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Mark Hughes

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  1. Content Article
    As part of the development of the new Learn from Patient Safety Events (LFPSE) service, this report from NHS England summarises the outcome of Discovery Phase research which considered how best patients, service users and their families can give their views on safety incidents, for the whole NHS to learn from.
  2. Content Article
    This is an oral statement given to the House of Commons by the Secretary of State for Health and Social Care, Steve Barclay MP, to update on the Lucy Letby statutory inquiry.
  3. Content Article
    In this letter, Rob Behrens, the Parliamentary and Health Service Ombudsman, calls on the Secretary of State for Health and Social Care, Steve Barclay MP, to prioritise improving patient safety in the wake of the Lucy Letby trial.
  4. Content Article
    This summary guide pulls together best practice to support NHS clinicians to better meet the Faster Diagnosis Standard for cancer. Getting It Right First Time (GIRFT) and NHS England’s Cancer Programme have worked in partnership to produce this guidance, which outlines how cancer alliances and local organisations can implement NHS England’s best practice timed diagnostic pathways for cancer. The guidance includes advice for all stages of a cancer diagnosis, from early identification of patients to onward referral, as well as useful insights from the relevant GIRFT national clinical leads and links to best practice case studies. This edition has a particular focus on colorectal cancer, prostate cancer and skin cancer.
  5. Content Article
    Peri-operative medication safety is complex. Avoidance of medication errors is both system- and practitioner-based, and many departments within the hospital contribute to safe and effective systems. For the individual anaesthetist, drawing up, labelling and then the correct administration of medications are key components in a patient's peri-operative journey. These guidelines from the Association of Anaesthetists aim to provide pragmatic safety steps for the practitioner and other individuals within the operative environment, as well as short- to long-term goals for development of a collaborative approach to reducing errors.
  6. Content Article
    While there is much potential and promise for the use of artificial intelligence in improving the safety and efficiency of health systems, this can at times be weakened by a narrow technology focus and by a lack of independent real-world evaluation. It should be expected that when AI is integrated into health systems, challenges to safety will emerge, some old, and some novel. In this chapter of the book Safety in the Digital Age: Sociotechnical Perspectives on Algorithms and Machine Learning, Mark Sujan argues that to address these issues, a systems approach is needed for the design of AI from the outset. He draws on two examples to help illustrate these issues: Design of an autonomous infusion pump and Implementation of AI in an ambulance service call centre to detect out-of-hospital cardiac arrest.
  7. Content Article
    This guide is intended for people caring for people living with Alzheimer’s Disease and other forms of dementia, to help facilitate conversations that can help to make health care decisions as the need arises. It has been produced as part of the Conversation Project, a public engagement initiative of the Institute for Healthcare Improvement (IHI). The Project’s goal is to help everyone talk about their wishes for care through the end of life, so those wishes can be understood and respected.
  8. Content Article
    Delayed discharges, where a patient is medically fit to leave hospital but is not discharged, were a particular problem in England in the winter of 2022/23. In this article, Camille Oung from the Nuffield Trust highlights some possible solutions to help better prepare health and care services for discharge pressures next winter.
  9. Content Article
    This annual report looks back at the work undertaken by NHS Resolution in 2022-23. NHS Resolution is an arm’s-length body of the Department of Health and Social Care, responsible for providing expertise to the NHS on resolving concerns and disputes fairly, sharing learning for improvement and preserving resources for patient care.
  10. Content Article
    All aspects of the diagnostic process are potentially vulnerable to error and this can occur in all healthcare settings and services. The Agency for Healthcare Research and Quality (AHRQ) is the lead Federal agency investing in research to improve diagnostic safety and reduce diagnostic error in the United States. On this webpage they collate a range of different research, tools and resources related to improving diagnostic safety.
  11. Content Article
    The Maternity Survey 2022, run by Ipsos on behalf of the Care Quality Commission, looked at the experiences of women and other pregnant people who had a live birth in early 2022. In this article Anita Jefferson from Ipsos looks at the results of this and considers what they tell us about experiences of maternity services.
