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Found 1,334 results
  1. Content Article
    Patient Safety Learning recently interviewed Keith Conradi, former HSIB chief executive, on why healthcare needs to operate as a safety management system. In this interview, we speak to Jono Broad, part of the South West Integrated Personalised Care team at NHS England, to hear his response to this, how patients, families and relatives can get involved, and why we need to really embed patient safety in a management culture and a healthcare management system.
  2. Content Article
    The Patient Safety Authority has developed a series of decision trees to determine whether a patient safety event is a serious event or incident in a range of different situations.
  3. Content Article
    This policy provides a national framework for health and disability providers in New Zealand to continually improve the quality and safety of services for consumers, whānau and healthcare workers. It provides a consistent way to understand and improve through reporting, reviewing and learning from all types of harm. The policy will guide the process for reporting to the Health Quality & Safety Commission in New Zealand and for using the information gathered from learning reviews, along with quality improvement approaches, to strengthen system safety.
  4. News Article
    The trust at the centre of a maternity scandal has been ordered to report on urgent improvements in services for women and babies, amid ‘significant concerns’ about the risk of harm. The Care Quality Commission (CQC) used its enforcement powers to issue the conditions on East Kent Hospitals University Foundation Trust, after it carried out an unannounced inspection last month. However, the “section 31” warning letter has just been made public, and the first deadline for the trust to report back to the CQC is Monday (20 February). The CQC said some of the problems it found were due to the labour ward environment – but others involved monitoring of women and babies whose conditions deteriorate and the risk of cross-infection due to poor cleanliness standards. “We have significant concerns about the ongoing wider risk of harm to patients and a need for greater recognition by the trust of the steps that can be taken in the interim to ensure safety and an improved quality of care,” Carolyn Jenkinson, CQC’s deputy director of secondary and specialist healthcare, said in a statement today. Read full story (paywalled) Source: HSJ, 17 February 2023
  5. Content Article
    Dr Freya Smith, a Specialty Trainee in General Practice, reflects on the sinister and toxic side of medicine, using the recent Paterson and vaginal mesh scandals to demonstrate how patients have been let down by the system. In an honest and personal account, she shares with us the horror and sadness she felt at learning of these scandals and how she aspires to keep her future patients safe.
  6. News Article
    A high court judge has expressed her “deep frustration” at NHS delays and bureaucracy that mean a suicidal 12-year-old girl has been held on her own, in a locked, windowless room with no access to the outdoors for three weeks. In a hearing on Thursday, Mrs Justice Lieven told North Staffordshire combined healthcare NHS trust “you are testing my patience”, after she heard that a proposal to move Becky (not her real name), could not progress until a planning meeting that would not be held until next week, and that a move was not anticipated until 2 March. Three sets of doctors at the hospital trust have disagreed as to Becky’s diagnosis; at her most recent assessment doctors said she was not eligible to be sectioned, which would trigger the protections provided by the Mental Health Act, because her mental disorder was not of the “nature and degree” as to warrant her detention. In a robust exchange, the judge demanded: “Where’s the urgency in this … I cannot believe that the life and health of a 12-year-old girl is hanging on an issue of NHS procurement, when you cannot tell me what it is you’re trying to procure. “If the delay is procurement, I’m not having it,” Lieven continued. “I will use the inherent jurisdiction to make an order. We have a 12-year-old child in a completely inappropriate NHS unit for about three weeks, and it’s suddenly dawned on your client that ‘actually we’ll put her in a Tier 4 unit and we might have to do some [building] work.’” Sometimes, the judge said, “public bodies have to move faster”. Read full story Source: The Guardian, 17 February 2023
  7. Content Article
    A BBC Newsnight investigation hears devastating evidence and testimony of ambulance failings in the north east of England. What does it take to run a safe service that patients can trust? 
