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Showing results for tags 'Patient harmed'.
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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.
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Content ArticleThe Serious Incident framework describes the process and procedures to help ensure serious incidents are identified correctly, investigated thoroughly and, most importantly, learned from to prevent the likelihood of similar incidents happening again. This framework explains the responsibilities involved when dealing with serious incidents and includes actions staff are required to take, and the tools available. It is designed to inform staff providing and commissioning NHS funded services in England who may be involved in identifying, investigating or managing a serious incident. It is relevant to all NHS-funded care in the primary, community, secondary and tertiary sectors, including private sector organisations providing NHS-funded services. At some point in 2022, the Serious Incident framework will be replaced by the Patient Safety Incident Response Framework
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Content ArticleDiabetic eye screening (DESP) is a national programme which is designed to pick up changes in the retina, at the back of the eye, in people with diabetes. These changes, known as diabetic retinopathy, are usually detected long before eyesight is affected. The goal of screening is to find people with sight threatening retinopathy, so that advice and treatment can be offered to prevent sight loss, as diabetic retinopathy is one of the leading causes of blindness in the UK. In this presentation, Dr Elizabeth Wilkinson, Clinical Lead Devon DESP, discusses harm in diabetic eye screening,what a clinical harm review is and communication, including Duty of Candour.
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Content ArticleFetal Alcohol Spectrum Disorder (FASD) refers to the range of neurodevelopmental problems caused by pre-natal exposure to alcohol. The effects are diverse and impact on the individual throughout their life course. This document from the Department of Health and Social Care (DHSC) is a health needs assessment for people living with FASD, their carers and families, and those at risk of alcohol-exposed pregnancies in England. The needs identified for this population group focus on: a lack of robust prevalence estimates in England the importance of multi-sector working to support individuals through the life course better training and awareness for health professionals better organisation of services to improve accessibility a need to develop innovative approaches to support those living with the condition.
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Content ArticleThis is the first in a series of thematic reports which will be published by the Independent Maternity Services Oversight Panel in the coming year. The purpose of the report is to summarise the learning which is emerging from the ongoing programme of independent clinical reviews of the maternity and neonatal care previously provided by the former Cwm Taf University Health Board. This particular report summarises the key themes and issues which emerged from the clinical review of 28 individual episodes of care1 which were provided by the Health Board between 01 January 2016 and 30 September 20182. It focuses on the care of mothers who needed unplanned emergency treatment during childbirth, including some who required admission to an Intensive Care Unit.
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Content ArticleNHS healthcare providers are under constant pressure to make costs savings. There does not appear to be a way to account for the costs of errors, harms and inefficiencies in patient care. If we could account for these costs, then medium to long term plans could be created in order to reduce the costs lost in the consequences of errors, harm and delayed or low-quality care of patients. If we get ‘Care Correct First Time’ then these wasted costs will fall, which could well achieve the 5% savings target within 5 years. Dr Gordon Caldwell proposes a conceptual framework, which would account for these costs wasted on the consequences of error, harm or delays caused by opportunity costs in the inefficient way that frontline staff have to provide patient care.
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Content ArticleThis is the Government’s formal response to the recommendations made by the Health and Social Care Committee in its report, ‘The Safety of Maternity Services in England’. The Committee’s inquiry examined evidence relating to the safety of maternity services. It builds upon current investigations following incidents at East Kent Hospitals University Trust and Shrewsbury and Telford Hospitals NHS Trust, as well as the inquiry into the University Hospitals of Morecambe Bay NHS Trust. The inquiry also considered whether the clinical negligence and litigation processes need to be changed to improve the safety of maternity services and explored the impact of blame culture on learning from incidents.
