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Content ArticleThe World Health Organization Global Patient Safety Challenge, Medication Without Harm, aims to reduce serious, avoidable medication-related harm by 50% in 5 years, globally. Three areas have been identified for early priority action. This technical report addresses Medication Safety in Transitions of Care; why it is a priority, what has been done to address it to date and what needs to be done.
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Content ArticleThe Queen’s Speech was debated on Tuesday 17 May 2022. Copied below is Baroness Julia Cumberlege's excerpts on fulfilling the recommendations of the Cumberlege Report for a redress scheme.
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Content ArticleThis US study in BMJ Quality & Safety aimed to assess whether limiting the hours worked by first-year resident doctors' had an impact on patient safety. In 2011, The Accreditation Council for Graduate Medical Education (ACGME) enacted a policy that restricted first-year resident doctors in the USA to working no more than 16 consecutive hours. This policy was rescinded in 2017, and this study assessed the impact of the policy change by comparing the number of medical errors reported by first-year doctors in the five years before the ACGME was enacted (2002/2007) and in the three years following its implementation. The authors found that the 2011 work-hour policy was associated with a: 32% reduced risk of resident physician-reported significant medical errors 34% reduced risk of reported preventable adverse events 63% reduced risk of reported medical errors resulting in patient death They conclude that rescinding the policy in 2017 may be exposing patients to preventable harm.
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Content ArticleNever Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations. This document details Never Events that were reported by NHS trusts in England between 1 April 2021 and 31 March 2022. Never Events are categorised by type of incident and by trust.
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Content ArticleIn this letter to Maria Caulfield MP, the All Party Parliamentary Group (APPG) First Do No Harm raises concerns that several recommendations from The Independent Medicines and Medical Devices Safety (IMMDS) Review have not so far been taken up by the government. The IMMDS Review looked at how the health system responds to reports from patients about harmful side effects from medicines and medical devices. It specifically looked at the cases of Primodos (a hormone pregnancy test), sodium valproate (an epilepsy medication) and pelvic mesh, and found that significant harm had been caused as a result of problems in the regulatory system and the reporting of side effects. It made a number of key recommendations to the government. The APPG highlights the urgent need to establish a redress scheme for those who have suffered avoidable harm related to the products in the IMMDS Review, a recommendation for which there is widespread cross-party support. They also express disappointment that the government continues to promote the litigation route for those who have suffered harm, arguing that it is an adversarial and difficult process for patients and families who have already suffered significant harm. The letter does recognise that the government has decided to appoint a Patient Safety Commissioner, as recommended by the IMMDS Review, and highlights the significance of this step.
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Content ArticleIn 2010, the US Department of Health and Human Services Office of Inspector General (OIG) reported the first national incidence rate of patient harm events in hospitals—27% of hospitalised Medicare patients experienced harm in October 2008. During that month, hospital care associated with these events cost Medicare and patients an estimated $324 million in reimbursement, coinsurance, and deductible payments. Nearly half of these events were preventable. OIG conducted a new study to update the national incidence rate of patient harm events among hospitalised Medicare patients in October 2018. This work included calculating a new rate of preventable events and updating the cost of patient harm to the Medicare programme.
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Content ArticleAdverse drug reactions (known as ADRs) can occur both in the home, and within the healthcare setting, when combinations of medications produce unexpected side effects. Unfortunately this means that in the most serious cases fatalities can occur. However ADRe has helped all service users by addressing life-threatening problems, reducing pain or improving quality of life. With preventable ADRs responsible for 5-8% unplanned hospital admissions in the UK, and costing the NHS up to £2.5bn pa, it is crucial that healthcare organisations take advantage of tools which can help improve how medicines are managed. ADRe has been developed with the aid of nursing professionals to help nursing staff take a structured approach to the monitoring of medicines, identifying any ADRs service users may be experiencing, and then making changes to improve a patients' health and wellbeing.
