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Mark Hughes

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  1. Content Article
    This article from the Agency for Healthcare Research and Quality (AHRQ) in the United States is the transcript of a conversation between AHRQ’s Acting Director David Meyers, MD, and the Agency’s chief patient safety official, Jeff Brady, MD MPH, about key issues in diagnostic safety. Diagnostic safety is “the newest frontier in patient safety,” according to Dr Brady, who emphasises the Agency’s commitment to improve diagnostic safety and explains how researchers are working to better understand diagnostic errors and design systems and processes to reduce errors.
  2. Content Article
    Hannah Royle was a sixteen-year-old girl on the autism spectrum. Her parents had contacted the NHS 111 service on 20 June 2020 after she became unwell with vomiting and diarrhoea, but they were not advised to go to hospital. Three hours later as her conditioned worsened they phoned again, and the call handler, who took advice from a clinical adviser, opted not to call an ambulance and instead told her parents to make their own way to hospital. She died following a cardiac arrest as she was driven to hospital by her parents. In her findings the Coroner states that the NHS 111 service failed to provide the appropriate triage for Hannah on the information provided to them by her parents. This resulted in a cardio-respiratory arrest arising from an avoidable delay in being adequately resuscitated either by prompt attendance of the emergency services or through earlier admission into hospital.
  3. Content Article
    Poppy Harris was born at Milton Keynes University hospital on 23 November 2020. Following a protracted labour, she was delivered using Kielland's forceps. She was transferred to John Radcliffe Hospital in Oxford where it was discovered that she had suffered a spinal cord injury and despite all efforts and care she died on 24 March 2021.
  4. Content Article
    This is an Early Day Motion tabled in the House of Commons on the 21st October 2021, which notes disappointment with the UK Government’s response to the Independent Medicines and Medical Devices Safety Review. The motion calls on the Government to reconsider its response and to implement all nine recommendations in their entirety, and to ensure patient safety remains paramount in any changes to regulatory approval frameworks.
  5. Content Article
    Nursing is a predominantly female profession, yet sex and gender bias is rife. In a remarkably candid conversation, feminist writer Caroline Criado Perez, author of ‘Invisible Women: Exposing Data Bias in a World Designed for Men’, talks about how health care and health care research fails women, how changes are needed for women experiencing miscarriage – and what it means when medicine treats the female body as atypical and niche. Nursing Matters is presented by PNC Chair Rachel Hollis and PNC member Alison Leary. For this episode they are also joined by RCN member Leanne Patrick, who works in services for women experiencing gender-based violence and tweets on behalf of the RCN Feminist Network.
  6. Content Article
    Mary Land was a patient on an Acute Respiratory care unit 'surge' ward at Pinderfield Hospital, being treated for COVID pneumonia against a backdrop of comorbidities. On 5 February 2021 she was discovered in an unresponsive condition, with the tube connecting her facemask to a BIPAP ventilator detached at the connection point to the mask. In his report, the Coroner raised patient safety concerns relating to how the tubes of her Philips Respironics AF 541 mask became detached from the ventilator.
  7. Content Article
    On Friday 17 September 2021 the World Health Organization (WHO) held their World Patient Safety Day 2021 Virtual Global Conference, focused on the theme of ‘Safe maternal and newborn care’. This page contains links to a number of presentations from the event.
  8. Content Article
    This study, published online by Cambridge University Press, looks at the impact of the Covid-19 pandemic on incidences of healthcare-associated infection in hospitals in the United States of America. The authors analyse events reported to the National Healthcare Safety Network for 2019 and 2020 by acute-care hospitals.
  9. Content Article
    In this blog, Mabel Prendergast reflects on key themes discussed at the Institute of Global Health Innovation's (IGHI) third World Patient Safety Day event on the 17 September 2021, with the theme of safer maternal and newborn care. This virtual event was chaired by Dr Mike Durkin, IGHI’s Senior Advisor on Patient Safety Policy and Leadership, and included a range of speakers and panellists.
  10. Content Article
    This is the transcript of a debate in the House of Commons ahead of Baby Loss Awareness Week (9 to 15 October 2021). In this debate, MPs reflected on personal experiences and those of their constituents, the role of Baby Loss Awareness Week as an essential focal point for bereaved families and the potential for the Government to mandate and fund the National Bereavement Care Pathway programme.
  11. Content Article
    This study, published in JAMA Network Open, looks at the effectiveness of using an evidence-based mobile app to reduce the occurrence of medication errors, compared with conventional preparation methods during simulated paediatric out-of-hospital cardiac arrest scenarios. Its results indicated a decreased rate of medication errors through use of a mobile app, suggesting this could have the potential to improve medication safety and change practices in paediatric emergency medicine.
  12. Content Article
    This is the transcript of a Westminster Hall debate in the House of Commons on Black Maternal Health Awareness Week, dedicated to raising awareness about the disparities in maternal outcomes for Black women.