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In most cases pregnancy and birth are a positive and safe experience for women and their families. This is the outcome that everyone working in maternity services wants every time, for every woman. But when things go wrong, we need to understand what happened, and whether the outcome could have been different. The death or injury of a new baby or mother is devastating and something that everyone working in the health and care system has a responsibility to do all they can to prevent. Following the publication of ‘Getting safer faster’ the Care Quality Commission (CQC) launched a programme of risk-based, focused maternity safety inspections involving a more focused in-depth assessment of relational elements such as teamworking and culture, staff and patient experience. Building on our previous calls for action, the CQC also sought to further explore the barriers that prevent some services from providing consistently good, safe care and to better understand the disparities in outcomes that exist for women and babies from Black and minority ethnic groups. This report presents the key themes from nine of those inspections alongside insight gathered from direct engagement with organisations representing women using maternity services and their families, including Five X More and local Maternity Voices Partnerships. -
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National Diabetes In-patient Audit - Harms (NaDIA-Harms)
PatientSafetyLearning Team posted an article in Diabetes
NaDIA-Harms is a year-round collection of four harms that can occur to diabetic inpatients in England: Hypoglycaemic Rescue Diabetic Keto Acidosis (DKA) Hyperglycaemic Hyperosmolar State (HHS) Diabetic foot ulcer The objective of the harms collection is to reduce the rates of the above serious inpatient harms by collecting and providing regular feedback to hospital trusts to inform quality improvement work on a monthly basis. All acute hospitals in England, with inpatients with diabetes are eligible to participate. This webpage includes guidance on how to participate and patient information. -
Content ArticleThe Patient Safety Movement Foundation has compiled all of their achievements over the past year into their first-ever annual report. Despite the global COVID-19 pandemic, they have stayed loyal to their vision of achieving ZERO preventable patient harm and death across the globe by 2030.
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Content ArticleSince Claire Griffiths underwent a rectopexy operation she has suffered almost constant, debilitating pain. In this article, published by Yahoo Style, she describes her experience and the devastating impact on her life. Also quoted in the article is Sling the Mesh’s founder Kath Samson, who says:"Nobody really knows how many are suffering because the NHS and the regulatory body the MHRA has not kept a database of how many women have had the operation and how many are suffering."
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Content ArticleAlthough many initiatives have been implemented and great strides have been achieved in improving patient safety and reducing preventable medical errors, progress towards achieving "zero" avoidable harm continues to be slow. This video presentation will address common medical errors, their recognition, potential for harm and the psychological and financial costs. The concepts of human factors, system design and the high reliability organisation will be reviewed. New approaches in reducing harm and restoring trust will be described along with the opportunity for physician leadership.
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Content ArticleThe ISMP Targeted Medication Safety Best Practices for Hospitals (TMSBP) were developed to identify, inspire, and mobilise widespread, national adoption in the US of consensus-based best practices for specific medication safety issues that continue to cause fatal and harmful errors in patients, despite repeated warnings in ISMP publications. The best practice recommendations presented in this guidance document are based on error reports received through the ISMP National Medication Errors Reporting Program (ISMP MERP) and have been reviewed by an external expert advisory panel and approved by the ISMP Board of Trustees. This initiative was first launched in 2014 and is updated with additional best practices, as needed, every two years. While targeted for the hospital-based setting, some best practices are applicable to other healthcare settings. Facilities can focus their medication safety efforts on these Best Practices, which are realistic and have been successfully adopted by numerous organisations.
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Content ArticleMedication reconciliation broadly defined includes both formal and informal processes that involve the comprehensive evaluation of a patient’s medications during each transition of care and change in therapy. The medication reconciliation process is complex, and studies have shown that up to 91% of medication reconciliation errors are clinically significant and 1–2% are serious or potentially life-threatening. The Pennsylvania Patient Safety Reporting System (PA-PSRS) identified 93 serious events related to the medication reconciliation process reported between January 2015 and August 2020.
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In this opinion piece, Kath Sansom, Founder of the Sling the Mesh Campaign, argues that the UK regulatory systems for medicines and healthcare have not been fit for purpose for a number of years. Framed within the context of the Cumberlege Review, Kath uses evidence and personal insight to highlight flaws in the system, and to make the case for urgent reform. -
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Kath Sansom, is a journalist and campaigner who, following a pelvic mesh implant, was left in intense pain and subsequently founded the Sling the Mesh campaign. In this powerful opinion piece, Kath highlights the lack of transparency and reporting around financial conflicts of interest in UK healthcare, and why this poses a serious threat to patient safety. Drawing on legislation that was introduced in the US and recommendations from the Cumberlege Review, Kath calls for urgent action to be taken to prevent patients from suffering harm in the future.