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Content Article
This is part of our new series of Patient Safety Spotlight interviews, where we talk to people about their role and what motivates them to make health and social care safer. Lou worked in family liaison for the police service for thirty years, and she talks to us about how this experience is helping her develop family engagement services at the Healthcare Safety Investigation Branch (HSIB). She describes the importance of valuing the voices of patients and their families, and the vital role of their input in improving safety in the healthcare system. She also talks about the challenges the Covid-19 pandemic posed to HSIB's family engagement work, and how speaking to patients and their families is being increasingly valued and professionalised by the healthcare system. -
Content ArticleThousands of patients worldwide have experienced extreme pain and life-altering side effects as a result of surgical mesh implants. This report was commissioned by the New Zealand Ministry of Health to evaluate the project ‘Hearing and responding to the stories of survivors of surgical mesh: Ngā korero a ngā mōrehu – he urupare’, which addressed issues raised by people injured by mesh in New Zealand. A restorative approach to addressing harm in healthcare seeks to provide a collaborative, non-adversarial approach to resolving disputes. It recognises the need for relational interaction and conversation to support healing. The project's restorative process was co-designed in 2019 by the Ministry of Health, advocacy group Mesh Down Under, and researchers and facilitators from Te Ngāpara Centre for Restorative Practice at Te Herenga Waka, Victoria University of Wellington. The evaluation was led by a team at the Te Ngāpara Centre, who evaluated the experiences of 230 people who took part in the restorative process. They aimed to find out if the project objectives were met and whether a restorative approach could be used in other health contexts.
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Content ArticleMaternity services shouldn’t be waiting for whistle-blowers or inquiries to alert them to problems, says Dr Mark Ratnarajah, a practising paediatrician and managing director of C2-Ai. Instead systematic transdisciplinary reviews and real-time data should support a culture of shared learning, that helps ensure patient safety is everybody’s responsibility.
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Content ArticleGB News interviews Kath Sansom, founder of Sling the Mesh, and Alec Shelbrooke, MP, on the thousands of lives that have been ruined by mesh implants.
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Content Article
The operation that ruined my life (BBC Panorama, 29 November 2022)
Sam posted an article in Women's health
Women across the UK are suffering after an operation they were told would transform their lives. Instead, some of them say their lives have been ruined. For years women have been fitted with mesh-like devices to treat prolapse or incontinence - often caused by childbirth. Although it's been a successful treatment for many of them, thousands of women in the US, the UK and Australia are now suing, after finding themselves in agony or suffering other serious complications. -
Content ArticleIn this letter nine charities and patient organisations write to Sajid Javid MP, Secretary of State for Health and Social Care, urging him to reconsider plans to impose fixed costs on lower value clinical negligence claims. They argue that the proposals are a threat to both access to justice and patient safety.
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Content Article
Who killed patient safety? (5 May 2022)
Patient Safety Learning posted an article in Research, data and insight
The medical communities commitment to patient safety has withered over the past 10-15 years after the original call for action in 2000 with the release of the IOM report. What was once a call for action, safety in hospitals and oversight by government has been deprioritised, defunded, and devalued, leaving patients like the authors of this article wondering: What happened to patient safety? -
Content ArticleIn this article for The Guardian, journalist Sirin Kale speaks to Janet Williams about the impact the epilepsy drug sodium valproate has had on her family. Janet took the medication to treat her epilepsy throughout her two pregnancies in 1989 and 1991, but had never been warned about the potential risks to her babies. Foetal valproate syndrome can cause spina bifida, congenital heart defects and developmental delays and is believed to have affected around 20,000 children in the UK. Both of Janet's sons were affected by the medication and require full time care as a result. Janet describes how being told about the risks would have enabled her to make an informed decision about whether to have children, and how her experience led her to help set up In-FACT (the Independent Fetal Anti Convulsant Trust) in 2012.
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Content ArticleInsight into medical device and system failure and the teachings of Henry Petroski, a professor of civil engineering at Duke University, who wrote about failure analysis and design theory.
