Search the hub
Showing results for tags 'Patient harmed'.
Found 1,338 results
-
Content ArticleIn the UK, maternal mortality for Black women is currently almost four times higher than for White women, and significant disparities also exist for women of Asian and mixed ethnicity. In this report the Women’s and Equalities Select Committee reviews what is currently understood about the reasons for disparities in maternal deaths, analyses Government and NHS action to date and existing recommendations for change and consider the ongoing challenges to addressing disparities.
-
Content ArticleThis Strategy is based on a vision of Finland being a model country for client and patient safety in 2026. It is divided into four strategic priorities, each of which have three corresponding objectives aimed at strengthening patient safety. It is accompanied by an Implementation Plan so that these objectives can be translated into everyday activities. It was published by the Finnish Ministry of Social Affairs and Health, supported by preparatory work by the Finnish Centre for Client and Patient Safety.
-
Content Article"One family told me their mum had only been waiting six hours on the floor for an ambulance. Only six hours. For a moment I thought this was a positive outcome. A patient in their 80s, lying on a cold hard floor for the equivalent of three quarters of my shift and I felt this was good patient care. Sadly, this genuinely was better than earlier in the year with patients waiting over 12 hours on the floor and an additional 16 plus hours in an ambulance. I cried when I got home about how far we’ve fallen." An anonymous junior doctor shares his experience on the NHS frontline.
-
Content ArticleClinicians in emergency departments (EDs) will see babies and young children with injuries that may be non-accidental. If the cause of such injuries is missed, there is a risk of further harm to the child. However, making a judgement about whether an injury might be accidental or not is complex and difficult. This Healthcare Safety Investigation Branch (HSIB) investigation explores the issues that influence the diagnosis of non-accidental injuries in infants (children under 1 year of age) who visit an ED. Specifically, it explores the information and support available to ED clinicians to help them to make such a diagnosis. Due to the nature of the subject matter no specific incident was used to explore this area of care. Instead, the investigation analysed 10 serious incident reports (reports written by NHS trusts when a serious patient safety incident occurs) to identify the factors that contribute to non-accidental injuries not being diagnosed. These factors were grouped into themes, which informed the terms of reference for the investigation.
-
Content Article
In this blog, Steve Turner reflects on why genuine patient safety whistleblowers are so frequently ignored, side-lined or victimised. Why staff don't speak out, why measures to change this have not worked and, in some cases, have exacerbated the problems. Steve concludes with optimism that new legislation going through Parliament offers a way forward from which everyone will benefit.- Posted
- 5 comments
-
- (and 16 more)
-
Content ArticleIn this article, critical criminologist Sharon Hartles looks at the ongoing fight for justice by families affected by the hormone pregnancy test (HPT) Primodos. Primodos was given to thousands of women in the 1960s and 70s which has been linked to miscarriages, birth defects and stillbirth. The Department of Health and Social Care (DHSC) and pharmaceutical company Bayer are applying to strike out court proceedings against them in a civil litigation case brought by the Association for Children Damaged by Hormone Pregnancy Tests (ACDHPT). This would prevent a five-day hearing scheduled to take place at the Royal Courts of Justice in May 2023 from going ahead. The article outlines the argument brought by the DHSC and Bayer that no additional evidence has been found to warrant the case being brought by the ACDHPT. It then goes on to highlight recent research that has established a causal link between HPTs and birth malformations and that therefore gives credence to the litigation. Sharon highlights the importance of the legal system acknowledging and confronting the damage inflicted upon the families affected by the use of Primodos, many of whom have been seeking justice for decades. Related reading Primodos, mesh and sodium valproate: Recommendations and the UK Government’s response (Sharon Hartles, August 2021) Sodium Valproate: The Fetal Valproate Syndrome Tragedy A year on from the Cumberlege Review: Initial reflections on the Government’s response (Patient Safety Learning, 23 July 2021)
-
Content ArticleNew study from Farr et al. into the effect of implanting polypropylene (PP) surgical mesh into patients. More evidence is needed to show the harmful effect to patients by implanting a foreign body into them, especially into the pelvic floor.
-
Content ArticleResearch paper by Toye et al. published in the Lancet on the experience of women reporting damage from vaginal mesh.
