director of research at Alzheimer’s Research UK, said the charity regularly heard from families impacted by dementia who said that even a delay of several months in their loved one’s decline “could provide valuable, meaningful time” that “shouldn’t be minimised”. She said: “Crucially, this study is attempting to paint an entire class of drugs with the same brush even though we know different anti-amyloid treatments can act in different ways. “Anti-amyloid treatments will not be the whole answer to curing Alzheimer’s, and research is already moving towards a wider range of biological targets. “But it’s not accurate to dismiss their impact as ‘trivial’, especially when the analysis has clear constraints that limit what it can tell us.” Read full story Source: The Independent, 16 April 2026
  5. Event
    This webinar, hosted by the International Association of Medical Regulatory Authorities, will explore how medical and health profession regulators and broader patient safety systems can work more closely together to strengthen care and reduce harm to patients. It aims to help improve understanding of the opportunities to better connect people and system focused safety systems, including through potential partnership models, to best support and ensure a safe and competent health workforce. Speakers include: Helen Hughes, Chief Executive, Patient Safety Learning Dr Gerry Hickson, Vanderbilt University Medical Center Professor Martin Fletcher, IAMRA Board Member You can sign up for the webinar here. Related reading Professional regulation and patient safety systems: parallel planets or partners in improvement?
  6. News Article
    A major investigation into the care of more than 200 NHS cases has been expanded to include a "small number" of heart patients, confirms Sussex Police. The force is looking into allegations of medical negligence at the Royal Sussex County Hospital in Brighton between 2015 and 2021 as part of Operation Bramber. Officers are examining claims about preventable deaths and injuries in the trust's neurosurgery and general surgery departments. University Hospital Sussex NHS Trust, which runs seven hospitals across East and West Sussex, said it would continue to "fully co-operate" with the police investigation. Initially, 40 deaths were investigated as part of Operation Bramber, which was launched by the police in 2023, after both a coroner and two consultant surgeons at the hospital raised concerns. A spokesperson for Sussex Police said: "As a result of a further witness coming forward during the course of the investigation, police are now starting to review a small number of cases relating to cardiothoracic surgery at the Royal Sussex County Hospital." And added: "Cases relating to neurosurgery and general surgery at the Royal Sussex County Hospital in Brighton between 2015 and 2021 have started to be reviewed by specialist consultant surgeons who are totally independent of University Hospitals Sussex NHS Foundation Trust. "They have been commissioned to provide expert medical opinion on individual cases, and their reports will be considered alongside information obtained from our police enquiries to determine whether any cases will be taken forward and if so, which ones." Read full story Source: BBC News, 15 April 2026
  7. Event
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    Kennedys healthcare team are delighted to be hosting the next webinar in their 2026 programme. With guest speaker, Mr Amar Alwitry, Consultant Ophthalmologist and author of Complaints, Litigation and Clinical Errors. Cataract surgery is the most commonly performed procedure in the NHS, with over 7.5 million outpatient attendances each year. Despite this, common errors still occur and can lead to visual loss and litigation. During this webinar, Mr Alwitry will discuss the most frequent issues in cataract surgery, exploring how these errors can be prevented. Learn from real experiences and shared insights, with a focus on creating sustainable, meaningful change in practice. Register
  8. Content Article
    Latest research from the King's Fund shows no improvement in people’s experiences of NHS admin. NHS admin plays a central role in shaping how people experience and perceive the NHS. Our findings point to a major opportunity for government and NHS leaders to act. Key findings Two thirds (66%) of patients and carers who used NHS services in the past 12 months experienced at least one administrative problem. There has been no improvement since the same polling was conducted the previous year. While the number of people experiencing admin issues has remained unchanged, what has shifted is wider public awareness: administrative failings are increasingly recognised as a frequent and persistent problem across the NHS. In 2025 less than half (43%) of the public said that the NHS is good at communicating with patients about things like appointments and test results, down from 52% in 2024. The percentage of the public who said the NHS was good at keeping people informed about what is happening with their care and treatment has fallen from 42% in 2024 to 32% in 2025. 33% of people who had used NHS services in the previous 12 months said they had not been kept updated about how long they would have to wait for care or treatment. Almost 1 in 4 people who had used NHS services in the previous 12 months (23%) reported being invited to an appointment after the date of the appointment – a 3 percentage point increase since 2024. 3 in 5 people who had experienced admin issues (60%) said it made them think that NHS money is being wasted. People living with a long-term health condition are more likely to say the NHS is poor at keeping people informed about what is happening with their care and treatment (45%), compared with 36% of people who do not have a long-term condition. 4 in 5 patients and carers (81%) who report they are struggling financially have experienced an issue with NHS admin, compared with 63% of those who are comfortable financially. Related reading on the hub: The challenges of navigating the healthcare system
