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Found 1,334 results
  1. Content Article
    Wales' national policy on patient safety incident reporting and management.
  2. Content Article
    This investigation aims to improve patient safety by supporting healthcare staff in a surgical setting to select and insert the appropriate type of implant (vascular graft) for haemodialysis treatment. The Healthcare and Safety Investigation Branch (HSIB) explored the factors that affect the ability of staff to safely select and insert vascular grafts for haemodialysis treatment. The national investigation focused on: The identification of factors within the healthcare system as a whole that influence patient safety risks associated with the selection and insertion of vascular grafts in an operating theatre environment. Exploration, using a systems approach, of the design of labelling and packaging used for the different types of vascular grafts for patients on haemodialysis treatment. Exploration of the impact on operating theatre teams of staff redeployment and repurposing of working environments in response to the COVID-19 pandemic.
  3. News Article
    Rishi Sunak says the government will wait for the Infected Blood Inquiry's final report before responding to questions around victim compensation. Bereaved families heckled the prime minister when he told the inquiry the government would act as "quickly as possible". Mr Sunak told the inquiry people infected and affected by the scandal had "suffered for decades" and he wanted a resolution to "this appalling tragedy". But although policy work was progressing and the government in a position to move quickly, the work had "not been concluded". He indicated there was a range of complicated issues to work through. "If it was a simple matter, no-one would have called for an inquiry," Mr Sunak said. Campaign group Factor 8 said Mr Sunak had offered "neither new information not commitments" to the victims and bereaved families, which felt "like a betrayal". Haemophilia Society chief executive Kate Burt said: "This final delay is demeaning, insulting and immensely damaging. "We urge the prime minister to find the will to do the right thing and finally deliver compensation which recognises the suffering that has been caused." Read full story Source: BBC News, 26 July 2023
  4. News Article
    Health officials waited six months to speak to the surgeon Sam Eljamel after a complaint was made about his conduct that eventually led to his suspension. Eljamel, who was head of neurosurgery at NHS Tayside in Dundee between 1995 and 2013, harmed dozens of patients before being suspended in 2013. Even as NHS Tayside commissioned an external review into Eljamel’s conduct, the surgeon was not suspended. Instead, the health board allowed him to continue practising as long as he was monitored. However, a letter sent to Eljamel by NHS Tayside’s clinical director, dated June 21, 2013, reveals that the surgeon was able to negotiate the extent of his own supervision. It was during this period of supervision that Jules Rose attended Ninewells Hospital to have a brain tumour removed by the surgeon. He performed two surgeries on her, in August and December, and she later discovered that he had removed her tear gland instead of the tumour. Since then she has founded and run the Patient’s Action Group, representing 126 of Eljamel’s patients calling for a public inquiry into how he was able to harm so many patients at NHS Tayside. Read full story (paywalled) Source: The Times, 25 July 2023
  5. Content Article
    This blog from Matthew Bacon, CEO of TCC-CASEMIX Ltd, looks at why a multi-factorial dataset is needed to create holistic understanding of medical device performance and is the only effective means for determining the multi-factorial causes of failure.
  6. News Article
    Just one-fifth of staff at a trust engulfed in an abuse scandal expressed confidence in the executive team, according to the Care Quality Commission (CQC), which has downgraded the trust and its leadership team to ‘inadequate’. The CQC inspected Greater Manchester Mental Health Trust following NHS England launching a review into the trust in November 2022 after BBC Panorama exposed abuse and care failings at the medium-secure Edenfield Centre. The two inspections, made between January and March 2023, which assessed inpatient services and whether the organisation was well-led, also saw the trust served with a warning notice due to continued concerns over safety and quality of care, including failure to manage ligature risks on inpatient wards. Inspectors identified more than 1,000 ligature incidents on adult acute and psychiatric intensive care wards in a six-month period. In the year to January, four deaths had occurred by use of ligature on wards which the CQC said “demonstrated that actions to mitigate ligature risks and incidents by clinical and operational management had not been effective”. Read full story (paywalled) Source: HSJ, 21 July 2023
  7. Content Article
    This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the Independent Investigation into East Kent Maternity services.