  13. Content Article
    The Lampard Inquiry is a statutory inquiry investigating mental health inpatient deaths in Essex, focused on services provided by the Essex Partnership University Foundation NHS Trust (EPUT) and the North East London Foundation Trust (NELFT) and their predecessor organisations. This Inquiry continues the work of the Essex Mental Health Independent Inquiry. This website provides information about the inquiry team, terms of reference and publications relating to this.
  14. Content Article
    This article, published by the Institute for Healthcare Improvement, discusses some of the key patient safety issues in the Danish Prison and Probation Service. The author, Christian Vestergaard, a Medical Advisor with the Danish Society for Patient Safety, highlights differences in approaches to patient safety in prisons compared to other areas of healthcare provision in Denmark and stresses the need for action to improve the safety of care in these settings.
  15. Content Article
    In this blog Alice Fletcher, Programme Manager for Patient Safety (Mental Health) at the Innovation Agency, talks about the first phrase of the Mental Health Safety Improvement Programme being delivered by the 15 Academic Health and Science Networks in England. Its initial focus is on reducing restrictive practice in mental health wards, considering where this can be dealt with differently if staff have adequate training and knowledge of other methods.
  16. Content Article
    Pharmacovigilance is the science and activities relating to the detection, assessment, understanding and prevention of adverse effects or any other medicine/vaccine related problem. This article, published in the journal Drug Safety, outlines how the Egypt Chapter of the International Society of Pharmacovigilance (ISoP) approached raising awareness of the importance of pharmacovigilance and reporting adverse drug reactions during MedSafetyWeek 2020.
  17. Content Article
    Published at the halfway point of the Global action plan on the public health response to dementia 2017 – 2025, this report from the World Health Organization assesses the actions taken by Member States, WHO and civil society since the adoption of this plan and identifies barriers to its implementation. The report also includes estimates on dementia burden and costs globally based on WHO’s Global Health Estimates 2019 and the Global Burden of Disease study 2019.
  18. Content Article
    Research suggests that a key factor contributing to diagnostic errors is the breakdown of communication between patients and healthcare professionals. The Agency for Healthcare Research and Quality (AHRQ) in the United States has developed this toolkit to promote enhanced communication and information sharing between patients and healthcare professionals. It is designed to help patients, families, and health professionals work together as partners to improve diagnostic safety.
  19. Content Article
    This document sets out guidelines for recommended nurse/midwife to patient ratios in the Kingdom of Saudi Arabia. It describes the rationale for introducing national regulations for safe staffing ratios, considers concerns and challenges in this respect, and then outlines specific ratios in different areas of care. This has been produced by the Saudi Patient Safety Center, in collaboration with the Saudi Commission for Health Specialties and the Saudi Nurses Association.
  20. Content Article
    This guide, developed by the charity Action Against Medical Accidents (AvMA), aims to provide support for people seeking legal advice about a possible clinical negligence claim. It is intended to provide information about what to expect from a first meeting with a lawyer and how to prepare for this.
  21. Content Article
    A new national NHS Learn from patient safety events service (previously called the patient safety incident management system – PSIMS – during development) is in the final stages of development as a central service for the recording and analysis of patient safety events that occur in healthcare. NHS England has now commenced the public beta stage, where some organisations can begin using the system, instead of the NRLS. LFPSE is replacing the current National Reporting and Learning System (NRLS) and Strategic Executive Information System (StEIS), to offer better support for staff from all health and care sectors.
  22. Content Article
    The Healthcare Safety Investigation Branch (HSIB) identified a patient safety risk involving the timely detection and treatment of non-malignant spinal compression (cauda equina syndrome). Cauda equina syndrome (CES) is a rare and severe type of spinal stenosis, causing all the nerves in the lower back to become suddenly and severely compressed. If CES is not diagnosed and treated in a timely way it can lead to permanent incontinence, sexual dysfunction and even paralysis. The investigation was launched after HSIB identified an event where a patient had several GP and hospital presentations before CES was diagnosed.
  23. Content Article
    In this study, published in the Journal of Patient Safety and Risk Management, the authors explore and compare types and longitudinal trends of hospital adverse events in Norway and Sweden in the years 2013-2018 with special reference to the adverse events that contributed to death. They found that 13.2% of hospital admissions in Norway and 13.1% in Sweden were associated with an adverse event, with 0.23% of admissions in Norway and 0.26% in Sweden associated with an adverse event that contributed to death. In addition to the similar rates in adverse events between the two countries, the authors also found that there was no significant change in the level adverse events or fatal adverse events in either country over the six-year time period.
  24. Content Article
    This episode of HSJ’s Health Check podcast considers concerns raised in Coroners Prevention of Future Deaths reports about the impact of pandemic hospital visiting restrictions on patient care and patient safety.
  25. Content Article
    This report provides a review of the Healthcare Safety Investigation Branch (HSIB) maternity investigation programme during 2020/21, including an overview of activity during this period, themes arising from investigations and plans for the future. It is intended for healthcare organisations, policymakers and the public to understand the work HSIB have undertaken.
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