  9. News Article
    Two-thirds of patients (66%) have experienced at least one NHS admin problem in the past year, according to a new study. The report from the King’s Fund, Healthwatch and National Voices exposed the admin “doom loop” with patients being forced to chase NHS test results, receiving appointment reminders after the date has passed, not being kept informed about waiting times and being given incorrect information. The report, based on responses from 1,908 adults in December, said: “The results overall make for difficult reading. Not only has there been little change in people’s experience of NHS admin since our previous polling (2024), but general perceptions of NHS admin and communications have actually gotten worse. “Less than half of those polled think the NHS is good at communicating with patients about things like appointments and test results, and around a third think it is poor at various aspects of communication with patients. “When we asked people how good or poor the NHS is at communicating with patients about things like appointments and test results, over two in five (43%) said it was good, while nearly one in three (30%) said it was poor. “This is worse than in 2024, when over one in two (52 per cent) said it was good and one in four (25 per cent) said it was poor.” The study found responses to particular aspects of admin have got worse. For example, in 2025, 32% of people said the NHS is good at ensuring patients have someone to contact about ongoing care (down from 43% in 2024), while just over 34% said it is poor (compared with 28% in 2024). People with long-term health conditions were more likely to say the NHS is poor, while carers and those on lower incomes were also more likely to say the same. Read full story Source: The Independent, 16 April 2026 Related reading on the hub: The challenges of navigating the healthcare system
  10. News Article
    It is a revolution that might just save the NHS – and the high street. Imagine being able to have your eyes tested, mole examined or get an appointment with a consultant without going to your local hospital – and maybe fit in some shopping or a cinema visit afterwards. That, increasingly, is what people in Barnsley are doing after an unprecedented relocation of medical services from the district general hospital into a purpose-built outpatients centre in the Alhambra shopping centre, which is getting a new lease of life thanks to the experiment. Those involved say the initiative – the first of its kind in the NHS – is trailblazing and revolutionary. After a recent visit, Wes Streeting, the health secretary, described it as “really inspiring”. He said: “What we’re seeing right here in the heart of Barnsley town centre is the future of the NHS.” The outpatients centre has been created as a result of a collaboration between Barnsley hospital NHS foundation trust and the town’s Labour-run council. Hundreds of people a week are visiting it to have tests or treatment, including minor operations,for example to treat cataracts, blocked tear ducts or ingrowing eyelashes. Soon the number will rise to 1,000 or more. It gives patients easier access to a range of non-urgent services than at the hospital on the town’s outskirts, where parking is limited. Through the extra footfall it is generating, it is also boosting custom for shops, cafes, restaurants and leisure facilities. “It’s about having your mammogram while your husband wanders around at Sports Direct, or meeting your friend for a coffee after a dermatology appointment where someone looked at your rash,” says Michael Brown, the architect who designed the new facility. The outpatient centre’s location is proving a hit with patients, partly because it is a quick walk from the bus and rail station, says Alan Heathcote, Barnsley hospital’s project manager. “Patient feedback has been very positive. And the themes are consistent: easier access, a better location, less walking, shorter waits and no need to battle for hospital parking”, he says. Parking near the Alhambra is plentiful and cheap. The experience of the CDC so far suggests that offering care in a town centre location has helped to reduce “DNAs” – patients who don’t show up – by 24%. Read full story Source: The Guardian, 16 April 2026
  11. News Article
    A chair finally been appointed for an independent review into maternity and neonatal services in Sussex, nearly 10 months after the investigation was first announced by Wes Streeting. Midwife Donna Ockenden will lead the review, which is now expected to look far wider than the nine deaths at University Hospitals Susex Foundation Trust it was originally expected to examine. Families affected have been calling for Ms Ockenden to be chosen. She is already chairing the inquiry into maternity at Nottingham University Hospitals Trust, and was recently appointed to head a similar inquiry into Leeds Teaching Hospitals. She previously led the inquiry into Shrewsbury and Telford maternity. The health and social care secretary, who met with Sussex families on Wednesday afternoon, said afterwards: “Donna Ockenden has earned the trust of families across the country through her tireless work to uncover the truth and drive lasting change in maternity care. I know she will bring that same dedication to Sussex.” Read full story (paywalled) Source: HSJ, 16 April 2026
  12. Content Article
    This guidance supports services to provide developmentally appropriate care for 0 to 25-year-olds. It sets out proposed actions for integrated care boards, providers and clinical teams to enable safe and effective transition between services. If adopted by systems, this approach will improve continuity of care, health outcomes and young people’s experience.
