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News Article
Spire Healthcare patients recalled over shoulder op concerns
Patient Safety Learning posted a news article in News
Spire Healthcare, a private healthcare company, has confirmed it will recall patients amid concerns about a surgeon's operations. It comes after Walsall Healthcare Trust announced it was recalling 600 NHS patients who underwent shoulder surgery performed by Mr Shah. Spire said it was committed to promptly responding to concerns and undertaking good governance. Mr Shah is the third shoulder surgeon since 2019 operating from Spire premises to have had issues. One private patient, Martin Byrne, said he was in immediate pain after an operation to repair his rotator cuff performed by Mr Shah at Spire, Little Aston, in Sutton Coldfield in August 2018. He had a further two operations, one on the NHS by Mr Shah and another at Spire, but has since been told nothing more can be done surgically. "This has broken me as a man," he said. "I can't do the things that I used to do with my children. I can't help out lifting at work. "I have sat on the bed crying at night from the pain and I feel that Spire have offered me a lot of tea and sympathy, but they have just fobbed me off. "In my opinion, he has ruined me." Read full story Source: BBC News, 11 October 2022 -
News Article
Brazilian Butt Lift can be made safer say surgeons
Patient Safety Learning posted a news article in News
UK plastic surgeons have released new guidelines to try to make Brazilian Butt Lift (BBL) procedures safer for people who desire a bigger bottom. Some women have died from the operation, which involves sucking out fat from elsewhere - such as the belly - and injecting it into butt cheeks. The British Association of Plastic Surgeons (BAAPS) says the injections should not go very deep to help avoid complications such as dangerous clots. According to the NHS, it has the highest death rate of all cosmetic procedures, and the risk of death from BBL surgery is at least 10 times higher than many other procedures. A major concern is that the injected fat can cause a blockage in a blood vessel in the lungs - called a pulmonary embolism - which can be fatal. This happened to Leah Cambridge, a beautician and mother of three from Leeds. She suffered a massive pulmonary embolism during the operation at a private hospital in Turkey in 2018, a coroner found. BAAPS president Marc Pacifico told the BBC: "Unfortunately we don't know how many people have been going for these risky BBL procedures. We have been recommending against it for a number of years after seeing quite a frightening death rate associated with it. But people have been going abroad to get it done." "Make sure you ask if the surgeon will be using ultrasound for gluteal fat grafting. We are recommending that surgeons should only perform this with real time ultrasound guidance as the only way to ensure the procedure is performed superficially and safely." Read full story Source: BBC News, 10 October 2022 -
News Article
More than 400 pregnant women prescribed topiramate in the past year
Patient Safety Learning posted a news article in News
Between April 2021 and March 2022, more than 400 pregnant women were prescribed the anti-epileptic medicine topiramate, which has been found to cause congenital malformations, figures published by NHS Digital have revealed. The data, published on 29 September 2022, covers prescribing of anti-epileptic drugs in females aged 0–54 years in England from 1 April 2018 through to 31 March 2022. Overall, it shows a reduction in the number of females prescribed sodium valproate; from 27,441 in April 2018 to 19,766 in March 2022. However, the numbers also show that sodium valproate, which can cause birth defects, is still being prescribed during pregnancy, with 42 women being prescribed the drug at some point during their pregnancy between April 2021 and March 2022, compared with 43 in the previous year. In addition, the data show that, during that same time period, 430 females were prescribed topiramate, which is used for treatment of migraines as well as epilepsy, during their pregnancy. In 2021, a safety review, carried out by the Medicines and Healthcare products Regulatory Agency (MHRA) found that carbamazepine, phenobarbital, phenytoin and topiramate were associated with an increased risk of major congenital malformations. In July 2022, the MHRA launched a further review looking specifically at the safety of topiramate, after study results showed an increased risk of autism, developmental disorders and learning difficulties among babies exposed to the medicine during their mother’s pregnancy. Daniel Jennings, senior policy and campaigns officer at Epilepsy Action, said it was “concerning” to see that prescribing figures for valproate had not decreased, compared with the previous year, and that despite the MHRA identifying other epilepsy medicines that could pose a risk if taken in pregnancy, there had been “little or no communication” about these risks. “There is also still a large group of epilepsy medicines where we don’t have an adequate bank of evidence about their safe use during pregnancy,” he added. “The MHRA and NHS England need to work together to communicate the risks and carry out research to protect women with epilepsy.” Read full story Source: The Pharmaceutical Journal. 7 October 2022 -
