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Clive Flashman

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  • First name
    Clive
  • Last name
    Flashman
  • Country
    United Kingdom

About me

  • About me
    I'm leading on the development of the hub for Patient Safety Learning. I have a background in patient safety, having worked at the National Patient Safety Agency from 2002 to 2007, designing and leading the development of the NRLS. So looking forward to sharing this bold expriment with you all!!
  • Organisation
    Patient Safety Learning
  • Role
    Chief Digital Officer

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  1. Content Article Comment
    Hi @Kenny Fraser, thanks for taking the time to respond. Yes, not having an EPR is definitely risky as it precludes the sharing of information, certainly within a single organisation. In terms of an assessment, I would guess that something like that was done at the beginning of the National Programme for IT back in 2003, but I've not seen anything more recently. With regard to benefits realisation, this is a useful document to look at: https://www.ouh.nhs.uk/patient-guide/documents/epr-case-study.pdf In terms of the safety reviews that EPRs have to go through, as you can imagine, they are a lot more robust than DTAC. There is an extremely detailed safety hazard assessment that was created by Dr Maureen Baker and others as part of the NPfIT roll out in the mid 2000s. That is where much of the slimmed down DCBs and DTAC material has come from. However, there are limitations to the self-assessed reviews, and there will always be 'snags' picked up post implementation. My key worry is that this 'post-market surveillance' is not sufficiently specified, or generally done, and while DCB0129 and DCB0160 are meant to be repeated also as part of this process, that hardly every happens.
  2. Content Article
    NHS England recently issued a national patient safety alert to all trusts providing maternity services after faults were discovered in IT software that could pose “potential serious risks to patient safety”. In this short blog, Clive Flashman, Patient Safety Learning’s Chief Digital Officer, calls for a closer look at the reasons into this and what we can learn from it.
  3. Content Article Comment
    That's great news @Chris W, would be good to share the results of that with the wider group @Patient_Safety_Learning
  4. Content Article Comment
    I am glad that the remit of PSPs has gone far beyond that originally envisaged by NHS E. This can only be a good thing. It would be interesting to collate this into a master job spec that can be shared across Trusts so that all can fully benefit from the input of their PSPs. Perhaps this can be done via the relevant area on this site @Claire Cox, @HelenH, @PatientSafetyLearning Team
  5. Content Article
    The benefits of giving patients a central role in developing healthcare solutions have been widely demonstrated, but meaningful engagement is still far too rare, particularly in digital healthcare. In this blog for World Patient Safety Day 2023, Clive Flashman, Chief Digital Officer at Patient Safety Learning, looks at the benefits and barriers to engaging patients in developing digital healthcare solutions. He looks at why healthcare innovators struggle to include patients at an early stage of development and suggests some ways that NHS England could help facilitate coproduction through its existing patient engagement and innovation structures.
  6. Content Article Comment
    If it is correct that the babies' deaths were reported into the local risk management system as medication errors, they would also have been reported onwards to the National Reporting and Learning System (NRLS); run by NHS England and all data analysed by them also. Given that these death records in the NRLS would have shown that they all occurred at the same Trust, involving babies, in the space of a 12-18 month period, I wonder whether this should have been picked up centrally?
  7. News Article
    The exodus of healthcare workers from Nigeria, Ghana and Zimbabwe continues, despite the WHO red list and a range of laws to keep them at home. It took nearly three hours of queueing in Ikorodu general hospital in Lagos state, Nigeria, before Hadijat Hassan, a retired civil servant, could see a nurse. The 66-year-old has attended the clinic for health checks since being diagnosed with diabetes nearly 10 years ago. But since May, she says, the delays, often while suffering from excruciating pain in her legs, are worse than ever. “You can get there [the hospital] and meet about 50 people waiting to be attended to,” Hassan says. “They said all of their nurses and doctors have been leaving for abroad. Just a few are left.” In Nigeria, there is one doctor for every 5,000 patients, whereas the average in developed countries is one doctor for about every 254 people. A hospital official said the Ikorodu management get resignation notices from nurses and doctors almost every month. “Many leave for the US, Canada, UK and, most recently, Australia,” says the official, who asked to remain anonymous. The National Association of Nigeria Nurses and Midwives has reported there is now a ratio of one nurse to 1,160 patients. Its president, Michael Nnachi, said that more than 75,000 nurses had left Nigeria since 2017. “If you look at the conditions of service of health workers generally, you’ll see the difficult challenges complicated by the current economic realities,” he said, adding that rising inflation has compounded the problems. The World Health Organization predicts a worldwide shortage of 10 million health and care workers by 2030 – mostly in low-income countries, where people are leaving for opportunities abroad. This is despite the WHO’s introduction of a safeguard list to stop rich countries poaching from poorer countries with staff shortages. The “red list”, launched in 2020 with plans to update it every three years, includes Nigeria, Ghana, Zimbabwe and 34 other African countries. Yet the UK’s nursing regulator, the Nursing and Midwifery Council, says more than 7,000 Nigerian nurses relocated to the UK between 2021 and 2022. Data from the Ghana Registered Nurses and Midwives Association shows that nearly 4,000 nurses left the country in 2022. In Zimbabwe, more than 4,000 health workers, including 2,600 nurses, left in 2021 and 2022, the government said. The WHO has no powers to prohibit recruitment of doctors from countries on the list, but recommends “government-to-government health worker migration agreements be informed by health labour market analysis and the adoption of measures to ensure adequate supply of health workers in the source countries”. Read the full article here