  13. News Article
    Women are waiting too long for care because of “medical misogyny” within the NHS, the UK’s top gynaecologist has warned. Dr Alison Wright, president of the Royal College of Gynaecologists and Obstetricians (RCOG), warned that women’s health conditions are often prioritised differently to men’s, with chronic and debilitating conditions such as endometriosis not being given the attention they deserve. She also warned that A&E was being clogged up with women who need emergency treatment because they are waiting too long for routine procedures. Speaking to The Independent ahead of the government’s new health plan for women, published by health secretary Wes Streeting on Wednesday, she said: “Misogyny exists across society... sadly, I’m having to say this in 2026. “Women are not prioritised as they should be across the board, including when it comes to the health service. We, as gynaecologists, often have to really push for women to get a place in the operating theatre.” She added: “An example [a colleague] gave me recently was of a man who had a testicular torsion, which is often treated as an emergency and taken to the operating room very quickly. “Whereas, when a woman has a similar equivalent of torsion of her ovary, it’s not always treated as an emergency in the same way.” Dr Wright claimed that robots were brought into hospitals “very quickly” for male urology surgery, while gynaecologists had to “jump through hoops” for the same technology. Read full story Source: The Independent, 15 April 2026
  14. Content Article
    Medicine is still debating whether artificial intelligence will match or exceed human diagnostic skill. But the most consequential change is already happening elsewhere. It is unfolding quietly in the relationships patients are forming with AI systems, and in the narratives they bring with them before a clinician ever enters the room. If general practice only looks for it inside the consultation, it will be reacting to consequences rather than causes. Adam Phillips is a UK medical student and former IBM technology consultant, and Simon Rudland, visiting professor of integrated digital health at the University of Suffolk, describe these dynamics as post-Turing clinical relationships (PTCRs). In these relationships, patients develop sustained, functionally supportive interactions with AI tools that influence how they interpret symptoms, regulate anxiety, decide when to seek care, and engage with clinicians. The changes are uneven, but they are already reshaping consultations and continuity in ways general practice is only beginning to notice.
  15. Content Article
    Artificial intelligence (AI)-driven chatbots have been rapidly adopted across research, education, business, marketing and medicine. Most interactions, however, come from non-experts using chatbots like search engines, including for everyday health and medical queries. This study, published in BMJ Open, audited chatbot responses in health and medical fields prone to misinformation. Five popular chatbots were assessed: Gemini (Google), DeepSeek (High-Flyer), Meta AI (Meta), ChatGPT (OpenAI) and Grok (xAI). In February 2025, each chatbot was prompted with 10 questions from five categories: cancer, vaccines, stem cells, nutrition and athletic performance. The authors deployed an adversarial-like framework, using open- and closed-ended prompts designed to strain models toward misinformation or contraindicated advice. Two experts from each category rated responses as ‘non-problematic’, ‘somewhat problematic’ or ‘highly problematic’ using a coding matrix based on objective, predefined criteria. Citations were scored for accuracy and completeness, and each response was given a Flesch Reading Ease score. The study found that nearly half (49.6%) of responses were problematic: 30% somewhat problematic and 19.6% highly problematic. Response quality did not differ significantly among chatbots, but Grok generated significantly more highly problematic responses than would be expected under a random distribution. Performance was strongest in vaccines and cancer, and weakest in stem cells, athletic performance and nutrition. Chatbot outputs were consistently expressed with confidence and certainty; from 250 total questions, there were only two refusals to answer, both from Meta AI. Reference quality was poor, with a median completeness score of 40%. Chatbot hallucinations and fabricated citations precluded any chatbot from producing a fully accurate reference list. All readability scores were graded as ‘Difficult’, equivalent to college sophomore–senior level. The audited chatbots performed poorly when answering questions in misinformation-prone health and medical fields. Continued deployment without public education and oversight risks amplifying misinformation.
