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Showing results for tags 'Patient harmed'.
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Content ArticleTraditional efforts to detect adverse events have focused on voluntary reporting and tracking of errors. However, public health researchers have established that only 10-20% of errors are ever reported and, of those, 90-95% cause no harm to patients. Hospitals need a more effective way to identify events that do cause harm to patients in order to quantify the degree and severity of harm, and to select and test changes to reduce harm. The IHI Global Trigger Tool for Measuring Adverse Events provides an easy-to-use method for accurately identifying adverse events (harm) and measuring the rate of adverse events over time. Tracking adverse events over time is a useful way to tell if changes being made are improving the safety of the care processes. The Trigger Tool methodology includes a retrospective review of a random sample of patient records using “triggers” (or clues) to identify possible adverse events. Many hospitals have used this tool to identify adverse events, to measure the level of harm from each adverse event, and to identify areas for improvement in their organizations. It is important to note, however, that the IHI Global Trigger Tool is not meant to identify every single adverse event in a patient record. The recommended time limitation for review and the random selection of records are designed to produce a sampling approach that is sufficient for the design of safety work in the hospital.
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Content ArticleAll health and care professionals have an ethical responsibility to be open and honest with service users and their employers when things go wrong with a person’s care. This is otherwise known as the professional duty of candour. Learn more about the Duty of Candour on the Health and Care Professions Council website.
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Content ArticleUnsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. The World Health Organization (WHO) has launched the Third WHO Global Patient Safety Challenge: Medication Without Harm to improve medication safety. Considering the huge burden of medication-related harm, Medication Safety has also been selected as theme for World Patient Safety Day 2022. WHO has launched a series of webinars to introduce the strategic framework for implementation of the Challenge, technical strategies, tools and provide technical support to countries for reducing medication-related harm. The webinars share country and patient experiences in implementing the Challenge. This webinar focuses on the role of patients and their families in improving medication safety, recognising that they are the only constants in increasingly complex healthcare systems, and that they can provide essential information and feedback.
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Content ArticleSharon Hartles is a critical criminologist and member of the Open University’s Harm and Evidence Research Collaborative. In this blog, Sharon reflects on events that have unfolded since the publication of the Independent Medicines and Medical Devices Safety Review 'First Do No Harm' report and the Government's response to it. She examines ongoing failures in the government's response and fulfilment of their policy recommendations. Related reading Primodos, mesh and sodium valproate: Recommendations and the UK Government’s response (Sharon Hartles, August 2021) Primodos: The next steps towards justice (November 2020) Mesh: Denial, half-truths and the harms (March 2021) Sodium Valproate: The Fetal Valproate Syndrome Tragedy
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Content ArticleIn this episode of the Institute of Economic Affairs (IEA) Podcast, IEA Head of Political Economy Dr Kristian Niemietz discusses the findings of the Independent Medicines and Medical Devices Safety Review, and how the healthcare system in England responds to reports about harmful side effects from medicines and medical devices. Kristian speaks with Simon Whale, panel member and communications lead for the Independent Medicines and Medical Devices Safety Review and Dr Sonia Macleod, lead researcher, Independent Medicines and Medical Devices Safety Review. They discuss how the NHS, and other health bodies, could improve their services to address poor care and prevent harm.
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Content ArticleMedications are an important component of health care, but each year their misuse results in over a million adverse drug events that lead to office and emergency room visits as well as hospitalisations and, in some cases, death. As a patient's most tangible source of information about what drug has been prescribed and how that drug is to be taken, the label on a container of prescription medication is a crucial line of defence against such medication safety problems, yet almost half of all patients misunderstand label instructions about how to take their medicines. This book, 'Standardizing Medication Labels: Confusing Patients Less', is the summary of a workshop, held in Washington, D.C. on 12 October 2007. It was organised to examine what is known about how medication container labelling affects patient safety and to discuss approaches to addressing identified problems.