News ArticleRussell-Cooke personal injury and clinical negligence partner Grant Incles recently represented Mrs Karen Preater in a clinical negligence case over vaginal mesh surgery performed on her at a hospital in north Wales in 2014. Wrexham County Court found in favour of Mrs Preater, and roundly dismissed allegations made by the defendant in this case, the Betsi Cadwaladr University Health Board, that the claimant had lied in the presentation of her case, as part of a Fundamental Dishonesty defence. Mrs Preater underwent vaginal mesh surgery in January 2014 - to which she had not been properly consented. The surgery itself was performed negligently and as a result she suffered a life-changing chronic pain condition. In late 2020, the defendant carried out intrusive video surveillance of Mrs Preater and trawled through her life on social media, proceeding to launch a defence of Fundamental Dishonesty pursuant to S.57 of the Criminal Justice and Courts Act 2015. The defendant alleged that the claimant was seeking to lie to the Court about her ability to work and need for care and assistance which, if found to be correct by the Court, would have meant that Mrs Preater would have lost all of her claimed compensation, and which may well have led to an application by the defendant to have her committed to prison for her alleged dishonesty. The case was fought to trial over seven days in July 2022. HHJ Howells found that Mrs Preater had not sought to deceive any party at any time and should be fully compensated for her grave suffering since being injured over eight years ago. Read full story Source: Russell-Cooke, 4 August 2022 Court judgement: 22081101.Preater v BCUHB approved judgment dated 4 August 2022.pdf
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News Article
How 175 British children were infected with HIV
Patient Safety Learning posted a news article in News
At least 175 children with the blood disorder haemophilia were infected with HIV in the 1980s, according to documents from the national archives seen by BBC News. Some of the families affected are giving evidence at a public inquiry into what has been called the worst treatment disaster in the history of the NHS. It was almost 36 years ago - in late October 1986 - but Linda will never forget the day she was told her son had been infected. She had been called into a consulting room in Birmingham Children's Hospital, with 16-year-old Michael. As a toddler, he had been diagnosed with haemophilia, a genetic disorder that stopped his blood clotting properly. Linda assumed the meeting was to discuss moving his care to the main Queen Elizabeth Hospital in the city. "It was so routine that my husband stayed in the car outside," she says. "Then, all of a sudden, the doctor said, 'Of course, Michael is HIV positive,' and he came out with it like he was talking about the weather outside. My stomach just fell." Between 1970 and 1991, 1,250 people with blood disorders were infected with HIV in the UK after taking Factor VIII - a new treatment that replaced the clotting protein missing from their blood. About half of those infected with HIV died of an Aids-related illness before life-saving antiretroviral drugs became available. Almost three decades later, Linda is giving evidence to the long-running public inquiry into the treatment disaster. She will appear alongside other parents, in a special session about the experiences of families whose children were infected in the 1970s and 80s. "I felt as though I needed to do it because I want to help get to the bottom of it," she says. "We all want to know why it was allowed to happen and to keep on happening as well." Read full story Source: BBC News, 6 October 2022 -
News Article
Vulnerable patients injured by 'inadequate' service
Patient Safety Learning posted a news article in News
A troubled trust’s inpatient wards for people with a learning disability or autism have been rated “inadequate”, with staff criticised for resorting to restraint too readily which sometimes injured patients. Care Quality Commission inspectors visited Lanchester Road Hospital in Durham and Bankfields Court in Middlesborough, run by Tees, Esk and Wear Valleys Foundation Trust, in May and June. They found most people were being nursed in long-term segregation and some patients had very limited interaction with staff. Among the CQC’s main criticisms was of high levels of restrictive practice used by staff, including seclusion, restraint and rapid tranquilisation. Inspectors said incidents were not always recorded and staff did not learn from them to reduce levels of restrictions in place. They also warned staff were not always able to understand how to protect people from poor care and abuse. Karen Knapton, CQC’s head of hospital inspection, said: “Three people had been injured during restraints, and 32 incidents of injury had been reported for healthcare assistants, some requiring treatment. “This is unacceptable and measures must be put in place to keep patients and staff safe.” Read full story (paywalled) Source: HSJ, 5 October 2022 -
