Mark Hughes
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Everything posted by Mark Hughes
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Content ArticleThis 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.
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Content ArticleThis 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.
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Content ArticleThis 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).
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Content ArticleThis 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.
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Content ArticleThis 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.
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Content ArticleA 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.
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Content ArticleThis 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.
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Content ArticleThis 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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Content ArticleThis report sets out the findings from the Healthcare Inspectorate Wales (HIW) COVID-19 themed national review. The purpose of the review is to understand how healthcare services across Wales met the needs of people and maintained their safety during the pandemic. It considers how services supported the physical and mental well-being of staff, reviewing all HIW assurance activity since March 2020. HIW is the independent inspectorate and regulator of healthcare in Wales.
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Content ArticleDiagnostic errors can result in avoidable harm when undiagnosed conditions remain untreated or when patients undergo unnecessary (or harmful) tests. This study seeks to estimate the incidence and origins of avoidable harm from diagnostic errors in English general practice. It defines diagnostic errors as missed opportunities to make a correct or timely diagnosis based on the evidence available. The authors conclude that although missed diagnostic opportunities (MDOs) occurred in fewer of 5% of the investigation consultations they analysed, high numbers of primary care contacts nationally suggest that several million patients are potentially at risk of avoidable harm from MDOs each year.
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Content ArticleThis is the report of an inquiry conducted by the Health and Social Care Select Committee in 2020/21 which examined the ongoing safety concerns with maternity services and the action needed to improve safety for mothers and babies. It suggests that improvements to maternity services have been too slow to date and recommends several changes, including increasing in the budget for maternity services and reforming existing to litigation processes.
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Content ArticleThis article considers the definition of a just culture and identifies the key elements associated with this. It then goes on to discuss tools and resources that may be beneficial for leaders who are seeking to create a just culture for staff safety in the perioperative setting.
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Content Article
What I never consented to (24 June 2021)
Mark Hughes posted an article in Consent issues
In this blog in the BMJ, Andrés J Lessing considers how consent forms and conversations about care and treatment often do not account for the possibility of incidental findings. The author suggests that incidental findings can be very stressful for patients and that as part of the pre-treatment consent process healthcare professionals could provide a reminder about the likelihood of incidental findings and what might be done to address them. -
Content ArticleMedicines optimisation is a multidisciplinary and patient-focused approach to achieving the best patient outcomes from the use of medicines. It involves the use of medicines to control disease while ensuring that adverse effects are kept to a minimum. This article explores strategies that enable nurses to take an increasingly active role in medicines optimisation. In its conclusion the authors suggest that to ensure medicines optimisation, nurses should be involved in monitoring patients’ signs and symptoms using a structured checklist such as the ADRe (Adverse Drug Reaction Profile) to identify and address any medicines-related harms.
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Content ArticleThis article describes the application of colour coding for cognitive aids to facilitate the management of an unanticipated difficult airway and its further local implementation in the form of a colour-coded difficult airway trolley. The authors conclude that the use of colour coding as a cognitive aid can enhance the management of an unanticipated difficult airway and make it simpler to obtain help from other operating room personnel who are not regularly involved in airway management. However, they note that frequent training and simulation with the material and equipment in the difficult airway trolley remains crucial.
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Content ArticleThis is an online directory which signposts brain injury and stroke survivors to local services in the UK. It lists over 90 neuro support charities and outpatient community services and is searchable by address, city or postcode. It is hosted by SameYou, a charity working to develop better recovery treatment for survivors of brain injury and stroke.
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Content ArticleThis framework provides guidance on how the NHS can involve people in their own safety as well as improving patient safety in partnership with staff. It is relevant to all NHS trusts and commissioners and should also be useful to other NHS settings, including primary care and community services, that are considering how they can involve patients in safety.
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Content ArticleImproving patient safety during anesthesia and surgery is a major public health issue, with safety standards varying from country to country. Anesthesia safety is often hampered by complex problems in low income countries. This survey assesses the unmet anesthesia needs in Ethiopia. The author concludes that anesthesia safety in Ethiopia appears challenged by substandard continuous medical education and continuous professional development practice, and limited availability of some essential equipment and medications. The study states that while patient monitoring and anesthesia conduct are relatively good, World Health Organization surgical safety checklist application and postoperative pain management are very low, affecting the delivery of safe anesthesia conduct.
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Content ArticleProduced by the ME Action Network, this is a form that patients with Myalgic Encephalomyelitis (ME)/Chronic Fatigue Syndrome (CFS) can complete for subsequent use by hospital staff. It aims to provide a better understanding of their symptoms and any medications they may be taking when admitted either for planned treatment, such as an operation, or in an emergency.
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Content ArticleThis systematic review, published in the International Journal of Environmental Research and Public Health, looks at different support resources in healthcare organisation that are available to healthcare professionals who have been involved in a patient safety incident. The authors identify a range of challenges to the implementation of these, including persistent blame culture, limited awareness of program availability, and lack of financial resources.
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Content ArticleThe Covid-19 pandemic has resulted in dental treatments having to be planned and carried out with extreme caution, with dental facilities and staff adapting to put in place appropriate infection control measures and safety precautions. This article, published in Patient safety in surgery, provides a summary of precautionary and prophylactic measures in preventing the cross-infection and the nosocomial spread of the infection in a dental setting.
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Content ArticleIn this webinar recording Tim McDonald, Chief Patient Safety and Risk Officer at RLDatix, and Phil Taylor, Chief Product Officer at RLDatix, describe a paradigm shift in the approach to preventing and responding to patient harm that includes establishment of a psychologically safe culture and management of harm that includes the benefits of providing effective empathic peer support for health care workers involved in harm events. They also emphasise the importance of the need to integrate the concepts of high reliability and human factors safety science into these compassionate patient safety efforts.
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Content ArticleNever Events are defined by the NHS as patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers. This study considers how effective using of the absolute number of Never Events that take place at English hospital trusts, without accounting for hospital workload, is for judging their underlying safety performance and safety culture. In its conclusions the authors suggest that there are flaws in the current approach regulators take to using Never Events data to judge hospital performance.
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Content Article
In this video, Tim McDonald, Chief Patient Safety and Risk Officer at RLDatix, Paul Bowie, Programme Director (Safety & Improvement) at NHS Education for Scotland, and Helen Hughes, Chief Executive of Patient Safety Learning, talk about the relationship between human factors, high reliability in healthcare and patient safety. -
Content ArticlePsychological safety (speaking up about ideas and concerns, free from interpersonal risk) is essential in high-risk environments, such as healthcare settings. This study, Enhancing psychological safety in mental health services, considers this issue within the context of mental health services. It provides an overview of the types of strategies and interventions for increasing the ethos of psychological safety and setting the foundations for delivering an organisation-wide programme on this topic. It also lists of key targeted areas in mental health that would maximally benefit from increasing psychological safety, both in clinical and non-clinical settings. Psychological safety as a cornerstone of improvement: blog by Joe Rafferty, Mersey Care Psychological safety and the critical role of leadership development (McKinsey and Company) The role of psychological safety in diversity and inclusion (Amy Edmondson) Three ways to create psychological safety in healthcare (Institute for Healthcare Improvement)
