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Mark Hughes

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  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. Content Article
    This is the response submitted by the Patients Association to the Department of Health and Social Care as part of its consultation seeking views on the proposed legislative details on the appointment and operation of the Patient Safety Commissioner for England. In this they argue for arrangements for the Commissioner's appointment and operation to guarantee their independence as securely as possible, and express disappointment that the role will not cover all aspects of patient safety.
  10. Content Article
    In this article Sharon Hartles looks at the tragic case of the death of Robbie Powell and the work of his parents, Will and Diane, in their relentless pursuit for truth, justice and accountability. It looks in detail at the events around and after Robbie's death and their campaign for a individual legal Duty of Candour for healthcare professionals (the current statutory Duty of Candour in the UK covers all care providers registered with the Care Quality Commission, but not individuals).
  11. Content Article
    Azra Hussain died by suicide while a patient at Mary Seacole House, operated and staffed by Birmingham and Solihull Mental Health Foundation Trust. In their report, the Coroner raised patient safety concerns relating to her family being unable to participate in a multidisciplinary team meeting prior to her death due to Covid-19 visiting restrictions.
  12. Content Article
    Do all your staff receive training for the management of anaphylaxis as part of their mandatory training? Do you have a specific maternal cardiac arrest emergency call to include obstetricians and neonatologists? Do all resuscitation trolleys in your trust have a scalpel and umbilical cord clamps as an essential kit requirement? Are you aware of the obstetric cardiac arrest quick reference guide from the Resus Council, OAA and MBRRACE? Obstetric cardiac arrest is rare but devastating. This quick reference guidance, produced by Resuscitation Council UK and Obstetric Anaesthetists’ Association (and endorsed by MBRRACE), has been developed to aid Advanced Life Support providers response to this. It aims to help structure the team response, with reminders of modifications required for the pregnant patient and causes of cardiac arrest to consider.
  13. Content Article
    This article reviews the Missouri Quality Initiative, which aims to reduce hospital admissions among nursing home residents. It involves placing an advanced practice registered nurse within the nursing home, supported by an interdisciplinary team of long-term care specialists, to identify when a resident may be experiencing a functional decline. Results from this initiative showed statistically significant decreases in hospitalisations.
  14. Content Article
    Kishorkumar Patel and Kofi Aning were both treated at the Nightingale Hospital in London in April 2021. In both cases there was a serious incident in which the wrong filter was found to have been used within the breathing systems of their intensive care ventilator.
  15. Content Article
    This study, published in the Journal of Advanced Nursing, investigates the processes through which personnel understaffing and expertise understaffing jointly shape near misses among nurses during the Covid-19 pandemic. It looks at survey data collected from 120 nurses in the United States of America working in hospitals during the pandemic. The authors conclude that the challenges created by understaffing of nurses have been amplified by the pandemic. They suggest that understanding the mechanisms through which safety outcomes are affected by understaffing can help healthcare organisations be better prepare for safety challenges that may arise when staffing shortages are experienced.
  16. Content Article
    Patient safety incidents can have significant effects on both patients and health professionals, including emotional distress and depression. This, published in British Journal of Surgery (BJS) Open, study explores the personal and professional impacts of surgical incidents on operating theatre staff. This study, published in BJS Open, involved 45 face-to-face interviews, with participants including surgeons, anaesthetists, scrub nurses, ODPs and healthcare assistants. The authors state that the results indicate that more support is needed for operating theatre staff involved in surgical incidents. They also suggest that there needs to be greater transparency and better information during the investigation of such incidents for staff.
  17. Content Article
    This is the National Guardian's Office annual data report covering the 1 April 2020 to 31 March 2021. It analyses the themes and learning from the speaking up data shared by Freedom to Speak Up Guardians across this period. There are over 700 Freedom to Speak Up Guardians in the NHS and there were 20,388 cases raised with them in 2020/21.
  18. Content Article
    This is the transcript of a backbench debate in the House of Commons focused on the UK Government's National Maternity Ambition to halve the rate of stillbirths, neonatal and maternal deaths and brain injuries that occur during or soon after birth by 2025, and to achieve a 20% reduction in these rates by 2020.
  19. Content Article
    This report considers the role and functions that clinical commissioning group medicines optimisation teams deliver in the existing healthcare structure to improve patient care. Medicines optimisation can be defined as a person-centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines.
  20. Content Article
    This study, published in the European Journal of General Practice, explores the type and nature of patient safety incidents in French primary care settings during the first wave of the Covid-19 pandemic. Its findings suggest that constraints of the first wave of the pandemic contributed towards patient safety incidents during non-Covid-19 care, with the authors suggesting a national primary care emergency response plan to support practitioners could have mitigated many of the non-Covid-19 related patient safety incidents during this period.
  21. Content Article
    This report from the Department of Health and Social Care sets out the Government's response to the recommendations of the Independent Medicines and Medical Devices Safety (IMMDS) Review, sometimes referred to as the Cumberlege Review.
  22. Content Article
    This report is from the Patient Reference Group established to provide advice, challenge and scrutiny to work to develop the government response to the Independent Medicines and Medical Devices Safety (IMMDS) Review, sometimes referred to as the Cumberlege Review.
  23. Content Article
    The waiting list for elective treatment in the NHS in England has reached an unprecedented level, with one in ten people – over 5.3 million – now waiting for a routine procedure. This report published by Policy Exchange sets out the scale of the challenge, opportunities to reform the existing approach to elective care and their proposed elective care recovery plan.
  24. Content Article
    This report from the Patients Association describes shared decision making and its benefits, before going on to assess how it has been formally embedded in NHS programmes and practice. It identifies the barriers preventing shared decision making becoming a reality for patients as a matter of course, and possible solutions.
  25. Content Article
    This is a study evaluating the implementation of a patient safety programme across a paediatric department at the largest public hospital in Guatemala. In their conclusion, the authors note that implementing such programmes in low-resource settings requires recognition of facilitators such as staff receptivity and patient-centredness as well as barriers such as lack of training in patient safety and poor organisational incentives.
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