News Article
Hospital merger confusion blamed for cancer deaths
Patient Safety Learning posted a news article in News
A ‘leading’ cancer service has reported a series of safety incidents which contributed to patients being severely harmed or dying, HSJ has reported. An internal report at Liverpool University Hospitals Foundation Trust suggests the incidents within the pancreatic cancer specialty were partly linked to patient pathways being ill-defined following the merger of its two major hospitals. The report lists seven incidents involving severe harm or death, and five involving moderate harm. It is not clear how many of the patients died. The trust was formed in 2019 through the merger of the Royal Liverpool and Aintree acute sites, with the consolidation of clinical services an integral part of the plans. However, there were no formal plans to change the configuration of pancreatic cancer services, which already operated under a “hub and spoke” model. In one finding relevant to all 12 incidents, the report said: “Patient ownership and clinician accountability (local vs specialist) have not been defined following the merger of the legacy trusts and subsequent service reconfigurations. “This has contributed to system failures in the provision of timely quality care, particularly in patients with time-critical clinical uncertainty.” Read full story (paywalled) Source: HSJ, 5 October 2022 -
News ArticleSurgical blunders have soared 60% in five years – and extreme mistakes are now a daily occurrence in the NHS. Some 13,921 people were treated for damage caused by botched operations in the year to March 31 – up from 8,695 in England in 2016/17. Cases involved an “unintentional cut, puncture, perforation or haemorrhage”. Separately, a report from NHS England shows 134 patients fell victim to so-called Never Events from April 1 to July 31. Extreme errors included two women left infertile after their ovaries were wrongly removed. Injections and invasive tests were given to the wrong patients and in 39 cases foreign objects, such as drill bits and wires, were left inside bodies. There were 57 cases of surgery on the wrong body part and 12 instances of patients being given the wrong implant or prosthesis. The Royal College of Surgeons in England said: “If the system is overstretched, there is a risk that mistakes will happen.” Rachel Power, chief executive of the Patients Association, said: “When Never Events occur, the physical and psychological effects can stay with a patient for life.” Read full story Source: The Mirror, 1 October 2022
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News Article
‘Appalled’ NHSE director orders safety review at all providers
Patient Safety Learning posted a news article in News
The NHS’ mental health director has branded abuse exposed at a city inpatient unit as “heartbreaking and shameful” and ordered a national review of safety across all providers. In a letter to all leaders of mental health, learning disability and autism providers, shared with HSJ, Claire Murdoch responded to BBC Panorama’s exposure of patient abuse at the Edenfield Centre run by Greater Manchester Mental Health FT by warning trusts they should leave “no stone unturned” in seeking to eradicate and prevent poor care. An investigation by the programme found a “toxic culture of humiliation, verbal abuse and bullying” at the medium-secure inpatient unit in Prestwich near Manchester. In response, Ms Murdoch said the mindset that “it could happen here” must be at the front and centre of national and local approaches, adding that trusts which already adopt this outlook are most likely to identify and prevent toxic and closed cultures. She also urged all boards to urgently review safeguarding of care in their organisations and identify any immediate issues requiring action now, such as freedom to speak up arrangements, complaints, and care and treatment reviews. A separate national probe into the quality of inpatient care is due to launch imminently. Read full story (paywalled) Source: HSJ, 30 September 2022 -