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Content ArticleTimely written communication between primary and secondary healthcare providers is paramount to ensure effective patient care. In 2020, there was a technical issue between two interconnected electronic patient record (EPR) systems that were used by a large hospital trust and the local community partners. The trust provides healthcare to a diverse multiethnic inner-city population across three inner-city London boroughs from two extremely busy acute district general hospitals. Consequently, over a four-month period, 58,521 outpatient clinic letters were not electronically sent to general practitioners following clinic appointments. This issue affected 27.9% of the total number of outpatient clinic letters sent during this period and 42,251 individual patients. This paper from Patel et al. describes the structure, methodological process, and outcomes of the review process established to examine the harm that may have resulted due to the delay.
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Content ArticleFrom April 2023 the new Health Services Safety Investigations Body will require doctors to be candid about errors that have led to patient harm. But can medics trust that material given in this “safe space” won’t be used against them?
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Content ArticleDiagnostic errors are major contributors to patient harm. Strategies to identify and analyse these events are still emerging, but several show promise for use in operational settings. The Agency for Healthcare Research and Quality (QHRQ) has developed Measure Dx to help healthcare organisations identify diagnostic safety events and gain insights for improvement. Measure Dx can be used by any healthcare organisation interested in promoting diagnostic excellence and reducing harm from diagnostic safety events. Potential users include clinicians, quality and safety professionals, risk management professionals, health system leaders, and clinical managers.
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Content ArticleNot knowing how to unfold or even sit in a wheelchair the right way can cause a catastrophic injury to patients, visitors, volunteers, and staff of a healthcare facility. Wheelchairs are one of the most common assistive devices used in healthcare facilities, from admission to discharge. They are often found at the entrance of a facility for use by both patients and visitors with mobility issues. Hospital volunteers, transport staff, and clinical staff use wheelchairs to take patients to different care areas to have tests performed. Many facilities require that patients be transported in a wheelchair upon discharge. However, not knowing the proper method of unfolding a wheelchair or where to place your hands when sitting down in the seat can cause injuries, specifically to fingers, ranging from lacerations to amputations.
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Content ArticleRecognising the scale of avoidable harm linked with unsafe medication practices and medication errors, WHO launched its third Global Patient Safety Challenge: Medication Without Harm in March 2017, with the goal of reducing severe, avoidable medication-related harm by 50% over the next five years, globally. This report, 'Medication safety in high-risk situations', outlines the problem, current situation and key strategies to reduce medication-related harm in high-risk situation.
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Content ArticleIn the aftermath of an adverse event, an apology can bring comfort to the patient, forgiveness to the health practitioner, and help restore trust to their relationship. According to the Health and Disability Commissioner: "The way a practitioner handles the situation at the outset can influence a patient's decision about what further action to take, and an appropriate apology may prevent the problem escalating into a complaint to HDC". Yet, for many health practitioners saying "I'm sorry" remains a difficult and uncomfortable thing to do. We can help to bring down this wall of silence by developing a clear understanding of the importance of apologies to patients and health practitioners; appreciating the difference between expressing empathy and accepting legal responsibility for an adverse outcome; knowing the key elements of a full apology and when they should be used; and supporting those who have the honesty and courage to say "I'm sorry" to patients who have been harmed while receiving healthcare.
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Content Article
In this blog, Patient Safety Learning marks World Patient Safety Day 2022. It sets out the scale of avoidable harm in health and social care, the need for a transformation in our approach to patient safety and considers the theme of this year’s World Patient Safety Day, medication safety. -
Content ArticleDo patients’ and families’ experiences with communication-and-resolution programmes suggest aspects of institutional responses to injury that could better promote reconciliation after medical injuries? This interview study of 40 patients, family members, and hospital staff in Australia found that patients have a strong need to be heard after medical injury that is often unmet. Although 18 of 30 patient and family participants (60%) reported positive experiences with communication-and-resolution programmes overall and continued to receive care at the hospital, they reported that hospitals rarely communicated information about efforts to prevent recurrences. Opportunities are available to provide institutional responses to medical injuries that are more patient centred.
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Content ArticleToo often in health and social care poor medication practices and inadequate system infrastructure result in patient harm, with as many as 1 in 10 hospitalisations in OECD countries potentially caused by a medication related event. This report considers the human impact and the economic costs of medication safety events, exploring opportunities to improve systems and policies and how to improve medication safety at a national level.
