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Showing results for tags 'Patient harmed'.
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Content ArticleHealthcare leaders are bringing renewed attention to patient safety issues that have been overshadowed by another year of the COVID-19 pandemic. Becker's Hospital Review asked patient safety experts the following question: "If you could fix one patient safety issue overnight, what would it be and why?" Read the answers Cynthia Barnard, Vice President of Quality at Northwestern Memorial Healthcare (Chicago), Patricia McGaffigan, Vice President of Safety Programs at the Institute for Healthcare Improvement, Ana Pujols McKee Vice president and CMO and Chief Diversity, Equity and Inclusion Officer at The Joint Commission and Gary Stuck, CMO at Advocate Aurora Health gave.
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Content ArticleThis is a debate from the House of Commons on 16 December 2021 on the issue of preventing surgical fires in the NHS.
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Content ArticlePatient safety incidents are any unintended or unexpected incident which could have, or did, lead to harm for one or more patients receiving healthcare. Reporting them supports the NHS to learn from mistakes and to take action to keep patients safe. Both healthcare staff and the general public are encouraged to report any incidents, whether they result in harm or not, to the National Reporting and Learning System (NRLS). You can find out how to do this from the link below.
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Content ArticleThis report from the Department of Health and Social Care sets out the Government’s response to the Independent Inquiry into the Issues raised by Paterson.
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This is the fourth of a short series of blogs in which we take a look back at our work in five areas of patient safety during 2021. In this blog we consider the need for greater patient engagement to support improvements to patient safety. Throughout our work, Patient Safety Learning seeks to harness the knowledge, insights, enthusiasm and commitment of health and social care organisations, professionals and patients for system-wide change and the reduction of avoidable harm. We believe patient safety is not just another priority; it is a core purpose of health and social care. Patient safety should not be negotiable. -
Content Article'Kicking the Hornet’s Nest' is a documentary that looks at power morcellation, a popular gynaecologic procedure used to perform hysterectomies. The documentary demonstrates how the practice has been inadvertently spreading cancer in patients for decades. It includes first-person testimonies and archival footage and follows two married, Harvard-affiliated whistle-blowers who have been personally impacted by the procedure, as they campaign to expose the controversial practice and prevent future needless deaths.
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Patient Safety Learning and the Safer Healthcare and Biosafety Network (SHBN) are undertaking a project, working with patient safety experts and frontline staff, to produce a manual to support staff after a serious safety incident. As part of this work, we are asking healthcare staff to complete a short survey relating to experiences of a serious safety incident. -
Content ArticleThis report looks at how the inaccurate use of the skin cleaning agent chlorhexidine in neonatal care caused severe chemical burns to a baby.
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Content ArticleThis report looks at an incident where a neonate suffered an oesophageal perforation following endotracheal and nasogastric tube insertion.
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Content ArticleThis report highlights the risk of patient overdose when converting tacrolimus (a medicine used following organ transplantation) from an oral to intravenous route.
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NHS England: Ceftazidime as a 24-hour infusion
Becky T posted an article in Medication administration
Through its core work to review patients safety events, recorded on national systems such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources, the National Patient Safety Team identified a patient safety issue where the antibiotic ceftazidime was infused over 24 hours. -
Content ArticleIn this podcast episode, host Aaron Harmon speaks to Dr Neil Vargesson, chair in developmental biology at the University of Aberdeen, about the importance of Good Laboratory Practice (GLP) and why pre-clinical studies are key to keeping people safe. They discuss the history of Primodos, a hormone-based pregnancy test that was given to women between 1959 and 1978. It was developed before GLP and before standardised testing for teratogenesis (causing birth defects). There are data that suggests Primodos caused birth defects, but more questions remain.
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Content ArticleCase study looking at how a Covid patient on a ventilator deteriorated due to their heat and moisture exchanger filter (HMEF) being flooded with secretions. The identified incident highlighted a possible under-recognised patient safety risk of the need to replace such filters.
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Content ArticleThis article in the Journal of Minimally Invasive Gynaecology provides an interpretation of the 2014 US Food and Drug Administration (FDA) statement on power morcellation, a gynaecological procedure in which a device is used to slice up fibroid tissue for extraction through small incisions. Although use of power morcellation makes surgery less invasive, it has been shown to spread cancer if it exists within the patient's tissues. This article looks at the legal impact of the FDA statement, which warns against using laparoscopic power morcellators in the majority of women undergoing hysterectomy or myomectomy for uterine fibroids.
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Content ArticleThis special article in Mayo Clinic Proceedings outlines practical recommendations for diabetes injections and infusions, developed at the Forum for Injection Technique and Therapy: Expert Recommendations (FITTER) workshop held in Italy in 2015. These recommendations were informed by a large international survey of current practice and were written and vetted by 183 diabetes experts from 54 countries. Recommendations are organised around the themes of anatomy, physiology, pathology, psychology and technology and aim to produce more effective therapies, improved outcomes and lower costs for patients with diabetes.