News ArticleGreater Manchester Mental Health NHS Foundation Trust said a number of staff at its Edenfield Centre had been suspended after an undercover investigation found what was described as a "toxic culture" of humiliation, verbal abuse, and bullying of patients. BBC Panorama reporter, Alan Haslam, spent 3 months as a support worker at the Centre in Prestwich. Wearing a hidden camera, he said he observed staff swearing at patients, mocking them, and falsifying observation records. A consultant psychiatrist, Dr Cleo Van Velsen, who was asked by the BBC to review its footage, said it showed a "toxic culture" among staff at the Centre with "corruption, perversion, aggression, hostility, [and a] lack of boundaries". Dr Van Velsen told the BBC that staff members at the Edenfield Centre acted "like a gang, not a group of healthcare professionals". Patients at the Centre told the undercover reporter that they felt "bullied and dehumanised". Greater Manchester Police said it was working with the Crown Prosecution Service with a view to prosecuting anyone who had committed a crime. In a statement, Greater Manchester Mental Health NHS Foundation Trust said: "We are taking the allegations raised by Panorama very seriously since the BBC sent them to us earlier this month. We have put in place immediate actions to protect patient safety, which is our utmost priority. "Since then, senior doctors at the Trust have undertaken clinical reviews of the patients affected, we have suspended a number of staff pending further investigations, and we have also commissioned an independent clinical review of the services provided at the Edenfield Centre. " Read full story Source: Medscape. 29 September 2022
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News Article
Hospital seclusion: ‘I’ve been treated like an animal’
Patient Safety Learning posted a news article in News
Evidence of abusive and inappropriate treatment of vulnerable patients at a secure mental health hospital has been uncovered by BBC Panorama. One young woman was locked in a seclusion room for 17 days, was then allowed out for a day, only to be hauled back in for another 10 days. Harley was sitting on the floor wearing pink pyjamas, with her hair tied up in neat braids, when hospital staff piled through the door one after another. Two male nurses grabbed her by the arms. "You're not giving me a chance to work with you," she screamed. "Let me get up." But it was no use. Managers at the secure mental health hospital had decided there would be - in their words - "no negotiation". As she struggled, other nurses and support staff joined in. With her arms, legs and head restrained, she was pinned to the floor, face down. Secret filming by BBC Panorama captured the moment the 23-year-old was forced into a seclusion room at the Edenfield Centre in Prestwich, near Manchester. The hidden camera had already recorded staff justifying their actions and agreeing they would not try to reason with her this time. Panorama's undercover reporter was told that Harley had previously been aggressive towards staff - but, this time they said she was being isolated for screaming and being verbally abusive. Seclusion should only be used when it is of "immediate necessity" to contain behaviour that is likely to harm others, with patients locked away for the shortest time necessary, guidelines say. England's independent healthcare regulator, the Care Quality Commission, says it should only be used in extreme cases - while the government has said the use of restrictive methods in hospitals should be reduced. But research by BBC News has found the numbers are steadily increasing. Read full story Source: BBC News, 28 September 2022 -
News Article
Almost 6,000 people harmed by prescription errors in NHS last year
Patient Safety Learning posted a news article in News
A pregnant woman who died after being given the wrong dosage of drugs was one of almost 6,000 people harmed and 29 killed following prescription errors in the NHS in England last year. Figures from NHS England show that 98 hospital trusts experienced an increase in the number of prescription errors reported in 2021, including cases where patients were given the wrong drug, wrong dosage or were not given medicine when needed. Meanwhile, the number of errors fell at 105 trusts. Leeds Community healthcare trust had a sixfold increase in prescription errors – with 111 errors, up from just 17 in 2020. At the Royal National Orthopaedic hospital errors rose from 60 to 193, while Herefordshire partnership university NHS trust had 55 errors, up from 20 in 2020. The NHS said that some trusts still did not have a fully funded plan to introduce electronic prescribing, meaning they are still run at least partially using paper notes. Peter Walsh, the chief executive of Action against Medical Accidents, said: “These are very disappointing statistics and behind every one there is a story of personal suffering or tragedy. What is particularly frustrating is that prescription errors are probably easier to avoid than many things that go wrong in healthcare". “We are particularly concerned about vulnerable people such as elderly or disabled people in care homes, who may be more at risk because they may be less able to check for themselves and because they tend to get a less personalised service than the average patient.” Read full story Source: The Guardian, 26 September 2022 -
News Article
Hundreds recalled over shoulder op concerns at Walsall hospital