-
Content Article
Surgeon's News: Surgical safety update (March 2023)
Patient Safety Learning posted an article in Surgery
Surgeons' News is a magazine for surgical, dental and allied healthcare professionals. Published quarterly by the Royal College of Surgeons of Edinburgh, it features comment and opinion from leading professionals, plus reviews and reports on subjects relevant to all career levels. Two articles in this month's issue we want to highlight are the Surgical safety update (p.10) on cases from the Confidential Reporting System for Surgery (CORESS) and Safe passage (p.18) discussing the National Patient Safety Syllabus. -
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety by supporting healthcare staff in the safe use of central venous catheters to access a patient’s blood supply. Specifically, it looks into the use of tunnelled haemodialysis central venous catheters, which are a type of central line. The reference event involved Joan, who had a cardiac arrest caused by an air embolus after her haemodialysis catheter was uncapped, unclamped, and left open to air. This took place during a procedure to take blood culture samples to test for a possible line infection (where bacteria or viruses enter the bloodstream). This investigation’s findings, safety recommendations and safety observations aim to prevent the future occurrence of an air embolus following uncapped and unclamped haemodialysis catheters, and to improve care for patients across the NHS.
-
Content ArticleReducing avoidable healthcare-associated harm is a global health priority. Progress in evaluating the burden and aetiology of avoidable harm in prisons is limited compared with other healthcare sectors. To address this gap, this study, published in PLOS ONE, aimed to develop a definition of avoidable harm to facilitate future epidemiological studies in prisons. Authors conclude: "We have developed a working definition of avoidable harm in prison health care that enables consideration of caveats associated with prison environments and systems. Our definition enables future studies of the safety of prison healthcare to standardise outcome measurement."
-
Content ArticleWomen should be able to have confidence that they will receive safe, effective, compassionate maternity care that focuses on their individual needs. That is the experience of many people. But too many families still face care that puts the safety and wellbeing of women and babies at risk. This Parliamentary and Health Service Ombudsman (PHSO) report looks at themes from maternity complaints families have brought to us, to shine a light on their experiences and encourage others to let their voices be heard. It shares case summaries and guidance to help families complain and help NHS organisations understand the issues.
-
Content ArticleThis is Patient Safety Learning’s submission to the consultation on the Professional Standards Authority (PSA) draft strategic plan 2023-26. The PSA were seeking the views of patients, service users, regulators, Accredited Registers and other stakeholders on the work that they do, how they work and how their strategic plan can help them to have a meaningful impact on patient and service user safety and public protection. The consultation is now closed.
-
Content ArticleCan you imagine the distress of going to hospital for an operation and having to return to theatre to have forceps removed because they were left inside your abdomen. Or going in for a left hip operation because of years of agonising pain and waking up to find out they had operated on your good hip. Or having surgery to preserve your ovaries — but they are accidentally removed. Or, worst of all, realising you have had a procedure intended for a different patient. Fanciful stories made up for a TV drama? Sadly not. These were just some of the awful mishaps that occurred in hospitals in England over the space of just ten months. Professor Rob Galloway, writing for the Daily Mail, shares his tips on what patients can you do to protect themselves.
-
Content ArticleThis guide from the Patient Safety Movement Foundation gives actions and resources for creating and sustaining safe practices for reducing medication errors. In it, you’ll find: Executive summary checklist What we know about medication errors Leadership plan Action plan Technology plan Measuring outcomes Conflicts of interest disclosure. Workgroup References.
-
Content ArticleIn this BMJ article, Ryan Essex and colleagues consider whether patients have more to gain than to lose from healthcare worker strikes in poorly functioning health systems Available research on the relationship between strikes and patient harm is limited and offers mixed results, most of which are not widely generalisable across different care settings, researchers said. Overall, the researchers in the study observed a substantial decrease in the number of admissions or care visits during strikes, with broader care delivery changes varying based on who is striking. For example, when early-career physicians strike, research suggests wait times and length of stay are unaffected or become shorter. "While patient safety obviously matters, the overly narrow framing of strikes as harmful to patients is not supported by current evidence; this also shifts focus away from the structural failings that drive strike action in the first place," "When health workers lack other avenues to enact change, failing to strike against suboptimal working conditions may actually be more harmful to patient health in the long run."