  12. Content Article
    In June 2023 the AHSN Network published a refreshed Patient Safety Plan, reflecting progress made across focus areas including managing deterioration in care homes; maternity and neonatal health; medicines safety; mental health; and system safety. In this podcast episode, Caroline Kenyon talks to four leaders responsible for delivering the plan across the country, Tasha Swinscoe, Alison White, Katie Whittle and Jodie Mazar.
  13. Content Article
    Reflecting on the impact of restrictions placed on families and visitors to hospitals and care homes during the Covid-19 pandemic, this article, published in the BMJ, argues that families must be recognised and valued as partners in patient care.
  14. Content Article
    This report provides a review of the Healthcare Safety Investigation Branch (HSIB) maternity investigation programme during 2022/23. During this period HSIB completed 702 reports and made more than 1,380 safety recommendations.
  15. Content Article
    The Healthcare Safety Investigation Branch (HSIB) Annual Review 2022/23 looks back at its work over this period, during which HSIB published 16 investigation reports and issued 36 safety recommendations to 13 different organisation.
  16. Content Article
    On Monday 10 July 2023 the Centre for Perioperative Care (CPOC) and Patient Safety Learning jointly hosted a webinar on the new National Safety Standards for Invasive Procedures 2 (NatSSIPs 2). This article contains links to video recordings of this webinar.
  17. Content Article
    This article provides an overview of a Parliamentary reception, hosted by Carolyn Harris MP, as part of the Safety for All campaign. The event was attended by over 50 guests including MPs, Peers, frontline healthcare professionals, patients and representatives from NHS organisations, regulators, charities, unions and industry.
  18. Content Article
    On the 18 April 2023 the Women and Equalities Select Committee published a report on Black maternal health. This analysed Government and NHS activities to date in this area and made a number of recommendations for further action needed to end disparities in maternal deaths. This paper sets out the UK Government’s response to the recommendations in this report.
  19. Content Article
    On the 23 January 2023 the Minister for Mental Health and Women’s Health Strategy, Maria Caulfield MP, announced the commencement of a rapid review into patient safety in mental health inpatient settings in England. The review Chair, Dr Geraldine Strathdee, was asked to consider how improvements could be made to the way that data and information is used in relation to patient safety in mental health inpatient care settings and pathways, including for people with a learning disability and autistic people. This report contains the findings of this review and an associated set of recommendations.
  20. Content Article
    This is the transcript of an oral statement to the House of Commons by Steve Barclay MP, Secretary of State for Health and Social Care, on improving safety in mental health in-patient services across England.
  21. Content Article
    This is an overview of the role and responsibilities of the National Patient Safety Committee. This was established in 2021 to bring key national healthcare organisations together to address complex patient safety issues that require cross-organisation effort and input to make care safer within the NHS.
  22. Content Article
    David Wilson was admitted to Pinderfields Hospital on 27 December 2022 and subsequently underwent a CT scan which indicated an inflammation in the distal section of his colon. To identify the cause of this he underwent a flexible sigmoidoscopy, during which there was a colonic perforation which resulted in his death the following day.
  23. Content Article
    In this blog Aiden Fowler, the National Director of Patient Safety in England and a Deputy Chief Medical Officer at the Department of Health and Social Care, reflects on progress made in implementing the NHS Patient Safety Strategy, four years on from its publication. He outlines some of the main programmes of work associated with this and considers their impact on avoidable harm in the NHS.
  24. Content Article
    The NHS Staff Survey is an essential tool for assessing the experiences and opinions of NHS workers in Trusts in England. It also provides valuable insights to help understand the speaking up culture in the NHS. In this report the National Guardian’s Office analyse the results of the 2022 NHS Staff Survey, focusing on questions relating to speaking up.
  25. Content Article
    This article highlights three questions tabled in the House of Commons relating to the Yellow Card Scheme, the system for recording adverse incidents with medicines and medical devices in the UK.
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