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Mark Hughes

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  1. 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.
  2. 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).
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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.
  16. 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.
  17. 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.
  18. Content Article
    This toolkit has been developed to inform improvement work in inpatient and residential settings which support people with dementia. It provides guidance on the steps needed to organise and manage an improvement project, how to utilise the experiences of people affected by dementia to develop improvement priorities and shares work and interventions by teams across Scotland.
  19. Content Article
    This video, produced in conjunction with Royds Withy King Solicitors, provides a quick overview of AvMA’s services and how volunteers help them to deliver the vital support people need after experiencing medical harm.
  20. Content Article
    This is the transcript of a backbench debate in the House of Commons regarding the implementation of the recommendations of First Do No Harm report, published by the Independent Medicines and Medical Devices Safety Review on the 8 July 2020, chaired by Baroness Cumberlege (also known as the Cumberlege Review).
  21. Content Article
    This page from Pulse Today provides a list of resources concerning Covid-19 vaccination for patients in the UK. It includes information about where to find providers of private covid tests and how to check vaccination status. It is sourced from Public Health England, the Royal College of Obstetricians and Gynaecologists, the British Fertility Society and the Association of Reproductive and Clinical Scientists.
  22. Content Article
    This review was undertaken as part of the remit of MBRRACE-UK to ensure that key learning and recommendations for changes to care and services for pregnant women during the second wave of the SARS-CoV-2 infection in the UK are identified in a timely manner in order to implement rapid change. The report’s authors reviewed the care of all pregnant and postnatal women who died with SARS-CoV-2 infection, and women who died and whose care or engagement with care was influenced by changes as a consequence of the pandemic between 1 June 2020 and 1 March this year. Fourteen women died with SARS-CoV-2 infection, ten from COVID-19 and four from other causes, three further women's deaths were influenced by changes as a consequence of the pandemic. The report identifies several themes affecting the care of pregnant and postpartum women in the context of the pandemic and suggests that there needs to be wider awareness of how best to treat pregnant and postnatal women with COVID-19.
  23. Content Article
    A timeout is an immediate pause by the entire surgical team to confirm the correct patient, procedure and site. This article discusses the use of timeout policy within a dental team prior to invasive or irreversible treatment as a means to improve patient safety, by creating a safe space for team members to express any concerns about procedure verification.
  24. Content Article
    This report shares findings from complaints made to Parliamentary and Health Service Ombudsman (PHSO) about failings in imaging in the NHS. The majority of these complaints involve people who had cancer at the time they used imaging services. Through highlighting these complaints, the PHSO’s objective is to support NHS services to improve. It suggests that failings in imaging services can only be addressed and learned from through collaboration across clinical specialties, looking at the whole imaging journey and its intersections as part of the patient’s care pathway.
  25. Content Article
    This Lancet article argues that the UK Government's plan to lift almost all COVID-19 restrictions on 19 July 2021 is a mistake, setting out five main concerns in this regard.
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