  16. News Article
    Experts have issued a stark warning about the use of AI chatbots for health and medical information. Chatbots such as ChatGPT and Grok frequently "hallucinate," delivering inaccurate and incomplete medical information, research has found. Half of the responses to 50 medical questions in a recent study were deemed "problematic." All AI types were implicated, with Grok showing the most issues (58%), followed by ChatGPT (52%) and Meta AI (50%). Researchers said “chatbots often hallucinate, generating incorrect or misleading responses due to biased or incomplete training data, and models that are fine-tuned on human feedback are known to exhibit sycophancy – prioritising answers that align with user beliefs over the truth”. They said the incorporation of AI chatbots into medicine requires diligent oversight, “especially since they are not licensed to dispense medical advice and may not have access to up-to-date medical knowledge”. Previous work has found that only 32% of more than 500 citations from ChatGPT, ScholarGPT and DeepSeek were accurate and almost half were at least partially fabricated, according to the study. Read full story Source: The Independent, 15 April 2026
  17. News Article
    Compensation payments will rise for people affected by the infected blood scandal, including an extra £35,000 each for former pupils who were experimented on at school without their knowledge, the paymaster general has announced. The government has allocated £1bn for the payments. The final report of the inquiry into what has been described as the biggest treatment disaster in NHS history was published in May 2024. The compensation scheme that followed has also been blighted by controversy. People who were infected, and their relatives, had complained about delays, qualifying criteria, the size of payments and the complex application process. Among those angry at the amount they were offered were former pupils at Treloar’s college, a specialist school in Hampshire for haemophiliacs, where they were infected in experimental trials. On Tuesday, the paymaster general, Nick Thomas-Symonds, announced the government’s response to the public consultation on proposed changes to the infected blood compensation scheme. The compensation pot was set at £11.8bn in the 2024 autumn budget, with the announced changes estimated to cost £1bn. Thomas-Symonds said: “While this government understands no amount of money will make up for the suffering endured by the infected blood community, I hope that these changes to the compensation scheme demonstrate our commitment in ensuring this community receives the compensation they rightly deserve.” Read full story Source: The Guardian, 14 April 2026
  18. News Article
    Wes Streeting has vowed to stop women being “gaslit” by doctors as he relaunches the women’s health strategy for England. Speaking before the publication of the renewed strategy on Wednesday, Streeting said the NHS was “failing women” and set out measures to help them access the healthcare they need. The government said the strategy would include a new standard of care to ensure women were offered pain relief for invasive procedures, such as fitting a contraceptive coil and hysteroscopies. Feedback would be directly linked to provider funding via a new trial, giving women more power to affect change if they have a poor experience. Action would also be taken to ensure women no longer face long waits for diagnoses for conditions such as endometriosis, which can take a decade to diagnose. MPs said parts of the 10-year women’s health strategy, launched in 2022 by the Conservatives, were at risk of being scaled back or discontinued under wider changes to the NHS. These included initiatives that had reduced waiting lists and improved women’s access to healthcare, such as women’s health hubs. Sarah Owen, the chair of the committee and a Labour MP, said: “This would be a disaster for girls’ and women’s menstrual healthcare, when it is in dire need of more support. “It is a national scandal that nearly half a million women are on hospital gynaecology waiting lists when there are effective treatments that could be administered in primary and community care, if only they could access them.” Streeting said: “[Women] have for so long been let down by a healthcare system that too often gaslights women, treating their pain as an inconvenience and their symptoms as an overreaction.” He added: “Whether it’s being passed from one appointment to another for conditions like endometriosis and fibroids, or a lack of proper pain relief during invasive procedures, through to having to navigate symptoms for years before receiving a diagnosis, it’s clear the system is failing women. “Women’s voices must be central to delivering effective, respectful and empathetic care. We need to hit medical misogyny where it hurts – the wallet. Today’s renewed strategy will tackle the issues women face every day and ensure no woman is left fighting to be heard.” Read full story Source: The Guardian, 14 April 2026
  19. News Article
