Mark Hughes
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Everything posted by Mark Hughes
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Content ArticleThis systematic literature review looks at the international evidence on how interventions to improve safety culture may benefit hospital staff and how they can be designed and implemented. In its conclusion, the authors note that the impact of safety culture interventions on staff outcomes, evidence on staff experiences is scarce. They suggested that a greater focus on staff outcomes would provide more meaningful insight into staff experience within safety culture and results from the safety culture.
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Content ArticleIn this article, Sharon Hartles looks at the ongoing fight for justice by families affected by the hormone pregnancy test (HPT) Primodos. She discusses the impact of new evidence and advocacy efforts, highlighting the resilience of those involved in the quest for accountability. She also considers the absence of consideration of patients and family members affected by HPTs from the recent Hughes Report, which looked at redress options for the other two medical interventions covered by the Independent Medicines and Medical Devices Safety Review. Sharon Hartles is a member of the Harm and Evidence Research Collaborative at the Open University. Additionally, she is affiliated with the Risky Hormones research project, an international collaboration in partnership with patient groups. You can read the blog here. Related reading First Do No Harm. The report of the Independent Medicines and Medical Devices Safety Review (8 July 2020) The Hughes Report: Options for redress for those harmed by valproate and pelvic mesh (Patient Safety Commissioner for England, 7 February 2024) Reflections on The Hughes Report: Pelvic mesh, sodium valproate, hormone pregnancy tests and options for redress (a blog from Patient Safety Learning) A Bitter Pill: Primodos, The Forgotten Thalidomide (APPG on Hormone Pregnancy Tests, 27 February 2024) Patient Safety Spotlight interview with Marie Lyon, chair of the Association for Children Damaged by Hormone P
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The first ever World Health Organization (WHO) Global Report on Patient Safety will provide a comprehensive overview of patient safety measures globally, aligned with the Global Patient Safety Action Plan 2021–2030. It will include detailed analyses and summaries that highlight the burden of unsafe care and the strategies different countries are using to improve safety in health care. This WHO webinar will mark the launch of this report. Register here. agenda_global-patient-safety-report-2024-launch-webinar.pdf flyer_launch-event-global-patient-safety-report-2024.pdf -
Content ArticleIn January 2024, the Institute for Healthcare Improvement (IHI) Lucian Leape Institute convened an expert panel to explore the promise and potential risks for patient safety from generative artificial intelligence (genAI). This report is based on the expert panel’s review and discussion.
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Content ArticleThis investigation by the Health Services Safety Investigations Body (HSSIB) considers how patient safety can be improved in relation to children and young people with mental health needs while they stay on an acute paediatric ward—a ward for children and young people in a hospital that typically treats physical health conditions. It focuses on the risk factors associated with the design of these wards in acute hospitals.
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Content ArticleThis qualitative study looked at healthcare professionals perceptions of patient safety culture in Ghana. It was conducted with 42 healthcare professionals in two regional government hospitals in Ghana from March to June 2022. The authors note that despite positive attitudes and knowledge of patient safety, healthcare professionals expressed concerns about the implementation of patient safety policies outlined by hospitals. They also highlighted that there was a perception that curriculum training on patient safety during school education and the availability of dedicated officers for patient safety at their facilities may help improve patient safety.
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Content ArticleThis is the transcript of a statement in the House of Commons by the Minister for the Cabinet Office and Paymaster General, John Glen MP, in response to the publication of the final report of the Infected Blood Inquiry. He sets out plans for a proposed scheme to provide compensation to those infected and affected by this scandal. This was followed by comments from other members of the House of Commons.
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Content ArticleThis is the transcript of a statement in the House of Commons by the Prime Minister, Rishi Sunak MP, in response to the publication of the final report of the Infected Blood Inquiry. He apologises for the failure in blood policy and blood products, the repeated failure of the state and medical professionals to recognise the harm caused by this and for the institutional refusal to face up to these failings. He also says that the Government will pay comprehensive compensation to those infected and affected by this scandal. This statement is followed by a response from the Leader of the Opposition, Sir Keir Starmer MP, and comments from other members of the House of Commons.
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Content ArticleIn 2021, the Independent Medicines and Medical Devices Safety review, led by Baroness Cumberlege, conducted a comprehensive review of historic documents and found that Hormone Pregnancy Tests had caused avoidable harm, that they should have been withdrawn by the regulator after the first warnings in 1967 and that this failure to act meant that women were exposed unnecessarily to a potential risk. This report by the All-Party Parliamentary Group on Hormone Pregnancy Tests sets out the background to this and considers the findings in 2017 of an expert working group that was relied upon by the Government and manufacturers to strike out a claim for compensation in 2023. The report recommends that the Government sets up an independent review to examine the findings of this working group.
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Content ArticleThis cross-sectional study, published in Cureus, was conducted among 423 nurses working at tertiary care hospitals in the Al-Jouf region in Saudi Arabia. The authors note that participants valued the aspects of teamwork within units, organisational learning-continuous improvement, and overall perceptions of patient safety as areas of strength and important elements of patient safety culture. However, they also highlighted areas of concern that need improvement, such as nonpunitive response to errors, handoffs and transitions, communication openness, staffing, and frequency of events reported.
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Content ArticleIn vitro diagnostic (IVD) devices are used to examine samples taken from the human body and to diagnose and monitor health conditions. The Medicines and Healthcare products Regulatory Agency (MHRA) are seeking views on a new policy would require manufacturers to comply with additional measures for certain high risk IVDs, such as blood tests used to identify blood type before transfusions or tests which identify life-threatening diseases, introducing harmonised requirements for these products. The consultation closes at 11.59pm on 14 June 2024.