  8. News Article
    Making data on medical interventions easier to collect and collate would increase the odds of spotting patterns of harm, according to the panel of a recent HSJ webinar When Baroness Julia Cumberlege was asked to review the avoidable harm caused by two medicines and one medical device, she encountered no shortage of data. “We found that the NHS is awash with data, but it’s very fractured,” says Baroness Cumberlege, who chaired the Independent Medicines and Medical Devices Safety Review and now co-chairs the All-Party Parliamentary Group which raises awareness of and support for its findings. And it is that fracturing that can make patterns of harm difficult to spot. The report concluded that many women and children experienced avoidable harm through use of the hormone pregnancy test Primodos, the epilepsy drug sodium valproate, and the medical device pelvic mesh – simply because it hadn’t been possible to connect the dots. “It’s very hard to collect things together and to get an overall picture. And one of the things that we felt very strongly about was that data should be collected once, but used often,” said Baroness Cumberlege at a recent HSJ webinar. Run in association with GS1 UK, the event brought together a panel to consider how better data might help address patient safety challenges such as problems with implants. “But the big problem was they couldn’t identify who had which implants. No doubt somebody somewhere had written this down with a fountain pen and then someone spilt the tea over it and the unique information was lost,” recalled Sir Terence Stephenson , now Nuffield professor of child health at Great Ormond Street Institute of Child Health and chair of the Health Research Authority for England. The review he chaired therefore suggested establishing a concept of person, product place – “for everybody who had something implanted in them, we should have their name, the identifier of what had been put in, and where it had been put in. And one of my panel members said: ‘Well, how are we going to record this? We don’t want the fountain pen and the teacup.’” Ultimately the answer suggested was barcode scanning. By scanning the wristband of a patient, that on the product being implanted, and one for the hospital theatre or department at which it was being implanted, the idea was to create an immediate and easy-to-create record. For those long convinced of the virtues of barcode scanning in health, it is a welcome development Two years later, the then Department of Health launched the Scan4Safety programme, in which six “demonstrator sites” implemented the use of scanning across the patient journey. At these organisations, barcodes produced to GS1 standards – meaning they are globally unique – are present on patient wristbands; on equipment used for care, including implantable medical devices; in locations; and sometimes on staff badges. Link to full article here (paywalled)
  9. News Article
    A group of potent synthetic opioids called nitazenes have been linked to a rise in overdoses and deaths in people who use drugs, primarily heroin, in England over the past two months, drug regulators have warned. The Office for Health Improvements and Disparities has issued a National Patient Safety Alert on potent synthetic opioids implicated in heroin overdoses and deaths. In the past 8 weeks there has been an elevated number of overdoses (with some deaths) in people who use drugs, primarily heroin, in many parts of the country (reports are geographically widespread, with most regions affected but only a few cities or towns in each region). Testing in some of these cases has found nitazenes, a group of potent synthetic opioids. Nitazenes have been identified previously in this country, but their use has been more common in the USA. Their potency and toxicity are uncertain but perhaps similar to, or more than fentanyl, which is about 100x morphine. The National Patient Safety Alert provides further background and clinical information and actions for providers.
  10. News Article
    As junior doctors begin a four-day strike today with a two-day strike by consultants a fortnight later, Sir Julian Hartley, chief executive of NHS Providers, said: "Trust leaders are very worried about six more days of severe disruption across the NHS this month. "We could be close to a tipping point. Trusts and staff are pulling out all the stops to reduce waiting times for patients but with no end to strikes in sight the sheer volume of planned treatment being put back due to industrial action will make it almost impossible for trusts to cut waiting lists as much as the government wants. "Waiting lists are now at a record high of 7.57 million, the pressure on urgent and emergency care services is relentless and an already stretched NHS is gearing up for another high-demand winter as pressure on tight budgets mounts. "A string of strikes – which have led to more than 835,000 routine treatments and appointments being put back since December – is estimated to have cost the NHS around £1bn already including lost income and hiring expensive staff cover. "The number of rescheduled appointments could be close to 1 million after this month's strikes and consultants have called another two-day strike in September. There will be a long-lasting effect on patients who have had treatment delayed and on already low staff morale. "Concerns are mounting too over how patient safety will be maintained during August's strikes as many NHS services will be even more stretched as many staff are on much-needed summer holidays and cover is harder to secure. "It's vital that the government and unions find a breakthrough urgently. Trust leaders understand the strength of feeling among striking staff and why they're taking action. Everyone in the NHS wants to concentrate on treating more patients more quickly rather than spend days making plans to cope with strikes. "People can still rely on the NHS during strikes, calling 999 in an emergency. For less urgent cases people should use 111 online for help and advice."