    Pawel Bukowski, 48, was found dead at his home in Norfolk in April last year after Turkish dentists removed his teeth but sent him home without new implants. An inquest has now found that the NHS “missed” opportunities to prevent the forklift driver’s death, which a coroner ruled was suicide. Mr Bukowski travelled to the country in January 2025 for the treatment after suffering from periodontal disease, a chronic inflammatory condition. Mr Bukowsi was told by dentists that once his teeth were removed, he would be given temporary dentures while he waited for a second permanent implant procedure several months later. Daria Bukowska, his widow, told the inquest at Norfolk coroner’s court: “Unfortunately, after removing all of his teeth, the clinic told him they could not proceed further. “They sent him home without any teeth and told him to return in six months. This was emotionally devastating for him.” The inquest heard mental health workers concluded he was “hopeless with a strong suicidal ideation” and there were concerns for his “safety and wellbeing”. However, they chose not to admit him to psychiatric care because of “sufficient protective factors” and sent him home to his family, who were given medication for him and advice on keeping him safe. On April 26, his “heavy” drinking prevented a nurse from prescribing him further medication. On April 28, a psychiatrist was due to visit him at home at 10am but staff sickness meant he was not visited until shortly before 1pm, when he was found dead. Johanna Thompson, the area coroner, recorded his cause of death as suicide and said there was “evidence of Pawel’s intent to end his life in the messages and notes he left”. The Norfolk and Suffolk NHS Foundation Trust investigated itself following his death and found the decision not to admit him on April 24 was a “missed opportunity”, the coroner said. Read full story (paywalled) Source: The Telegraph, 13 April 2026
  20. Content Article
    Advice and guidance (A&G) enables dialogue between specialists and GPs before a referral is made. The aim is to ensure patients are managed in the right setting and to avoid unnecessary hospital referrals. A&G was first introduced as a formal pathway in 2015, so the concept itself is not new. However, its prominence as a policy lever is. The GP Contract 2026/27 outlines that GPs will be required to use A&G “prior to or in place of a planned care referral where clinically appropriate”. The Neighbourhood Health Framework goes further, stating an aim to achieve a “diversion rate of at least 25 per cent by March 2027 for at least 10 high-volume specialties”. This has not come without debate. Wes Streeting recently published a blog to “set out the facts” following media coverage alleging that A&G targets may lead to rationing of care. Transparency will be critical to evaluate whether increased use of A&G leads to better experiences and outcomes, says William Pett in this HSJ article.
  21. News Article
    In a letter to healthcare professionals, drugs manufacturer Pfizer is to warn of serious and fatal adverse reactions following inadvertent administration of tranexamic acid instead of local anaesthetics. The letter, seen by The Pharmaceutical Journal and dated 30 April 2026, says: “Serious, including fatal, adverse reactions have been reported after inadvertent intrathecal administration [of tranexamic acid] due to mix-ups, mostly with injectable local anaesthetics.” Pfizer said it was sending the letter on behalf of marketing authorisation holders and in agreement with the Medicines and Healthcare products Regulatory Agency (MHRA). Tranexamic acid is an antifibrinolytic, used in the prevention and treatment of haemorrhages. “Intrathecal, epidural, intraventricular and intracerebral use of tranexamic acid solution for injection is contraindicated,” the letter added. “Cases of medication errors have been identified, including cases reported in the EU, where tranexamic acid injection was inadvertently administered intrathecally or epidurally. “Most of these cases involved mix-ups of vials or ampoules resulting in erroneous administration of tranexamic acid instead of the intended injectable local anaesthetic (e.g. bupivacaine, levobupivacaine, prilocaine).” It has added that, when administered intrathecally, serious patient harms had been reported, including prolonged hospitalisation and death, while serious adverse reactions that were reported include severe back, gluteal and lower limb pain, myoclonus, generalised seizures and cardiac arrhythmias. “Extreme caution should be taken when storing, handling and administering IV formulations of tranexamic acid to ensure the correct route of administration. This includes clearly labelling syringes containing tranexamic acid for IV use only and storing tranexamic acid injectables separately from injectable local anaesthetics,” it added. Read full story Source: The Pharmaceutical Journal, 14 April 2026
  22. Event
