Mark Hughes
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Content ArticleThis 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.
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Content ArticleThis 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.
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Content ArticleIn 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.
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Content ArticleAs 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.
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Content ArticleHuge 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.
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Content Article
The medical algorithmic audit (5 April 2022)
Mark Hughes posted an article in Artificial Intelligence
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. -
Content ArticleThis 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.
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Content ArticleA 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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Prevention of Future Deaths report – Van Tuyen (22 February 2022)
Mark Hughes posted an article in Coroner reports
Van Thai Tuyen was admitted to the Royal London Hospital on 1 August 2021 for treatment of a stroke. A nasogastric tube was inserted to administer medication and food, due to Mr Tuyen being assessed as having an unsafe swallow. Despite an x-ray showing that the nasogastric tube had been misplaced into his right lung the tube was used to administer approximately 300ml of liquid feed. This caused the cavitating necrotising pneumonia from which he died.- Posted
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Content Article
Prevention of Future Deaths report – Chloe Lumb (17 February 2022)
Mark Hughes posted an article in Coroner reports
Chloe Lumb was known to have a genetic risk of aortic dissection that was being monitored. When she presented to James Cook University Hospital in Middlesbrough on 4 January 2021 a diagnosis of aortic dissection was not made, despite the prior knowledge about her risk and her clinical symptoms. The next day she contacted the hospital following discharge because of ongoing symptoms but was not asked to return to hospital. In her report, the Coroner states that a diagnosis of aortic dissection and appropriate surgical treatment would have prevented Ms Lumb’s death. -
Content ArticleLanguage barriers, reduced self-advocacy, lower health literacy and biased care may hinder the diagnostic process. This US study in BMJ Quality & Safety looks at patient-reported diagnostic errors, what contributes to them and the impact they have, and examines the differences between respondents with limited English-language health literacy or disadvantaged socioeconomic position, and their counterparts. The authors conclude that: interpreter access should be viewed as a diagnostic safety imperative. social determinants affecting care access and affordability should be routinely addressed as part of the diagnostic process. patients and their families should be encouraged to access and update their medical records.
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Content ArticleIn this episode of the Institute of Economic Affairs (IEA) Podcast, IEA Head of Political Economy Dr Kristian Niemietz discusses the findings of the Independent Medicines and Medical Devices Safety Review, and how the healthcare system in England responds to reports about harmful side effects from medicines and medical devices. Kristian speaks with Simon Whale, panel member and communications lead for the Independent Medicines and Medical Devices Safety Review and Dr Sonia Macleod, lead researcher, Independent Medicines and Medical Devices Safety Review. They discuss how the NHS, and other health bodies, could improve their services to address poor care and prevent harm.
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Content ArticleThis is an Early Day Motion tabled in the House of Commons on 28 February 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.
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Content ArticleThe purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) was to help improve patient safety in relation to the instructions 999 call handlers give to women and pregnant people who are waiting for an ambulance because of an emergency during their pregnancy. The HSIB investigation reviewed the case of Amy, who was 39 weeks and 4 days pregnant with her first child. She contacted 999 after experiencing abdominal cramps and bleeding. While waiting for an ambulance to arrive, Amy received pre-arrival instructions which were generated through a clinical decision support system (CDSS) from a non-clinical call handler. Amy was then taken by ambulance to hospital where her baby, Benjamin, was delivered by emergency caesarean section. Amy had excessive blood loss due to a placental abruption and was admitted to the high dependency unit for 12 hours following the birth. Benjamin required resuscitation to help him breathe on his own, he was intubated, and he received 72 hours of therapeutic cooling. He spent 13 days in hospital.
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Content ArticleThis is the transcript of a Westminster Hall debate in the House of Commons on fulfilling the recommendations of the Cumberlege Report.
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Content ArticleThis is an Adjournment Debate from the House of Commons on the 31 January 2022 on NHS Hysteroscopy Treatment, tabled by Lyn Brown MP.
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Content ArticleThe UK Government committed to establishing a Patient Safety Commissioner for England in the Medicines and Medical Devices Act 2021. The decision to create this role came about as a result of a specific recommendation in First Do No Harm: The Report of the Independent Medicines and Medical Devices Safety Review (also known as the Cumberlege Review), published in July 2020. The Department of Health and Social Care held a consultation asking for comments on the proposed arrangements for the appointment and operation of the new Patient Safety Commissioner between 10 June and 5 August 2021. This report analyses responses from the public and other interested parties.
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Content ArticleThis report was submitted to the United States Congress by the Department of Health and Human Services, in consultation with the Agency for Healthcare Research and Quality (AHRQ). It sets out effective strategies to improve patient safety and reduce medical error.
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Content ArticleThis paper, published in the Journal of Health Services Research & Policy, examines the potential of combining insights from patient complaints and staff incident reports for a more comprehensive understanding of the causes and severity of harm. In their conclusion, the authors state that this study demonstrates the value of using patient complaints to supplement, test and challenge staff reports, including to provide greater insight on the many potential factors that may cause unsafe care.
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Content ArticleThis study, published in BMJ Open, seeks to evaluate variation in Illinois hospital nurse staffing ratios. It attempts to determine how higher nurse workloads are associated with mortality and length of stay for patients, and cost outcomes for hospitals. In their conclusion, the authors suggest that if nurses in Illinois hospital medical–surgical units cared for no more than four patients each, thousands of deaths could be avoided, and patients would experience shorter lengths of stay, resulting in cost-savings for hospitals.
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Content ArticleMedication errors are preventable events that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional or patient. This paper, published in the Cochrane Database of Systematic Reviews, considers the effectiveness of interventions to reduce medication errors in adults in hospital settings. The review covered 65 studies involving 110,875 participants.
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Content ArticleThis report, published by the Agency for Healthcare Research and Quality (AHRQ) in the United States, presents findings from a review of 5,500 patient safety records in which the Covid-19 public health emergency was included as part of the description of the event or unsafe condition. It forms part of a series of Network of Patient Safety Databases Data Spotlight reports.
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Content ArticleA surgical fire is one that occurs in, on or around a patient undergoing a surgical procedure and is an internationally recognised patient safety issue. On 16 December 2021, Members of Parliament held a general debate on preventing surgical fires in Westminster Hall. In this article, the Association for Perioperative Practice (AfPP) sets out its response to issues raised in the debate.
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Content ArticleThis is a debate from the House of Commons on 16 December 2021 on the issue of preventing surgical fires in the NHS.
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Content ArticleThis report from the Department of Health and Social Care sets out the Government’s response to the Independent Inquiry into the Issues raised by Paterson.