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Content ArticleThis is an Early Day Motion tabled in the House of Commons on 28 February 2022, which calls on the Government to implement the recommendations of the Independent Medicines and Medical Devices Safety Review in full, including paying compensation to people disabled by Sodium Valproate.
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Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) explores the prescription of oral paracetamol in adult inpatients who, on admission to hospital, have low bodyweight (less than 50kg). Paracetamol is a common painkiller often used as first-line management for mild to moderate pain. Although it is safe if taken at the right dose, paracetamol in large amounts is toxic to the liver and therefore the maximum dose must never be exceeded. As its 'reference case', the investigation used the case of Dora, an 83-year-old woman who weighed less than 50kg on admission and lost further weight in hospital. While in hospital, Dora was prescribed oral paracetamol 1g four times a day and towards the end of her admission, she developed multiorgan failure due to sepsis and was diagnosed with paracetamol-induced liver toxicity.
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NHS England: Our National Patient Safety Alerts
Patient-Safety-Learning posted an article in NHS England
This webpage provides links to all recent NHS England national Patient Safety Alerts and sets out the criteria for issuing a Patient Safety Alert. -
Content ArticleWhere a new or under-recognised risk identified through the NHS England's review of patient safety events doesn’t meet the criteria for a National Patient Safety Alert, NHS England look to work with partner organisations, who may be better placed to take action to address the issue. To highlight this work and show the importance of recording patient safety events, they publish regular case studies. These case studies show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.
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In this opinion piece, Kath Sansom, founder of the Sling the Mesh campaign, highlights the many issues that women face when trying to get pelvic mesh slings surgically removed. She calls for the NHS to give patients a voice and to develop a robust and consistent plan to tackle the issues faced by patients harmed by surgical mesh. -
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Surgical fires are a serious a patient safety issue. In this blog, Patient Safety Learning analyses a recent response from Maria Caulfield MP, Minister for Patient Safety and Primary Care, to several questions tabled in the House of Commons about surgical fires in the NHS, and outlines the need for further action to prevent these incidents.- Posted
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Content ArticleThe use of healthcare complaints to improve quality and safety has been limited by a lack of reliable analysis tools and uncertainty about the insights that can be obtained. The Healthcare Complaints Analysis Tool, developed by Alex Gillespie and Tom W. Reader was used to analyse a benchmark national data set, conceptualise a systematic analysis, and identify the added value of complaint data.
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Content ArticleIn this blog Patient Safety Learning provides an overview of the key points included in its response to the call for evidence for the Health and Social Care Select Committee Inquiry examining the case for reform of NHS litigation.
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Content ArticlePrehospital care is the care received by a patient from an emergency medical service before arriving at a hospital. This systematic review in the International Journal for Quality in Health and Care aimed to identify: how the prevalence and level of harm associated with patient safety incidents (PSIs) in prehospital care are assessed. the frequency of PSIs in prehospital care. the harm associated with PSIs in prehospital care.
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Content ArticleHarm reviews give assurance to patients, patient groups, commissioners and the public as to whether patients have been harmed, or are at risk of harm, as well as helping to avoid future harm to patient. Patients may be harmed not only by clinical treatment, but also as a result of the need to be on a waiting list for clinical treatment, as this may result in deterioration of their physical or mental condition. Royal Cornwall Hospitals standard operating procedure (SOP) identifies a standardised approach to harm reviews for all specialities at the Trust that support the Trusts' governance and assurance processes and maintains practice in line with national expectations.
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Content ArticleThere are many respects in which the modern medical system is not fit for purpose and poses a threat to human health. In so many situations, our superficial assumptions about medicine are wrong. Having more tests to identify disease is often not better than leaving those “well enough” alone, labelling people with a specific disease may not be helpful, and more medicine may not be better than less medicine or no medicine at all. In our eagerness to intervene, we can end up doing harm. This fits with the estimation that around 30% of medical care is ineffective and another 10% is harmful. But why do doctors recommend tests, or diagnose and prescribe treatments that don’t help people? Ian A Harris, an orthopaedic surgeon, and Rachelle Buchbinder, a professor of clinical epidemiology, discuss in this BMJ opinion article.