  8. Content Article
    This constructive commentary reflects on two recent related publications, the Healthcare Safety Investigation Branch (HSIB) report, Variations in the delivery of palliative care services to adults, and an article from Sarcoma UK, Family insights from Dermot’s experience of sarcoma care. Drawing from these publications, Richard, brother-in-law of Dermot, gives a family perspective, calling for a more open discussion around how we can improve palliative care and sarcoma services, and why we must listen and act upon family and patient experience and insight.
  9. Content Article
    In 2020, the Independent Medicines and Medical Devices Safety Review (IMMDS), chaired by Baroness Cumberlege, highlighted the avoidable harm caused by both pelvic and sodium valproate. It also set out the devastating impact on people’s lives when patients’ voices go unheard. The Minister for Mental Health and Women’s Health Strategy, Maria Caulfield MP, asked the Patient Safety Commissioner (PSC) to explore redress options for those who have been harmed by pelvic mesh and sodium valproate. The work will focus on what a suitable redress scheme for those affected should look like, to meet the needs of those affected. The PSC will publish a public report of this work. Once the project is complete, the Government will consider the report and set out next steps. The project will engage with patients through: meeting patients and their representative organisations. an online survey to gather views, which will be launched in due course.
  10. News Article
    Just one in five staff who were approached in a trust’s internal inquiry – prompted by an undercover broadcast raising serious care concerns – engaged with the process, a report has revealed. Essex Partnership University Foundation Trust said it took “immediate action” to investigate issues highlighted in a Channel 4 Dispatches programme into two acute mental health wards last year. This included speaking to staff identified as a high priority in the investigation. However, a new Care Quality Commission report has revealed, of the 61 staff members the trust approached, only 12 engaged with the process. Read full story (paywalled) Source: HSJ, 19 July 2023
  11. Content Article
    Three years since Baroness Cumberlege published her damming First Do No Harm report and a new report will look into financial redress for women injured by pelvic mesh. The latest project, announced this week by Patient Safety Commissioner Dr Henrietta Hughes, will involve talking to patient groups and individuals to ask women what they want. The government will then make a decision on next steps. While it is tiring to see a report, following a report after a report, it is a step forwards from when the government refused to offer financial redress, instead promising to toughen regulations and systems to improve patient safety.
  12. News Article
    Concerns codeine-based cough syrup could be addictive and have serious health consequences have led the UK medicines safety regulator to consider stopping its sale over the counter. The Medicines and Healthcare products Regulatory Agency (MHRA) is asking the public for their views on changing codeine linctus - which is a syrup with the active ingredient codeine phosphate and is used to treat a dry cough - to a prescription-only medicine. This comes in the wake of multiple reports to the regulator that the medicine is instead being used recreationally for its opioid effects. Since 2018, the MHRA has received 116 reports of recreational drug abuse of, dependence on, and/or withdrawal from codeine medicines, including codeine linctus. Dr Alison Cave, MHRA Chief Safety Officer, said this can have a severe impact on people’s health. She said: “Codeine linctus is an effective medicine, but as it is an opioid, its misuse and abuse can have major health consequences.” Pharmacists are also “significantly” concerned, especially about the overdose risk. Read full story Source: The Independent, 18 July 2023
  13. Content Article
    At a recent Patient Safety Management Network meeting, Hester Wain, Head of Patient Safety Policy at NHS England, and Dr Matt Hill, Consultant Anaesthetist, University Hospitals Plymouth NHS Trust & National Clinical Advisor on Safety Culture at NHS England, presented slides on patient safety culture. Download the presentation slides from the attachment below.