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This joint letter calls on Maria Caulfield MP, Parliamentary Under Secretary of State for Patient Safety and Primary Care, to implement in full the recommendations of the Independent Medicines and Medical Devices Safety (IMMDS) Review on behalf of those harmed by the side effects of Primodos, Mesh and Sodium Valproate. It is signed by Marie Lyon from the Association for Children Damaged by Hormone Pregnancy Tests, Kath Sansom from Sling The Mesh and Emma Murphy and Janet Williams from In-Fact. -
Content ArticleRisk of complications following hernia repair is the key parameter to assess risk/benefit ratio of a technique. As mesh devices are permanent, their risks are life-long. Too many reports in the past assessed mesh safety prematurely after short follow-ups. Peterson et al. aimed to explore what length of follow up would reveal the full extent of complications. The authors concluded that follow-up of more than 15 years is needed to fully assess complications after mesh hernia repair. Especially longer periods are needed to detect mesh erosion into organs and complications in younger males. Presently, short observations and lack of reporting standard in the literature prohibit accurate assessment of complication risks.
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Content ArticleLast November, the UK, under its G7 Presidency, convened an event on patient safety entitled Patient Safety: from Vision to Reality, co-sponsored with the World Health Organization (WHO). The event was designed to build upon recent prominent initiatives taken forward by the UK Government and partner Member States to demonstrate the importance of taking action and facilitating collaboration to advance patient safety as an urgent global priority. This includes: annual Global Ministerial Summits on Patient Safety (from 2016) a Resolution on Global Action on Patient Safety (adopted by the World Health Assembly in 2019); and, the Global Patient Safety Collaborative developed in 2018 by the UK Government in partnership with the WHO to support patient safety improvement in low- and middle-income countries. Coupled with WHO’s Global Patient Safety Action Plan 2021-2030 and an annual World Patient Safety Day on 17th September, such initiatives will ensure that momentum can be maintained in order to tackle the truly global issue of patient safety within the wider context of strengthening national health systems. The link below is a recording of the event.
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This is a joint blog by Patient Safety Learning and Sling the Mesh, highlighting key areas of concern included in their recent response to the Royal College of Obstetricians and Gynaecologists consultation on a new Mesh Complications Management Training Pathway. -
Content ArticleIn this blog for National Voices, Sue Brown, CEO of the Arthritis and Musculoskeletal Alliance, argues that using the word 'elective' when referring to elective surgery is misleading, and downplays the seriousness of waiting for a long time for treatment or surgery. She looks at the impact of waiting too long for surgery such as joint replacement on the lives of patients. Intense, long term pain and loss of mobility can lead to deteriorating mental health, isolation from friends and family and job loss, among other things. Patients needs support while they wait for surgery, and Sue outlines what she believes is needed to support patients who have had community and secondary care delayed: Design support with those with lived experience – ask what is important to them. Use the things we know can help, like social prescribing and health coaching – individual or group personal support. Use the voluntary and community sector who have a wealth of experience in supporting long term condition management – people need to know they are not alone and get support from others in the same situation.
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Content ArticlePatients falling (falling, slipping) is considered one of the most important patient safety risks in the elderly, in health institutions (hospitals, health centres..., etc.) in particular, and more generally in daily life activities at home, out shopping, etc. In this article I call for a cultural transformation for avoiding falls: from a culture of patient safety that focuses on falls within health facilities to a wider societal culture that must be adhered to by all members of society to prevent the risks of falling in the elderly and other groups at high-risk (including those with specific diseases, disabilities due to congenital causes, accidents...).
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Content ArticleThis study in BMC Medicine aimed to quantify the prevalence, severity and type of preventable medication harm across medical care settings. It is the largest meta-analysis to assess preventable medication harm to date. The authors found that one in 30 patients are exposed to preventable medication harm in medical care, and more than a quarter of this harm is considered severe or life-threatening. Their results support the World Health Organization’s priority of detecting and mitigating medication-related harm and highlight other potential intervention targets that should be a priority research focus.
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This is the second in our new series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Marie talks about her campaign for justice for families affected by hormone pregnancy tests, why she is passionate about reforming medicines regulation and the important role patient campaigners play in improving patient safety. -
Content ArticleThe Muckamore Abbey Hospital Public Inquiry is a statutory inquiry established under the Inquiries Act 2005, to examine the issue of abuse of patients at Muckamore Abbey Hospital (MAH). It aims to determine why the abuse happened and the range of circumstances that allowed it to happen. The purpose of the Inquiry is to ensure that such abuse does not occur again at MAH or any other institution in Northern Ireland which provides similar services. This website contains all documentation, reports and news about the inquiry.
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Content ArticleIn this blog, a patient who experienced life-changing surgical complications describes the process of reconciliation between medical staff and patients when harm has occurred in healthcare. She highlights the need for both the patient and healthcare professional to be engaged and open in the process. She also looks at how different human factors can negatively impact on the duty of candour process, and why they need to be acknowledged. These factors include lack of communication, distraction, lack of resources, stress, complacency, lack of teamwork, pressure, lack of awareness, lack of knowledge, fatigue, lack of assertiveness and norms.