Patient Safety Learning posted a news article in News
Up to 600 patients are to be recalled by a hospital after concerns were raised about shoulder operations. Some patients have lost the use of their arm after surgery by Mian Munawar Shah at Walsall Manor Hospital. Angela Glover had two operations by Mr Shah - the first, it later emerged after a review, was unnecessary and a screw had been placed inappropriately. Her partner Simon Roberts said she was in "constant pain" and was unable to raise her arm or grip things in her right hand. It has affected her mental health to the point she had to be sectioned after a suicide attempt, Mr Roberts added. Mr Martin Crowley had an operation in 2019 after dislocating his shoulder - Mr Shah then replaced the joint when the first operation was unsuccessful. Since then, he said he struggled with basic tasks such as buttoning up a shirt or holding a cup of tea. "It's affecting me quite bad, there's a lot of stuff I want to do that I can't do," he said. Between 2010 and 2018 there were 21 medical negligence claims relating to Mr Shah's surgery. In 2020, Walsall Healthcare Trust contacted the Royal College of Surgeons (RCS) which carried out a general review of surgery and then a further review into Mr Shah's individual work. A recall of his patients was recommended by the RCS. The surgeon has been given an interim order by the Medical Practitioners Tribunal Service (MPTS), stopping him from doing laterjet procedures or shoulder joint replacements without supervision. Medical director at the Walsall trust Dr Manjeet Shehmar told the BBC there had been a failure to carry out multi-disciplinary team meetings and some of the procedures should have been performed in a specialist orthopaedic hospital rather than at Walsall Manor. Read full story Source: BBC News, 26 September 2022 -
News Article
Low staffing during pandemic harmed US nursing home residents, House panel says
Patient Safety Learning posted a news article in News
A special House panel investigating America's response to the coronavirus pandemic said it has found anecdotal evidence of understaffing at nursing homes that led to patient neglect and harm. At a hearing Wednesday, the select subcommittee on the coronavirus crisis plans to discuss some of its findings, including how large nursing home chains reacted to complaints from staff and families. “Many nursing home facilities were severely understaffed during the early months of the pandemic, leading to deficient care, neglect, and negative health outcomes for residents,” the committee reported Wednesday in a news release in advance of the hearing. President Biden earlier this year instructed the Centers for Medicare and Medicaid Services [CMS] to develop minimum staffing standards for nursing homes. By highlighting problems during the pandemic, the House hearing on Wednesday increases pressure on nursing homes and the Biden administration as that work by CMS continues. The agency said recently it plans to study staffing levels through the winter. Read full story (paywalled) Source: The Washington Post, 21 September 2022 -
News Article
Scotland's A&E waiting times worst on record
Patient Safety Learning posted a news article in News
Performance on waiting times targets at Scotland's hospital A&E units has hit a new low. Figures for the week ending 11 September showed just 63.5% of patients were dealt with within four hours. Health Secretary Humza Yousaf said the figures were "not acceptable" and he was determined to improve performance. Scottish Tory health spokesman Dr Sandesh Gulhane said the figures showed the "crisis in A&E is not merely continuing, but deepening". The Scottish government target is that 95% of patients attending A&E are seen and subsequently admitted or discharged within four hours. Doctors working in emergency medicine have issued stark warnings recently about the impact of long waits in A&E. It is simply not safe, and patients are dying as a result, they say. Read full story Source: BBC News, 20 September 2022 -
News Article
Many English maternity units not meeting safety standards
Patient Safety Learning posted a news article in News
More than half of maternity units in England fail consistently to meet safety standards, BBC analysis of official statistics shows. Health regulator the Care Quality Commission (CQC) rates 7% of units as posing a high risk of avoidable harm. A further 48% require improvement. The figures are slightly worse than a few years ago, despite several attempts to transform maternity care. The regulator says the pace of improvement has been disappointing. In most cases, pregnancy and birth are a positive and safe experience for women and their families, says the CQC. But when things do go wrong, it is important to understand what happened and whether the outcome could have been different. Laura Ellis lost her newborn son when he was unexpectedly breech during advanced labour. She checked out the CQC rating of her local hospital, Frimley Park, when she was pregnant. Maternity services were good. But Laura didn't realise the unit had been told that it required improvement on safety. Laura said: "It was just so hard. So hard to deal with. So hard to leave as well. How would you leave your baby in hospital when you should be taking them home?" Frimley Park NHS Foundation Trust says it has made a number of changes since Theo died, including an emergency response if a baby is unexpectedly breech during advanced labour. Read full story Source: BBC News, 21 September 2022 -