  14. Content Article
    Food allergy affects around 7-8% of children worldwide, or about two children in an average-sized classroom. As children spend at least 20% of their waking hours in school, it is not surprising that data show that 18% of food allergy reactions and 25% of first-time anaphylactic reactions occur at school. This report by the Benedict Blythe Foundations looks at the prevalence and seriousness of allergies in school-aged children, and the devastating consequences when things go wrong at school.
  15. Content Article
    This webpage explains the approach of the Parliamentary and Health Service Ombudsman (PHSO) to financial remedy relating to complaints against organisations. Where someone believes they have experienced an injustice or hardship because an organisation has not acted properly, or has given a poor service and not put things right, PHSO makes recommendations on the amount of compensation based on its severity of injustice scale. The scale contains six different levels of injustice that a complaint could fall into, which increase in severity. Each level is then linked to a range of the financial amounts the PHSO would usually recommend in those circumstances.
  16. Content Article
    NHS urgent and emergency care is under intolerable strain. This strain is increasingly causing harm to patients. Timely and high quality patient care is often not being delivered due to overcrowding driven by workforce and capacity constraints. While the covid-19 pandemic has accentuated and arguably expedited the crisis; the spiral of decline in urgent and emergency care has been decades long and unless urgent action is taken, we may not yet have reached its nadir, writes Tim Cooksley and colleagues in this BMJ opinion article.
  17. Content Article
    Extravasation injuries occur when some intravenous drugs leak outside the vein into the surrounding tissue which can damage the tissue and cause serious harm to the patient. This is a survey for healthcare professionals on approaches to extravasation management outside of cancer care. It is part of a campaign led by the National Infusion and Vascular Access Society (NIVAS) to improve awareness of infiltration and extravasation to reduce avoidable harm.
  18. News Article
    A further 11 inquests are to be opened this week as part of an investigation into dozens of deaths linked to jailed breast surgeon Ian Paterson. Paterson is currently serving a 20-year sentence after he carried out unnecessary or unapproved procedures on more than 1,000 breast cancer patients. Judge Richard Foster said 417 cases of former patients had been reviewed. The inquests will open and be adjourned on Friday. More than 30 deaths are already the subject of an inquest. Paterson worked at Spire Parkway Hospital and Spire Little Aston Hospital in the West Midlands between 1997 and 2011, as well as NHS hospitals run by the Heart of England NHS Foundation Trust. Paterson was jailed in 2017 after being convicted of 17 counts of wounding with intent. An independent inquiry found he had been free to perform harmful surgery in NHS and private hospitals due to "a culture of avoidance and denial" in a healthcare system where there was "wilful blindness" to his behaviour. Read full story Source: BBC News, 10 July 2023
  19. News Article
    A review into failings in maternity care in hospitals in Nottingham is set to become the largest in the UK, the BBC understands. Donna Ockenden, chair of the inquiry, is expected to announce that 1,700 families' cases will be examined. She was in charge of the probe into services in Shropshire, which found at least 201 babies and mothers might have survived had they received better care. The review comes after dozens of baby deaths and injuries in Nottingham and focuses on the maternity units at the Queen's Medical Centre and City Hospital. So far, 1,266 families have contacted the review team themselves directly and to date, 674 of these have given consent to join it. But Ms Ockenden has called for a "radical review" to ensure "women from all communities" were being contacted by the trust and "felt confident" to come forward. Read full story Source: BBC News, 10 July 2023
  20. Content Article
    NHS Resolution has launched its first eLearning module that focuses on learning from the significant avoidable harm that can occur during antenatal and postnatal care and is seen in the cases notified to its Early Notification Scheme. This free resource is designed to support clinicians working in maternity services. The module uses three illustrative case stories to immerse learners into the antenatal, intrapartum and postnatal care provided to mothers and the neonatal care provided to their babies. It aims to deepen learners' understanding of NHS Resolution’s role within the healthcare system, develop their understanding of the law of negligence as applied to clinical claims and explore how clinical decisions and actions can lead to avoidable harm. The module takes approximately two-and-a-half hours to complete and can be used as evidence of CPD hours undertaken for revalidation.