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Content ArticleThis guidance from the General Medical Council sets out the how doctors should raise and act on concerns about patient care, dignity and safety.
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Content ArticleThe COVID-19 pandemic resulted in an unprecedented reduction in the delivery of surgical services worldwide, especially in non-urgent, non-cancer procedures. A prolonged period without operating (or ‘layoff period’) can result in surgeons experiencing skill fade (both technical and non-technical) and a loss of confidence. While senior surgeons in the UK may be General Medical Council (GMC) validated and capable of performing a procedure, a loss of ‘currency’ may increase the risk of error and intraoperative patient harm, particularly if unexpected or adverse events are encountered. Dual surgeon operating may mitigate risks to patient safety as surgeons regain currency while returning to non-urgent operating and may also be beneficial after the greatly reduced activity observed during the COVID-19 pandemic for low-volume complex operations. In addition, it could be a useful tool for annual appraisal, sharing updated surgical techniques and helping team cohesion. This paper explores lessons from aviation, a leading industry in human factors principles, for regaining surgical skills currency. We discuss real and perceived barriers to dual surgeon operating including finance, training, substantial patient waiting lists, and intraoperative power dynamics.
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Content ArticleSecond harm is the added psychological distress from an inadequate response by healthcare providers in response to medical errors or neglect. This inadequate response may require patients to seek counselling. The counselling needs of patients who have experienced second harm have received limited research attention. This Q methodology study addresses this gap in knowledge in order to further inform counselling practice.
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Content ArticleIn this article, Dr Ivan Ramos-Galvez, Consultant in Pain Medicine at the Royal Berkshire Hospital, discusses the physical and psychological issues that can arise following surgery for pelvic mesh implants. Dr Ramoz-Galvez highlights that around a third of reported complications are systemic symptoms such as runny nose, muscle pain, brain fog and lethargy, which may be the result of a chronic inflammatory state within the body. Their link to pelvic mesh implants is suggested by the fact that many women report that these symptoms resolve after their implant is removed. He also discusses the wide-ranging impact of pelvic mesh side effects for women who experience them, highlighting that the consequences are not only physical, but also psychological, social and financial. He calls for the medical profession to recognise this and develop treatments that cover all aspects of pelvic mesh complications.
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Content ArticleThis is an Early Day Motion tabled in the House of Commons on the 21st October 2021, which notes disappointment with the UK Government’s response to the Independent Medicines and Medical Devices Safety Review. The motion calls on the Government to reconsider its response and to implement all nine recommendations in their entirety, and to ensure patient safety remains paramount in any changes to regulatory approval frameworks.
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Ineffective medical device recalls are a patient safety scandal
Kath Sansom posted an article in Women's health
A medical device is any piece of equipment, material or apparatus used to diagnose or treat a medical condition. When a medical device is recalled because of safety concerns, it can affect a large number of patients, often on a global scale. However, manufacturers and regulators of these devices don’t often have effective ways to ensure patients know about safety concerns, understand the risks or know what to do if their medical device is recalled. This blog by Kath Samson, founder of the Sling the Mesh campaign, looks at some of the issues around medical device recalls. She suggests ways that device manufacturers and regulators can improve their communication with patients and healthcare staff when a medical device is recalled.- Posted
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Transvaginal mesh timeline (7 December 2017)
Patient-Safety-Learning posted an article in Women's health
This blog sets out a timeline of the major landmarks for transvaginal surgical mesh since its first approval in 1996. -
Content ArticleThese tools and worksheets have been produced by NHS England to assist staff in conducting patient safety incident investigations. NHS England stresses that patient safety investigation is an important and complex task and should only be undertaken by those who have attended training and gained skills and experience from specialists in the field.
