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Showing results for tags 'Patient harmed'.
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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. -
Content ArticleThis week Nadine Dorries MP, Minister for Patient Safety, Suicide Prevention and Mental Health, provided an update on the Government’s response to the Independent Inquiry into the Issues raised by Paterson.[1] Here, Patient Safety Learning reflects on this statement and the need for the Government to urgently prioritise providing a full response to the Inquiry’s findings.
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Content ArticleIn April 2017, Ian Paterson, a surgeon in the West Midlands, was convicted of wounding with intent, and imprisoned. He had harmed patients in his care. The scale of his malpractice shocked the country. There was outrage too that the healthcare system had not prevented this and kept patients safe. At the time of his trial, Paterson was described as having breached his patients’ trust and abused his power. In December 2017, the Government commissioned an independent Inquiry to investigate Paterson’s malpractice and to make recommendations to improve patient safety. The report, outlining a series of recommendations to avoid future harm, was published in February 2020. On 23 March 2021 Nadine Dorries, Minister for Patient Safety, Suicide Prevention and Mental Health, provided an update on the Government’s response to the Independent Inquiry into the Issues raised by Paterson, accessible through the link below.
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Mesh: Denial, half-truths and the harms (March 2021)
Patient Safety Learning posted an article in Women's health
In this article, Sharon Hartles, a member of the Harm and Evidence Research Collaborative, critically discusses the harmful impacts of mesh medical devices against the backdrop of disempowerment, denial and half-truths. Surgical meshes have been in use since the late 19th century. In the mid-20th century the clinical usage of mesh increased. Now, in the early 21st century, procedures involving mesh implantation are common surgeries that are performed around the world. Despite the frequency and worldwide usage of mesh medical devices, the debate about whether or not the benefits outweigh the alleged harms remains highly contested. Read the full article Further recommended reading: Dangerous exclusions: The risk to patient safety of sex and gender bias Healing after harm: A restorative approach to incidents Analysing the Cumberlege Review: Who should join the dots for patient safety? Findings of the Cumberlege Review: informed consent Findings of the Cumberlege Review: patient complaints -
Content ArticleEvery year, avoidable harm leads to the deaths of hundreds of thousands of patients, each an unnecessary tragedy. Despite many people doing good work to improve patient safety, this remains a persistent problem. At the recent Future of Hospitals event from Health Plus Care Online, Helen Hughes, Patient Safety Learning's CEO, and Donna Prosser, Chief Clinical Officer of the Patient Safety Movement, consider the need for patient safety to be a core purpose of healthcare and how we can best achieve this. They also discuss whether patient safety can become a social movement - uniting clinicians, patients, leaders, policy-makers and communities.
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Content ArticleThis directive alert has been issued on the need to confirm intravenous (IV) lines and cannulae have been effectively flushed or removed at the end of the procedure.
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Content ArticleThis webinar is part of a series of seminars from the Yorkshire Quality and Safety Research Group. Jo Wailing, Registered Nurse, Research Fellow and Facilitator, talks about her work exploring the potential of restorative approaches to support healing following adverse clinical events. Jo draws on the lessons learned from investigations into the use of, and harm caused by, surgical mesh.
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Content ArticleThis was a debate in the House of Lords on the 2 March 2021 concerning the UK Government's plans regarding a redress scheme for those harmed by sodium valproate, stemming from recommendations in the First Do No Harm Report by the Independent Medicines and Medical Devices Safety Review chaired by Baroness Cumberlege (also known as the Cumberlege Review).
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Content ArticleThe Health Information and Quality Authority (HIQA) has published its annual overview report of lessons learned from receipt of statutory notifications of accidental and unintended exposures to ionising radiation in 2020. This report provides an overview of the findings from these notifications and shares learnings from the investigations of these incidents.
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WHO's Framework for Action - The 7x5 Matrix (Infographic)
Patient Safety Learning posted an article in WHO
The WHO's Global Patient Safety Action Plan aims to provide a strategic direction for concrete actions to be taken by countries, partner organisations, care facilities and World Health Organization (WHO). It sets out a vision of a “world in which no patient is harmed in healthcare, and everyone receives safe and respectful care, every time, everywhere” and a goal of achieving the maximum possible reduction in avoidable harm as a result of unsafe care. -
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This competency framework has been developed and updated to support prescribers in expanding their knowledge, skills, motives and personal traits, to continually improve their performance, and work safely and effectively.