    Aimed at Clinicians and Managers, this national virtual conference will provide a practical guide to human factors in healthcare, and how a human factors approach can improve patient care, quality, process, and safety. The conference delves into integrating human factors into healthcare systems and processes, clinical decision making, healthcare system design, quality of patient experience, medication safety, and workload, fatigue, and stress management. Throughout the day there will be interactive sessions, small breakout groups, and collaborative exercises, fostering a dynamic learning experience. This conference will enable you to: Network with colleagues who are working to embed a human factors approach. Learn from outstanding practice in using human factors and ergonomics to improve patient safety and quality. Reflect on national developments and learning including the patient safety syllabus and the role of human factors within the new Patient Safety Incident Response Framework (PSIRF). Understand the tools and methodology. Develop your skills in training and educating frontline staff in human factors. Understand how you can improve patient safety incident investigation by using a human factors approach. Learn from case studies demonstrating the practical application of human factors to improve patient care and safety. Understand the role of human factors in improving culture and delivering psychological safety. Self assess and reflect on your own practice. Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register We are pleased to offer hub members a free place using the code HCUK00HFPSL
  23. Event
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    How the Patient Safety Framework and related investigations should work when serious incidents happen Join Making Families Count for a new series of lunchtime online seminars for families, carers, and health professionals. These free one-hour sessions bring together expert speakers with family carers to explore key issues in mental health care, patient confidentiality, suicide bereavement, and patient safety. Each event will include the opportunity to submit questions in advance. Whether you are supporting a loved one, working in health services, or seeking to better understand these issues, these sessions aim to provide practical insight, clearer understanding, and greater confidence. Led by: Ashley Windebank-Brooks, Head of Patient Safety at North Bristol NHS Trust Respondent: [Name to be confirmed] About this session This session will explain how the Patient Safety Framework and related investigations should work when serious incidents happen. Topics will include: What patient safety investigations are for. What families should be entitled to expect. What good practice looks like. How learning and accountability should be handled. A valuable session for anyone wanting to better understand how safety investigations should support learning, transparency, and improvement. Register
  24. Event
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    Bereavement by suicide can be especially painful, complex, and isolating. Join Making Families Count for a new series of lunchtime online seminars for families, carers, and health professionals. These free one-hour sessions bring together expert speakers with family carers to explore key issues in mental health care, patient confidentiality, suicide bereavement, and patient safety. Each event will include the opportunity to submit questions in advance. Whether you are supporting a loved one, working in health services, or seeking to better understand these issues, these sessions aim to provide practical insight, clearer understanding, and greater confidence. Led by: Dr Rachel Gibbons Respondent: Dorit Braun Bereavement by suicide can be especially painful, complex, and isolating. This session will explore: Why suicide bereavement can is so complex relative to other forms of grief. What suicide-bereaved people may need. How professionals, families, and communities can respond better to suicide bereaved people. This session is for both those with lived experience and professionals who want to respond more helpfully and compassionately. Register
  25. Event
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    Families often struggle to give and get information about a loved one’s care “because of confidentiality” - find out how it should work Join Making Families Count for a new series of lunchtime online seminars for families, carers, and health professionals. These free one-hour sessions bring together expert speakers with family carers to explore key issues in mental health care, patient confidentiality, suicide bereavement, and patient safety. Each event will include the opportunity to submit questions in advance. Whether you are supporting a loved one, working in health services, or seeking to better understand these issues, these sessions aim to provide practical insight, clearer understanding, and greater confidence. Led by: Dr Sarah Constantine, Caldicott Guardian at Avon and Wiltshire Mental Health Partnership NHS Trust Respondent: Sam Robinson, MFC Lived Experience Director Families are often told they cannot receive information about a loved one’s care “because of confidentiality” — and often struggle to have the information they want to provide taken seriously. This session will explore: How confidentiality should work in mental health care What information families want to share and why it matters How families can and should help influence care and safety planning What best practice looks like in real life Ideal for: families, carers, clinicians, and mental health professionals. Register

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