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Mark Hughes

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  1. Content Article
    The Scottish Government has published a new Bill to establish a Patient Safety Commissioner for Scotland. This article provides an overview of the remit, accountability, powers, and responsibilities of the new Commissioner that are proposed in this Bill.
  2. Content Article
    Daily huddles with staff are used to support incident reporting and learning in healthcare. This study considers a Safety-II-inspired model for safety huddles developed and implemented at the Neonatal Care Unit at a regional hospital in Sweden.
  3. Content Article
    In this report the Professional Standards Authority for Health and Social Care sets out its view on the biggest challenges affecting the quality and safety of health and social care. It puts forward a number of recommendations to ensure safer care for all, with its main recommendation being that an independent Health and Social Care Safety Commissioner should be appointed for each UK country to identify current, emerging and potential risks across the whole health and social care system, and bring about the necessary action across organisations.
  4. Content Article
    Gloves are an important part of infection prevention and control, but they are often misused and overused in clinical practice, putting patients at increased risk of infection. During the Covid-19 pandemic, this issue has been exacerbated due to health professionals’ fear and anxiety. This article, published by Nursing Times, explores these issues, as well as actions to encourage the appropriate use of non-sterile gloves to protect both patients and health professionals.
  5. Content Article
    A good safety culture in healthcare is one that includes value and respect for diversity, strong leadership and teamwork, openness to learning, and staff who feel psychologically safe. In this article the Nuffield Trust use data from the NHS Staff Survey to look at safety culture in the NHS.
  6. Content Article
    The NHS Patient Safety Incident Response Framework (PSIRF) promotes a range of system-based approaches for learning from patient safety incidents. These national tools and guides have been developed to incorporate the well-established SEIPS framework (Systems Engineering Initiative for Patient Safety) to help support organisations implementing PSIRF.
  7. Content Article
    This article, published in Women Fitness Magazine, argues that a lack of awareness about safety measures and a shortage of healthcare professionals make it difficult for hospitals to ensure patient safety in the United States. It sets out six ways hospitals can ensure patient safety during treatment.
  8. Content Article
    The review, which has now concluded, advised the government on the health impact of potential ethnic and other biases in medical devices and made recommendations for more equitable solutions. The final report was published on 11 March 2024.
  9. Content Article
    This is the transcript of a Westminster Hall debate in the House of Commons on waiting lists for gynaecological services.
  10. Content Article
    Frail older adults are often at increased risk of patient safety incidents including rehospitalisation and overtreatment. In this study, published in BMC Geriatrics, researchers in the United States assessed the association of care coordination and preventable adverse events in frail older adults. Compared with non-frail older adults, they found that frail older adults reported experiencing more adverse events they believed could have been prevented with better care coordination.
  11. Content Article
    This study, published in the Journal of Patient Safety, looks at how preventable adverse events and near misses are identified, based on data from an acute care hospital in western Sweden. It examines how many events are identified through structured record review, web-based incident reporting and daily safety briefings, and the different types of events identified by each method. Reflecting on its findings, the authors suggest that health care organisations should adopt multiple methods to get a comprehensive review of the number and type of events occurring in their setting.
  12. Content Article
    The NHS in England has introduced a range of policy measures aimed at fostering greater openness, transparency and candour about quality and safety. This study looks at the implementation of these policies within NHS organisations, with the aim of identifying key implications for policy and practice.
  13. Content Article
    This blog considers the similarities and differences between the Healthcare Safety Investigation Branch in England and Ukom, the Norwegian Healthcare Investigation Board. Both are independent national organisations, which take a no blame approach to patient safety investigations, however they also have a number of distinct differences in their approach.
  14. Content Article
    This article highlights two written questions tabled in the House of Commons relating to recommendations of the Independent Medicines and Medical Devices Safety (IMMDS) Review concerning surgical mesh implants.
  15. Content Article
    Unsafe medication practices and medication errors are a leading cause of avoidable harm in healthcare and are the focus of this year’s World Patient Safety Day on 17 September 2022. This article highlights two written questions tabled in the House of Commons asking about medication safety issues in the UK and the Government’s responses.
  16. Content Article
    This review, published in official journal of the International Society of Pharmacovigilance, Drug Safety, is aimed at determining the overall incidence, severity and preventability of medication-related hospital admissions in Australia. In its conclusions, the authors estimate that 250,000 hospital admissions in Australia are medication-related, with an annual cost of AUD$1.4 billion to the healthcare system, and that two-thirds of medication-related hospital admissions are potentially preventable.
  17. Content Article
    People with living dementia or mild cognitive impairment and their family carers face challenges in managing medicines. This review, published in Age and Ageing, identifies interventions to improve medicine self-management for people with dementia and mild cognitive impairment and their family carers, and the core components of medicine self-management that they address.
  18. Content Article
    This study, published in the Journal of the Royal Society of Medicine, examines national policies of complaint handling in English hospitals, how they are understood by those responsible for enacting them, and explores if there are any discrepancies between policies-as-intended and their reality in local practice.
  19. Content Article
    This is an Early Day Motion tabled in the House of Commons on 18 May 2022, which calls on the Government to implement the recommendations of the Independent Medicines and Medical Devices Safety Review in full, including paying compensation to people disabled by sodium valproate.
  20. Content Article
    In this letter nine charities and patient organisations write to Sajid Javid MP, Secretary of State for Health and Social Care, urging him to reconsider plans to impose fixed costs on lower value clinical negligence claims. They argue that the proposals are a threat to both access to justice and patient safety.
  21. Content Article
    As part of the Medicines and Medical Devices Act 2021, the UK Government formally committed to establishing the new role of a Patient Safety Commissioner for England. In this blog Dr Victoria Moore explores the role of the proposed Patient Safety Commissioner, arguing that this may not be sufficient to ensure patient safety.
  22. Content Article
    Huge numbers of patients suffer avoidable harm in US hospitals each year as a result of unsafe care. In this blog, published in the Harvard Business Review, the authors argue that these numbers could be greatly reduced by taking four actions: Make patient safety a top priority in hospitals’ practices and cultures, establish a National Patient Safety Board, create a national patient and staff reporting mechanism, and turn on EHRs machine learning systems that can alert staff to risky conditions.
  23. Content Article
    Artificial intelligence systems for healthcare, like any other medical device, have the potential to fail. In this article, published in The Lancet: Digital Health, the authors recommend a medical algorithmic audit framework as a tool that can be used to better understand the weaknesses of an artificial intelligence system and put in place mechanisms to mitigate their impact. They propose that this framework should be the joint responsibility of users and developers who can collaborate to ensure patient safety and correct performance of the system in question.
  24. Content Article
    This is the transcript of a statement given in the House of Commons by the Secretary of State for Health and Social Care, Sajid Javid MP, in response to the publication of the final report of the Ockenden Review. In the statement he makes a commitment that the local trust, NHS England and the Department of Health and Social Care will accept all 84 recommendations made by the Review. This is followed by questions from MPs in the Chamber and Mr Javid's responses.
  25. Content Article
    A key part of healthcare digital transformation is the development and adoption of artificial intelligence technologies. This article, published in BMJ Health & Care Informatics, considers how human factors and ergonomic principles can be applied to the use of artificial intelligence in healthcare.
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