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Content ArticleAlthough much of the national press coverage of healthcare in the UK often focuses on the impact of delayed discharges from hospitals, ineffective discharge from mental health settings can lead to higher levels of patient readmission. In this blog CJ Nwasike looks at how discharge without support exacerbates pressure on community mental health services and can risk readmission.
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Content ArticleThe Thirlwall Inquiry is examining events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital. As part of this Inquiry, its Terms of Reference asks: “Whether recommendations to address culture and governance issues made by previous inquiries into the NHS have been implemented into wider NHS practice? To what effect?”. To help inform its work in this area, the Inquiry Legal Team has produced this Table of Inquiries and reviews which have been conducted in England and Wales over the last thirty years. Recommendations from each Inquiry have been set out in a comprehensive table, alongside details of whether or not those recommendations have been implemented.
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Content ArticleMore than 30,000 people were infected from 1970 to 1991 by contaminated blood products and transfusions provided by the NHS. It is estimated that more than 3,000 deaths are attributable to infected blood, products and tissue. This report sets out the findings of a five-year investigation by the Infected Blood Inquiry. The principal infections considered by the Inquiry are Hepatitis (B and C) and HIV. The transmission of vCJD is also considered. Update 9 July 2025: The Chair of the Inquiry, Sir Brian Langstaff, has published the Additional Report on Compensation. You can read the Report here.
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Content ArticleNHS bosses are destroying the careers of whistleblowers who stand up to protect patients’ lives, according to an exclusive investigation by The Telegraph. More than 50 doctors and nurses told us they have been targeted after raising concerns about upwards of 170 patient deaths and nearly 700 cases of poor care. In this episode of The Daily T podcast, Kamal Ahmed and Camilla Tominey are joined by the journalists behind the story, Janet Eastham and Gordon Rayner. This discussion takes in the video from 2 minutes 52 seconds to 16 minutes 40 seconds.
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Content ArticleIn this interview, Patrick Christys from GB News speaks to former Consultant Urological Surgeon, Peter Duffy, about the treatment of whistleblowers in the NHS who raise patient safety concerns. You can find out more about Peter’s experiences in his books Whistle in the Wind and Smoke and Mirrors. To watch the interview, click on the link below.
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Content ArticleThis report, commissioned by Alzheimer’s Society from Carnall Farrar, sets out estimates of current and future economic and healthcare costs of dementia in the UK. It breaks down this data by cost type, dementia severity and the regions of England and the devolved nations.
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Content ArticleIn April 2024 the World Health Organization published the Patient Safety Rights charter, outlining patients’ rights in the context of safety in healthcare. In this blog, Assistant Professor John Tingle and Teaching Fellow Angela Eggleton from Birmingham Law School at the University of Birmingham, consider the rights included in the Charter and applying this to the NHS.
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Content ArticleDiagnostic errors are associated with patient harm and suboptimal outcomes. However, despite efforts to advance definition, measurement and interventions for diagnostic error, diagnosis in mental health is not well represented in this ongoing work. The authors of this article, published in BMJ Safety & Quality, summarise the current state of research on diagnostic errors in mental health and identify opportunities to align future research with the emerging science of diagnostic safety. Further reading on the hub: This year’s World Patient Safety Day on 17 September 2024 (WPSD 2024) is focused on the theme “Improving diagnosis for patient safety”. Find out more.
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Content ArticleIn this opinion piece for BMJ, David Oliver, consultant in geriatrics and acute general medicine, looks at how the professional duty of candour operates in the NHS. In doing so he considers the effectiveness of actions taken in the last five years by the Care Quality Commission, General Medical Council and Nursing and Midwifery Council over failure to exercise the duty of candour.
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Content ArticlePatient Safety Specialists are individuals in NHS healthcare organisations who have been designated to provide dynamic senior patient safety leadership. This report shares the findings of an evaluation of this role conducted by THIS Institute, which took place between September 2022 and March 2024. As part of this they spoke to people involved in developing and supporting the role and examined the perspectives of role holders using a survey, focus groups and case-study interviews.
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Content ArticleThis investigation by the Health Services Safety Investigations Body (HSSIB) considers improvements that can be made to patient safety in relation to the use of continuous observation with adult patients in acute hospital wards who are at risk of self-harm. For its reference case, it looks at the case of a patient who self-harmed when receiving care at a high dependency unit while two members of staff were continuously observing her.
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Content ArticleIn this opinion piece for the BMJ, Scarlett McNally looks at patient safety concerns relating to maternity care in the NHS. She considers the costs associated with additional spending in the sector intended to improve safety and emphases the need to train and retain more midwives.
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Content ArticleThis report by the Maternity & Newborn Safety Investigations (MNSI) programme examines findings from 92 of their investigations where safety recommendations were made to midwife-led units in NHS hospital trusts in England. It highlights key learnings and prompts to help trusts to consider how safety risks can be mitigated and drive improvements in care.
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Content ArticleAntimicrobial resistance (AMR) occurs when bacteria, and other microorganisms, develop resistance to antimicrobial drugs, such as antibiotics, making them less responsive or unresponsive to treatment. This National Action Plan sets out how the UK will reduce its use of antimicrobials in humans and animals, strengthen surveillance of drug resistant infections before they emerge and incentivise industry to develop the next generation of treatments.