News ArticleRegina Stepherson needed surgery for rectocele, a prolapse of the wall between the rectum and the vagina. Her surgeons said that her bladder also needed to be lifted and did so with vaginal mesh, a surgical mesh used to reinforce the bladder. Following the surgery in 2010, Stepherson, then 48. said she suffered debilitating symptoms for two years. An active woman who rode horses, Stepherson said she had constant pain, trouble walking, fevers off and on, weight loss, nausea and lethargy after the surgery. She spent days sitting on the couch, she said. In August 2012, Stepherson and her daughter saw an ad relating to vaginal mesh that mentioned 10 symptoms and said that if you had them, to call a lawyer. Vaginal mesh, used to repair and improve weakened pelvic tissues, is implanted in the vaginal wall. It was initially — in 1998 — thought to be a safe and easy solution for women suffering from stress urinary incontinence. But over time, complications were reported, including chronic inflammation, and mesh that shrinks and becomes encased in scar tissue causing pain, infection and protrusion through the vaginal wall. More than 100,000 lawsuits have been filed against makers of mesh, according to ConsumerSafety.org, making it “one of the largest mass torts in history.” Read full story Source: Washington Post, 20 January 2019
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News Article
Nurse struck off for failing to dispense morphine
Patient Safety Learning posted a news article in News
A nurse in Somerset has been struck off after she failed to give morphine to a patient before they underwent surgery. Amanda-Jane Price had been suspended from front-line duties since the incident in March 2019. The Nursing and Midwifery Council ruled that Miss Price had been "dishonest" with her colleagues and her ability to practice medicine safely was "impaired". Miss Price had been a nurse at Musgrove Park Hospital in Taunton since 2018. On 31 March 2019, Miss Price did not administer morphine to an individual in her care, falsely recording in her notes that morphine had been given. An investigation by the hospital's emergency medicine consultant found that the morphine dose of 6mg had been noted on the patient's chart, but that the drug had not actually been administered. Miss Price subsequently admitted to falsifying the prescription chart, and to "being consciously aware of her decision". As a result of Miss Price's actions, the patient underwent an invasive procedure without analgesia, and subsequently complained of being in pain. The panel concluded that Miss Price was guilty of misconduct and would initially be suspended. "This was deliberate dishonesty which concealed her failure in clinical issues and caused actual patient harm to a vulnerable victim," the panel concluded. Read full story Source: BBC News, 20 September 2022 -
News ArticlePolice are preparing to investigate alleged mistreatment of patients at a mental health unit. The Edenfield Centre based in the grounds of the former Prestwich Hospital in Bury is at the centre of the claims. The unit cares for adult patients. The Manchester Evening News understands that action was taken after the BBC Panorama programme embedded a reporter undercover in the unit and then presented the NHS Trust which runs it with their evidence. A spokesperson for Greater Manchester Police said: "We are aware of the allegations and are liaising with partner agencies to safeguard vulnerable individuals and obtain all information required to open an investigation." A spokesperson for Greater Manchester Mental Health NHS Foundation Trust said: "We can confirm that BBC Panorama has contacted the Trust, following research it conducted into the Edenfield Centre. We would like to reassure patients, carers, staff, and the public that we are taking the matters raised by the BBC very seriously". "Immediate action has been taken to address the issues raised and to ensure patient safety, which is our utmost priority. We are liaising with partner agencies and stakeholders, including Greater Manchester Police. We are not able to comment any further on these matters at this stage." Read full story Source: Manchester Evening News, 14 September 2022
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News Article
Leapfrog Group will measure US hospitals on diagnostic performance in 2024
Patient Safety Learning posted a news article in News