  8. News Article
    A government review into mental health hospitals will fail to prevent the “appalling” treatment of patients, campaigners have warned. The urgent inquiry into inpatient mental health services will focus solely on data, the government said on Tuesday. The “rapid review”, launched following investigations by The Independent into “systemic abuse” across a group of children’s mental health hospitals, will last 12 weeks and is being led by a former national NHS mental health director Dr Geraldine Strathdee. In an outline of what it will cover, the Department for Health and Social Care said it would look at what data is collected by the NHS on inpatient mental health services and whether it is used effectively to identify patient safety problems. It will also look at the quality of data and identify good examples of care but it won’t look at individual cases of abuse or community services. Major mental health charity Mind has warned the review “is not enough” and will not provide any learnings on how to prevent poor care. The charity is instead calling for a national statutory public inquiry into inpatient mental health services. Read full story Source: The Independent, 15 February 2023
  9. News Article
    President Biden has endorsed “harm reduction,” which aims to cut down on overdoses by encouraging safer drug use. But the organizations carrying out that strategy are severely underfunded. In his State of the Union address on Tuesday, Mr Biden, the first president to endorse the strategy, highlighted the federal government’s attention to some of the core features of harm reduction work, including a provision in a recently enacted spending package that makes it easier for doctors to prescribe buprenorphine, an effective addiction medication that Ms Krauss works to get to drug users. During his speech, Mr Biden recognised the father of a 20-year-old from New Hampshire who died from a fentanyl overdose, citing the more than 70,000 Americans dying each year from the potent synthetic opioid. But two years after Mr Biden took office, with the nation’s drug supply increasingly complex and deadly, the practice of harm reduction remains underfunded and partially outlawed in many states. Read full story (paywalled) Source: New York Times, 10 February 2023
  10. News Article
    A woman who underwent needless surgery at the hands of convicted surgeon Ian Paterson said patient safety was still not being prioritised. Paterson was convicted of 17 counts of wounding with intent in 2017 and was jailed for 20 years. Debbie Douglas, who now campaigns for his victims, said more still needed to be done following a damning report. In December, the Department for Health said it was making "good progress" on changes. The inquiry, published in 2020, made 15 recommendations and Ms Douglas called on health chiefs to "get on" with the improvements. "It's three years and technically none of the recommendations are closed," she said. "It's all around patient safety and it's not being given the priority it deserves." Read full story Source: BBC News, 9 February 2023
  11. Content Article
    This Sky News investigation looks at one of the pharmaceutical industry's biggest scandals—the hormone pregnancy test Primodos which was prescribed to pregnant mothers in the UK between 1958 and 1978. Primodos was found to lead to birth defects, miscarriages and stillbirth, and regulatory failings led to avoidable harm to thousands of babies.
  12. Content Article
    There is little longitudinal information about the type and frequency of harm resulting from medication errors among outpatient children with cancer. This study aimed to characterise rates and types of medication errors and harm to outpatient children with leukaemia and lymphoma over 7 months of treatment.
  13. News Article
    A Norfolk surgeon who left two patients with life-changing injuries has received a formal warning by a disciplinary panel. Camilo Valero Valdivieso was found guilty of "serious misconduct" by an independent medical panel after two operations went wrong in six days. One of his patients, Paul Tooth, 65, said his life was "a constant struggle" since his operation in January 2020. However, the panel found the surgeon had "learned from these events". The findings from the Medical Practitioners Service (MPTS) panel said that his actions had "risked damaging public confidence in the profession". It heard that he twice "misinterpreted the anatomy" - on one occasion severing a patient's gallbladder. The panel also concluded Mr Valero's fitness to practise was not currently impaired, allowing him to continue working. Read full story Source: BBC News, 7 February 2023
  14. News Article
    Thousands of patients are being recalled for urgent eye checks after regulators raised safety concerns related to a product used in cataract surgery. It is thought around 20 trusts have suspended use of the EyeCee One lenses, after the Medicines and Healthcare Products Regulatory Agency warned of links to higher pressure in the eye, which can cause lost vision. The MHRA has issued an alert ordering trusts to recall patients who have had surgery since October, and estimates between 2 and 4 per cent of patients could have complications. The watchdog stressed reduced vision would only occur if patients were not treated. It is thought the complications could be down to the way the implant was being used in surgery, rather than the product itself. Read full story (paywalled) Source: HSJ, 7 February 2023
  15. Content Article
    The MHRA is aware of cases of increased intraocular pressure in patients recently implanted with EyeCee One preloaded and EyeCee One Crystal preloaded intraocular lenses (IOLs), which are manufactured by NIDEK and distributed by Bausch + Lomb. The root cause has not been identified and further investigations are ongoing with the manufacturer.  Due to the potential risks for patient safety, you should stop using these IOLs and quarantine remaining stock immediately pending the results of further investigations. Additional communications will be issued shortly advising clinicians and affected patients on the next steps.