  21. News Article
    Nearly half of all NHS hospital maternity services covered so far by a national inspection programme have been rated as substandard, the Observer can reveal. The Care Quality Commission (CQC), which regulates health and care providers in England, began its maternity inspection programme last August after the Ockenden review into the Shropshire maternity scandal, which saw 300 babies left dead or brain damaged by inadequate NHS care. Of the services inspected under the programme, which focuses on safety and leadership, about two-thirds have been found to have insufficient staffing, including some services that were rated as good overall. Eleven services saw their rating fall from their previous inspection. Dr Suzanne Tyler of the Royal College of Midwives said: “Report after report has made a direct connection between staffing levels and safety, yet the midwife shortage is worsening. Midwives are desperately trying to plug the gaps – in England alone we estimate that midwives work around 100,000 extra unpaid hours a week to keep maternity services safe. This is clearly unsustainable and now is the time for the chancellor to put his hand in the Treasury pocket and give maternity services the funding that is so desperately needed.” Read full story Source: The Guardian, 9 July 2023
  22. Content Article
    In this opinion piece, a patient shares their experience of trying to access support from the healthcare system for debilitating jaw pain. They describe being dismissed and laughed at by doctors and orthodontists, highlight a knowledge gap around jaw issues and outline the need for more accountability in the orthodontics industry.
  23. News Article
    A cancer patient has died and three others have been hospitalised after they were administered unlicensed versions of chemotherapy by Sciensus, a private company paid millions by the NHS to provide essential medication. Three health regulators have launched inquiries into the incident, according to people familiar with the matter. It was caused by an issue at the firm’s medicines manufacturing unit. In a statement, Sciensus confirmed an “isolated incident” had “affected four patients” and that it was “deeply saddened” that one of them had died. Sciensus offered its “sincere condolences” to the family and friends of the patient who died, and is conducting a thorough investigation, it added. The four patients received unlicensed versions of cabazitaxel, a licensed chemotherapy used to treat prostate cancer. The versions administered to the patients differed from the licensed product and therefore were considered unlicensed medicines. Sciensus is required to comply with official standards to ensure the quality of the products it produces and the protection of public health. Breaches of these standards can result in the MHRA suspending or removing a company’s licence. “Patient safety is our highest priority,” said Dr Alison Cave, the MHRA’s chief safety officer. “We are urgently investigating this issue and we will take any necessary regulatory measures to ensure patients are protected." Read full story Source: The Guardian, 7 July 2023
  24. Content Article
    Video of the 10th Annual World Patient Safety, Science & Technology Summit presentations. The event fostered a high-level exchange of ideas and initiatives to improve global patient safety with expert speakers and panelists, inspiring messages from hospital executives, and the sharing of tragic patient stories. The programme ignited further momentum to reach ZERO harm. You can view all the speaker presentations by clicking on the image below. There is also a link to the Patient Safety Movement Foundation website with all the presentations at the end of the page.
  25. News Article
    Daniel was about to get the fright of his life. He was sitting in a consulting room at the Royal Free hospital in London, speaking to doctors with his limited English. The 21-year-old street trader from Lagos, Nigeria, had come to the UK days earlier for what he had been told was a "life-changing opportunity". He thought he was going to get a better job. But now doctors were talking to him about the risks of the operation and the need for lifelong medical care. It was at that moment, Daniel told investigators, that he realised there was no job opportunity and he had been brought to the UK to give a kidney to a stranger. "He was going to literally be cut up like a piece of meat, take what they wanted out of him and then stitch him back up," according to Cristina Huddleston, from the anti modern slavery group Justice and Care. Luckily for Daniel, the doctors had become suspicious that he didn't know what was going on and feared he was being coerced. So they halted the process. The BBC's File on 4 has learned that his ground-breaking case alerted UK authorities to other instances of organ trafficking. Read full story Source: BBC News, 4 July 2023
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