The Leapfrog Group will add a section to its annual survey in 2024 asking US hospitals to report their progress on evidence-based practices designed to prevent and reduce patient injury and death from diagnostic error and delay. This Autumn, Leapfrog will pilot test survey questions about a range of diagnostic practices from holding leaders accountable for diagnostic safety to openly communicating diagnostic errors to patients and optimising electronic records to support accurate and timely diagnosis. Results of the Leapfrog Hospital Survey — completed voluntarily each year by more than 2,300 U.S. hospitals — rate participants’ progress toward Leapfrog’s standards for safety, quality and transparency and are publicly reported. Since 2000, the survey has been the centerpiece of Leapfrog’s mission to “support informed health care decisions and promote high-value care.” The results are also used by hospitals to benchmark their performance to others in the industry. The addition to the survery is part of a larger push to reduce harm caused by diagnostic error. Leapfrog is working with the Society to Improve Diagnosis in Medicine (SIDM) on a multi-year project called “Recognizing Excellence in Diagnosis.” Mark L. Graber, SIDM’s Founder and President Emeritus, expects that including diagnosis in the survey will elevate organizations’ interest in addressing diagnostic error. “Healthcare organizations need to address the harm arising from diagnostic error in their own hospitals.” says Dr. Graber. “The new Leapfrog report gives them ideas on where to start.” Read full story Source: Betsey Lehman Center, 14 September 2022 -
Content ArticleOn the 20 January 2023 the Health and Social Care Select Committee published a reported with reviewed the progress that the UK Government has made in implementing the recommendations of the Independent Medicines and Medical Devices Safety Review, sometimes referred to as the Cumberlege Review. This paper sets out the UK Government’s response to the recommendations set out in this report. Related reading: Health and Social Care Select Committee: Follow-up on the IMMDS report and the Government’s response (20 January 2023) Patient Safety Learning: Response to the Select Committee report on the Independent Medicines and Medical Devices Safety Review (20 January 2023)
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Content ArticleIn this blog, Carl Heneghan, Professor of Evidence-based Medicine at the University of Oxford and Clinical Epidemiologist Tom Jefferson look at the long-term consequences of inadequate regulation and approval of pelvic mesh devices. They argue that regulators and health systems around the world failed to heed the early warnings, which lead to thousands of women being irreversibly harmed. They highlight that as early as 1999, a study of 34 women who had ProteGen mesh implants showed that 50% of mesh devices had eroded through the vaginal wall. Boston Scientific voluntarily recalled 20,000 devices as a result. In spite of this, the FDA continued to approve vaginal mesh devices, citing ProteGen as their predicate device.
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Content ArticleA research paper was published in October 2021 highlighting results of Freedom of Information (FOI) Requests sent to NHS Trusts in England. The FOI Requests asked for the number of incidents of sexual assault reported by hospitals where the victim was aged over 60, and the alleged perpetrator was a member of staff. The resulting findings were that there were at least 75 reports of sexual assault on patients over 60 by hospital staff in the past five years. The findings also show that whilst the majority of victims were female, 30% were male and that a disappointing number were reported to police – only 16. Of these, 14 were closed as “No Further Action” by the police. In this viewpoint paper published in the Journal of Adult Protection, Amanda Warburton-Wynn highlights the findings of this research.
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Content ArticleOn Saturday 17 September 2022, the fourth annual World Patient Safety Day took place, established as a day to call for global solidarity and concerted action to improve patient safety. Medication safety was chosen as the focused for World Patient Safety Day 2022 due to the substantial burden of medication-related harm at all levels of care. In this report, the World Health Organization (WHO) provides an overview of activities in the countries that observed World Patient Safety Day 2022 to make this event.
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Content ArticleWe often hear the mesh scandal blamed on poor surgeon skill. We also hear the argument that high use mesh implanting surgeons are likely to have fewer patients suffering mesh complications, than a less experienced surgeon. However, this study published in JAMA in October 2018, based on NHS data, shows that high mesh implanting surgeons produce the same or even more mesh complications compared to low volume implanters.