  16. Content Article
    This blog by Carl Heneghan, Professor of Evidence-based Medicine at the University of Oxford and Clinical Epidemiologist Tom Jefferson, looks at safety and regulatory issues associated with Essure, a permanent contraceptive implant. Essure anchors inside the fallopian tubes and reacts with the tissues, causing them to become inflamed and scarred. The resulting scar tissue then blocks the tubes off, intending to prevent fertilisation. The devices are about 4cm long and contain a stainless steel, nickel and titanium inner coil and an expanding outer coil containing iron, chromium and tin. Essure has been shown to cause allergic reactions, lifelong inflammatory reactions and internal injuries. The authors examine how Essure came to be approved for use in the USA, the UK and the rest of Europe, highlighting regulatory failings and conflicts of interest with the medical tech industry. They also highlight how pressure from women harmed by Essure resulted in its use being banned in several countries. The blog then describes ongoing efforts to access UK data on reports of adverse events due to Essure that are held by the Medicines and Healthcare Regulations Agency (MHRA). Freedom of Information requests for this data have been denied.
  17. Content Article
    Simple, and relatively inexpensive, steps to implement care bundles can have a dramatic impact on rates of surgical site infection. The Burden of Infection Symposium provided an insight into the latest evidence and guidance around best practice, as well as offering expert advice on ‘overcoming the challenges of change’. Read a summary of the symposium published in the Clinical Services Journal.
  18. Content Article
    Ten years ago today, a public inquiry concluded that patients were subject to shocking levels of neglect at Stafford Hospital - putting it among the worst care scandals in NHS history. A young local reporter, Shaun Lintern – now The Sunday Times' health editor – helped expose the scandal. With the NHS again under huge pressure, can we be sure the same failings won't happen again? In this podcast, part of the Stories of our Times podcast series, Shaun speaks to the barrister who chaired the inquiry.
  19. News Article
    Nurses could refuse to carry out any further strikes alongside other health workers because of fears over patient safety, The Independent has learnt. A mass walkout billed as the largest strike in NHS history is due to take place on Monday as tens of thousands of nurses, paramedics and 999 call handlers walk out in a bid to force ministers to the negotiating table. But the coordinated strikes could be a one-off if nurses feel that the decision to take part in direct action compromises patient safety, The Independent has been told. One union source said walkouts are not carried out on a “come what may” basis, and that the unions would have to assess whether striking together was “helpful” or not. Unions have been escalating their industrial action in recent weeks in an attempt to secure higher pay rises. Any de-escalation in tactics will be seen as a blow to their campaign and a boost to Rishi Sunak’s hopes of riding out the wave of protests. With patient safety the priority, sources insisted there are strong local controls that will pull nurses from picket lines if they think there is an issue. Read full story Source: The Independent, 5 February 2023
  20. News Article
    Deadlock over NHS pay is putting patients in danger and risks hardening the position of unions, 10 chief nurses have warned. Unions have warned that the government is making no moves towards resolving the strikes, with one general secretary accusing the government of lying about the state of negotiations. In a joint statement shared with the Guardian, chief nurses from 10 leading hospitals known as the Shelford group highlighted their concern that patients’ health could suffer as a direct result of the increasing disruption the stoppages are causing. Tens of thousands of nurses and ambulance workers in England will stage what will be the biggest strike in the NHS’s 75-year history on Monday. In a plea to the government and health unions, but especially ministers, the 10 Shelford group chief nurses stress that they want both sides to end their standoff as a matter of urgency “because of the impact on the patients and communities we serve. “Industrial action means appointments cancelled, diagnostics delayed [and] operations postponed. The longer industrial action lasts, the greater the potential for positions to harden, waits for patients to grow, and risks of harm to accumulate.” This week will see just one day – Wednesday – when there are no NHS strikes. Nurses will strike again on Tuesday, physiotherapists will stage their second walkout on Thursday and ambulance personnel will stage a further stoppage on Friday. Read full story Source: The Guardian, 5 February 2023
  21. News Article
