Jump to content
 View Profile  See their activity

  • Posts

    269

  • Joined

  • Last visited

Mark Hughes

Members

 Content Type 

Everything posted by Mark Hughes

  1. Content Article
    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.
  2. Content Article
    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.
  3. Content Article
    Language 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.
  4. Content Article
    In 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.
  5. Content Article
    This 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.
  6. Content Article
    The 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.
  7. Content Article
    This is the transcript of a Westminster Hall debate in the House of Commons on fulfilling the recommendations of the Cumberlege Report.
  8. Content Article
    This is an Adjournment Debate from the House of Commons on the 31 January 2022 on NHS Hysteroscopy Treatment, tabled by Lyn Brown MP.
  9. Content Article
    The 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.
  10. Content Article
    This 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.
  11. Content Article
    This 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.
  12. Content Article
    This 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.
  13. Content Article
    Medication 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.
  14. Content Article
    This 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.
  15. Content Article
    A 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.
  16. Content Article
    This is a debate from the House of Commons on 16 December 2021 on the issue of preventing surgical fires in the NHS.
  17. Content Article
    This 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.
  18. Content Article
    This is a debate from the House of Lords on 2 December 2021 about when the process to appoint a Patient Safety Commissioner for England will commence and when the Commissioner is expected to be in post.
  19. Content Article
    This is the report of an inquiry conducted by the Health and Social Care Select Committee in 2020/21 which considers how the social care system is supporting those living with dementia. In the report the Committee make the case that the UK government’s plans for the health and care levy provides insufficient funding for social care over the next three years.
  20. Content Article
    This is the transcript of an Adjournment Debate from the House of Commons on the 29 October 2021 on NHS Allergy Services, tabled by Jon Cruddas MP.
  21. Content Article
    This study, published in JAMA Network Open, looks at whether publicly reported feedback was associated with hospital improvement in an evaluation of medication-related safety performance. The results indicate that publicly reported feedback was associated with quality improvement, and the authors suggest that targeted measurement and reporting of process quality may be effective in encouraging improvement in specific areas.
  22. Content Article
    The purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) is to help improve patient safety in relation to the care of patients who have NHS-funded surgery in an independent hospital. This was initiated in the context of the COVID-19 pandemic, where because of increased pressure on the NHS, independent hospitals have been providing more care for NHS patients, including urgent elective surgical care and delivery of cancer pathways. The HSIB investigation reviewed the experience of a patient with a diagnosis of bowel cancer, who was booked to undergo laparoscopic (keyhole) surgery to remove part of his bowel in in an independent hospital. Following surgery, the patient made slow progress and on day eight following surgery he started to deteriorate rapidly. He was transferred to the local NHS hospital for investigation and further surgery. He died later the same day as a result of sepsis following a complication of his recent surgery.
  23. Content Article
    The National patient safety syllabus outlines a new approach to patient safety, emphasising a proactive approach to identifying risks to safe care while also including systems thinking and human factors and applies to all NHS employees. This page provides access to learning materials (via the E-Learning for Health platform) for staff relating to Level one – Essentials for patient safety and Level two – Access to practice of the training associated with this.
  24. Content Article
    This short animation from SameYou, a charity working to develop better recovery treatment for survivors of brain injury and stroke, highlights the stories of survivors of brain injury and stroke. It is linked with their report, The Untold Story of Brain Injury.
  25. Content Article
    This report from SameYou, a charity working to develop better recovery treatment for survivors of brain injury and stroke, draws on the experiences of over 1,400 survivors of brain injury and stroke, as well as the experiences of their friends and family members. It highlights the lack of support for survivors and recommends some ways forward to improve outcomes.
×
×
  • Create New...