  11. News Article
    Despite regular MRI scans at the Royal Preston Hospital showing that the tumour was growing, May Ashford was not offered surgery until five years later. A woman died unnecessarily after doctors failed to operate soon enough on a growing brain tumour, according to the health complaints service. May Ashford, from Blackpool, was diagnosed with a brain tumour in 2010 after experiencing headaches and seizures. Despite regular MRI scans at the Royal Preston Hospital showing that the tumour was growing, she was not offered surgery until five years later. An investigation by the Parliamentary and Health Service Ombudsman (PHSO) said the treatment was too late as medical staff had failed to monitor the scan results properly. Medical experts said Mrs Ashford should have been operated on at least three years earlier, before the tumour had time to grow and affect the surrounding area of the brain. She tragically died aged 71 from a stroke following surgery. Link to full article here
  12. News Article
    The Care Quality Commission (CQC) has published a report on Stoke Mandeville Hospital, part of Buckinghamshire Healthcare NHS Trust following a recent inspection in June. CQC carried out a focused inspection of the trusts children’s emergency department in response to concerns raised about the safety and quality of the service. Inspectors found children and young people received safe care. However, the trust needs to review its systems to make sure potential serious incidents are managed in a way that allows any lessons learned to be shared, to reduce the risk of them happening again. Link to the full report (opens in a new browser window)
  13. Content Article
    A recent paper (from clinicians and Human Factors specialists at the Royal Surrey NHS Foundation Trust) jointly supported by Elsevier and BJA Education clarifies what Human Factors (HF) is by highlighting and redressing key myths.  The learning objectives from the paper are as follows: Identify common myths around HF Describe what HF is Discuss the importance of HF specialists in healthcare Distinguish the importance of a systems-based approach and user-centred design for HF practice.  It explains that HF is a scientific discipline in its own right, a complex adaptive system very much like healthcare. Its principle have been used within healthcare for decades but often in an informal way.  A link to the summary of the article on Science Direct and further links to purchase the paper can be found here: https://www.sciencedirect.com/science/article/abs/pii/S2058534923000963?dgcid=author 
  14. News Article
    After generations of inaction and very few novel ideas, researchers and activists are hopeful a new path is being charted in understanding and treating the crippling chronic condition “There’s an excitement at the moment,” says Andrew Horne. After decades of inaction, something is happening in endometriosis. Now, says the professor of gynaecology and reproductive sciences at the University of Edinburgh, “I do think things are changing. There are more people working on it, so it’s bringing in people from different disciplines with new ideas.” In the space of a few months, from gatherings in Edinburgh and Washington DC, labs in Sydney and Japan, there is a sense that new ideas are bubbling to the surface, including a fundamental rethinking of endometriosis not as a disease of the pelvis, but rather, says Horne, “a whole-body disease”. It’s hard to pinpoint the exact moment when despair turned to hope in the research and patient community. There was no single breakthrough. No one person responsible. In March, the largest ever study on the genetics of endometriosis was published in Nature Genetics, which found genetic links to 11 other pain conditions as well as other inflammatory conditions. The study, involving DNA from more than 760,000 women, found ovarian endometriosis is genetically distinct from other types and indicated there may be a genetic predisposition to excessive inflammation in people with the condition. One of the researchers, Dr Nilufer Rahmioglu from the University of Oxford, described the data as a “treasure trove of new information”. Weeks later on the other side of the world, researchers from Sydney’s Royal Hospital for Women attracted international attention after they grew tissue from different types of endometriosis and compared how each responded differently to treatments. Jason Abbott, professor of obstetrics and gynaecology at the hospital, likened the development to those made in the treatment of breast cancer three decades ago. Two weeks on from the Australian discovery, Japanese researchers found a common form of bacteria may be contributing to the growth of endometriosis via inflammation. The frisson was, by then, hard to miss. Read the full article here: https://www.theguardian.com/society/2023/aug/10/its-really-only-the-beginning-are-we-on-the-cusp-of-a-breakthrough-in-endometriosis
  15. Content Article Comment
    Thanks Richard, it is certainly not easy as a patient to get your voice heard, but we carry on looking to improve this through the conversations we have....
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