    Sickle cell patients are being put at risk because of a chronic shortage of specialist nurses to treat them, a damning new report has found. 'The Difference Between Life and Death', a new study by the Sickle Cell Society, found that there are not enough sickle cell workers to deliver a good standard of care. One patient called Abi Adeturinmo told researchers that previous traumatic experiences caused by delays in receiving pain relief medication and poor care meant she “tries not to go to the hospital when in sickle cell crisis unless it is life-threatening”. Another patient, Araba Mensah, whose daughter has sickle cell disorder, said there was a lack of “hands-on” nursing, and said patients who have difficulties feeding themselves or with personal hygiene were “left to suffer unattended”. John James, CEO of the Sickle Cell Society, said: “While there are undoubtedly workforce challenges across all parts of the health system, the evidence in this report suggests that sickle cell is disproportionately impacted as a result of the legacy of neglect of sickle cell care. “On behalf of everyone affected by sickle cell, we are urging NHS England to take action now to ensure all sickle cell patients have access to the specialist care they are entitled to.” Read full story Source: The Independent, 24 November 2023
  22. News Article
    Commissioners have begun a ‘serious incident review’ across their integrated care system after early indications showed patients may have suffered harm due to long waits for cancer treatment. The review has been launched by Somerset Integrated Care Board into dermatology services after an initial review found five of 50 patients had seen their skin lesions increase in size since being referred to hospital by their GPs. ICB board papers stated “potential patient harm has been identified” for those patients, who were on the two-week wait pathway to be seen by a specialist following a referral by their GP. Read full story (paywalled) Source: HSJ, 3 February 2023
  23. News Article
    Mesh campaigners claim Scotland's Health Secretary Humza Yousaf refused to meet them to hear their concerns. Patients blame surgical mesh products for leaving them disabled and in chronic pain and want the Scottish Government to hold an independent review into the use of the products. However, followihttps://www.dailyrecord.co.uk/news/mesh-campaigners-claim-humza-yousaf-29075491ng a debate in the Scottish Parliament earlier this month, the Health Secretary denied their request. Campaigner Roseanna Clarkin, of the Scottish Global Mesh Alliance, said Yousaf has refused several requests for meetings with campaigners spanning nearly two years. Roseanna, who has been left with crippling pain after mesh was used on her umbilical hernia in 2015, has blasted him for “ignoring” those affected by mesh procedures. From the late 90s until 2018, women in Scotland were treated with polypropylene mesh implants for stress urinary incontinence and pelvic organ prolapse. In some, it caused severe pain and life-changing side effects. While the Independent Medicines and Medical Devices Safety Review called for a pause in use of vaginal mesh, the products are not banned for all procedures. The Scottish Global Mesh Alliance were behind the petition calling for an independent review which was debated at Holyrood. They want to suspend the use of all surgical mesh and fixation devices while a review is carried out. Roseanna said: “Why do they assume mesh in another part of the body would respond differently and not cause extreme pain and serious infections?” Read full story Source: Daily Record, 29 January 2023
  24. News Article
    A seismic shift is needed in the way that patients’ and families’ voices are heard, with shared decision-making and patient partnership as the destination, says Patient Safety Commissioner, Dr Henrietta Hughes, on the day the Patient Safety Commissioner 100 Days Report is published. In the report, Henrietta reflects on her first 100 days in this new role. She sets out what she has heard, what she has done and her priorities for the year ahead. "Everyone... has a part to play in delivering safe care – know that you can make a difference by putting safety at the top of your agenda. Introduce patient voices into your governance – in your board meetings, commissioning and contracts meetings, design of strategies, policies and processes, team meeting agendas, annual objectives, appraisals, reviews of complaints and incidents, inspections, and reward and recognition. "I want us to be able to look back in astonishment on the way that we operate now. This is the moment to set a new course with shared decision-making and patient partnership as our destination. Without listening and acting on patient voices, safety will continue to be compromised and patients and families will continue to suffer the consequences of harm." Read full story (paywalled) Source: HSJ, 2 February 2023
  25. Content Article
    In this report, Dr Henrietta Hughes, Patient Safety Commissioner for England, reflects on her first 100 days in this new role. She sets out what she has heard, what she has done and her priorities for the year ahead.
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