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Showing results for tags 'Patient harmed'.
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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.
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Content ArticleThis is the transcript of a Westminster Hall debate in the House of Commons on fulfilling the recommendations of the Cumberlege Report.
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Content ArticleThis is an Adjournment Debate from the House of Commons on the 31 January 2022 on NHS Hysteroscopy Treatment, tabled by Lyn Brown MP.
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Content ArticleOn Wednesday 26 January, the All-Party Parliamentary Group for First Do No Harm (APPG FDNH) held a virtual public meeting on the topic of redress schemes for those who have suffered avoidable harm linked to pelvic mesh, sodium valproate and Primodos. This meeting was an opportunity to hear from representatives of various patient groups about what victims need and what they are missing from current support mechanisms. Below is a recording of the meeting.
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APIL report: The value of compensation (January 2022)
Patient Safety Learning posted an article in Legal matters
The essential purpose of compensation is to, as far as possible, enable the person who has suffered from negligent medical treatment to get back to a ‘normal life’, i.e. the position they were in prior to the negligence occurring. The impacts of negligence are wide-ranging and include job loss, poor physical health, financial troubles, relationship breakdowns and a loss of self-identity and self-worth. Patients who have suffered negligent medical treatment may be able to take legal action against the NHS and claim compensation if it can be shown that the negligence has directly resulted in injury. Patients can take legal action on behalf of themselves or on behalf of their next of kin if that person doesn’t have capacity to pursue action themselves or has died as a result of the negligence. -
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On Wednesday 26 January, the All-Party Parliamentary Group for First Do No Harm (APPG FDNH) held a virtual public meeting on the topic of redress schemes for those who have suffered avoidable harm linked to pelvic mesh, sodium valproate and Primodos. This meeting was an opportunity to hear from representatives of various patient groups about what victims need and what they are missing from current support mechanisms. The meeting heard from Kath Sansom, founder of the Sling the Mesh campaign. Attached is the speech she presented and results from the Sling the Mesh survey. View the recording of the public meeting -
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Statement from Sajid Javid, Secretary of State for Health and Social Care, to the House on establishing a Special Health Authority for Independent Maternity Investigations. -
EventuntilWorld Patient Safety Day, observed annually on 17 September, aims to raise global awareness about patient safety and calls for solidarity and united action by all countries and international partners to reduce harm to patients. Patient and family engagement is one of the main strategies to eliminate avoidable harm in healthcare and ‘Engaging Patients for Patient Safety’ is the defining theme for World Patient Safety Day 2023. Access to safe, quality, and affordable medicines and their correct administration and use is critical for patient treatment and satisfaction. However, harm from medication treatment, including that resulting from a medicine shortage, in hospitals is common. 80 million people in Europe report experiencing a serious medication error during hospitalisation. With the outcomes of enhanced pharmacovigilance practices on medication safety practices in hospitals unclear and widespread deployment and adoption of digitalisation that can contribute to medication safety lagging, error reporting remains one of the most effective strategies to improve patient safety from medication harm. The 72nd World Health Assembly affirms that informed patients and carers could support the elimination of avoidable harm during care delivery. However, in many cases, patients nor their families are unaware of what systems are available to report the error. Therefore, awareness, access and use of patient-centred, user-friendly, reporting systems, will strengthen the evidence base that medication errors are not an unfortunate occupational hazard in healthcare delivery. This webinar will raise awareness of the importance of all stakeholders engaging with patients to improve medication safety in hospitals. It will discuss the importance of ensuring that patients are informed about medication safety and know how to report an unintended medication error when it occurs. Register
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EventIt is now clear that hormone pregnancy test Primodos, the epilepsy drug sodium valproate, and that pelvic mesh causes avoidable harm to many thousands of women and children. Yet recognising these potential harms took many years, and it is still the case that the service does not know the identities of all those affected or potentially affected. The main reason is lack of data. Knowing which patients have received which medicines and devices where, and quickly connecting longer-term outcomes, has traditionally been somewhere between impossible and extremely slow and difficult. Unnecessary harm has often been the result. So how can the NHS solve this issue? What do we know about the traditional challenges with traceability in healthcare and the shortcomings of current data collection techniques? How can it be ensured that the right products are being used for the right patient? What approaches and technologies might solve these challenges, ensuring that the right products are being used for the right patient? How could this fit into wider digital transformation work, and resulting data best be used to improve patient safety and outcomes? This HSJ webinar, run in association with GS1 UK, will bring together a small panel to consider the answers to these important questions. Register
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Bevan Brittan webinar: Extravasation & clinical negligence
Sam posted an event in Community Calendar
Amy Walsh, an experienced IV nurse, will address the clinical negligence issues surrounding extravasation including: incidence and aetiology, presentation and recognition, management, treatment and prognosis of this iatrogenic injury. Register -
EventuntilDespite decades of attention to safety, the 2023 New England Journal of Medicine article titled "The Safety of Inpatient Health Care" ushers in a stark reminder that patients continue to experience unacceptably frequent, and often serious, harms while receiving care. This 2023 IHI Patient Safety Awareness Week free webinar features lead author and globally renown safety expert, Dr. David Bates, who will share perspective on the history of harm in health care, key findings, and insights from this recent publication, associated opportunities to improve identification and measurement of events, and methods for anticipating and preventing harm. Whether you’re a health care leader, safety or quality professional, direct care provider, or work in any setting or role in health care, you’ll leave this illuminating discussion with refreshed thinking about what’s essential for a radical reboot of safety and the role that you and your organizations can take to eliminate and prevent harm. Register
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