-
Content Article
In this blog, Patient Safety Learning looks in detail at the results of the NHS Staff Survey 2022, focusing on responses relating to reporting, speaking up and acting on safety concerns. It includes the following key points: It is difficult to imagine other safety critical industries would deem these results acceptable. Nearly half of all respondents did not feel confident their organisation would address their concerns about unsafe clinical practice. It is hugely concerning that over 40% of respondents could not say that they would be treated fairly if involved in a patient safety incident. This could significantly undermine the willingness of staff to raise concerns, with significant consequences for patient safety. There needs to be greater urgency to improve the safety culture in the health service. NHS England needs to recognise the scale of this challenge and provide clarity on how it will work with organisations to tackle this. NHS England, working in partnership with the National Guardian and the Care Quality Commission, should bring forward as a matter of urgency robust and specific commitments to drive forward the work of improving the safety culture in the NHS. -
Content ArticleThis editorial commentary, published in the Journal of the Royal College of Physicians of Edinburgh, looks at the College's response to the Mid Staffordshire inquiry.
-
Content ArticleNiche Health and Social Care Consulting (Niche) were commissioned by NHS England in November 2019 to undertake an independent investigation into the governance at West Lane Hospital (WLH), Middlesbrough between 2017 up to the hospital closure in 2019. WLH was provided by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) and delivered Tier 4 child and adolescent mental health services (CAMHS) inpatient services. This review initially incorporated the care and treatment review findings of two index case events for Christie and Nadia who both died following catastrophic self-ligature at the unit. The Trust subsequently agreed to include the findings of the care and treatment review of Emily which related directly to her time at West Lane Hospital, even though Emily did not die at this site. This is to ensure that optimal learning could be achieved from this review.
-
Content ArticleThe National Patient Safety Board (NPSB) is a proposed independent federal agency modelled in part after the National Transportation Safety Board (NTSB) and Commercial Aviation Safety Team (CAST) that would identify and anticipate significant harm in health care; provide expertise to study the context and causes of harm and solutions; and create solutions to prevent patient safety events from occurring. Watch this video from the Pittsburgh Regional Health Initiative.
-
Content ArticleSome medical mistakes have been stubbornly hard to eliminate. Now, hospitals hope technology can make a difference. This Washington Post article highlights are some of the biggest problems that caregivers are trying to address with technology.
-
Content Article
Patient Safety 5th Global Ministerial Summit 2023
Patient Safety Learning posted an article in WHO
The World Health Organization's 5th Global Ministerial Summit took place on the 23 and 24 February and was an opportunity for experts from across the world to send clear messages to ministers globally, and for ministers to respond with their pledges about what they were going to do to improve patient safety. Watch the opening and read the outcomes and documents from the Summit, -
Content Article
.jpg.1b3e4321fdb9130c7ed63fc1cc4905a4.jpg)
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.- Posted
- 1 comment
-
1
-
- (and 8 more)
-
Content ArticleStatement from Maria Caulfield, Parliamentary Under Secretary of State (Minister for Mental Health and Women's Health Strategy) on the Government’s initial response to the report of the independent review into the maternity and neonatal services at East Kent University NHS Foundation Trust that was published on the 19 October 2022. NHS England commissioned Dr Bill Kirkup to undertake this review following concerns about the quality and outcomes of care.
-
Content ArticleDysphagia (swallowing problems) occurs in all care settings and although the true incidence and prevalence are unknown, it is estimated the condition can occur in up to 30% of people aged over 65 years of age. Stroke, neurodegenerative diseases and learning disabilities can be the cause of some cases of dysphagia, and may also result in cognitive or intellectual impairment, as well as visual impairment, NHS England received details of an incident where a care home resident died following the accidental ingestion of the thickening powder that had been left within their reach. Whilst it is important that products remain accessible, all relevant staff need to be aware of potential risks to patient safety. Appropriate storage and administration of thickening powder needs to be embedded within the wider context of protocols, bedside documentation, training programmes and access to expert advice required to safely manage all aspects of the care of individuals with dysphagia. Individualised risk assessment and care planning is required to ensure that vulnerable people are identified and protected.
.jpg.1b3e4321fdb9130c7ed63fc1cc4905a4.jpg)