Search the hub
Showing results for tags 'Patient harmed'.
Found 1,338 results
-
Content ArticleThis methodological review of racial/ethnic disparities in patient safety in the United States was published in the Journal of Patient Safety. The paper concludes that although there is extensive evidence on disparities in the process and outcomes of health care, data on racial and ethnic disparities in patient safety remain inconclusive in the United States.
-
Content ArticleChaired by Baroness Julia Cumberlege, the Independent Medicines and Medical Devices Safety Review report, First Do No Harm, examines how the healthcare system in England responds to reports about the harmful side effects from medicines and medical devices. In this blog, Patient Safety Learning reflects on one of the key patient safety themes featured in the Review – informed consent.
- Posted
- 6 comments
-
1
-
- (and 5 more)
-
News ArticleThe safety of maternity services in the NHS are to be investigated by MPs after a string of scandals involving the deaths of mothers and babies highlighted by The Independent. The Commons health select committee, chaired by former health secretary Jeremy Hunt, has announced it will hold an inquiry looking at why maternity incidents keep re-occurring and what needs to be done to improve safety. The committee will also examine whether the clinical negligence process needs to change and the wider aspects of a “blame culture” in the health service and its affects on medical advice and decision making. Read the full article here
-
News Article
Kent and Medway: Dermatology patients 'exposed to risk of harm'
Patient Safety Learning posted a news article in News
A private company carrying out dermatology services has had its contract suspended by the NHS over concerns about patients safety. DMC Healthcare ran the service which oversaw the care of almost 2,000 patients in north Kent and Medway for more than a year. NHS bosses says those patients may have been harmed and the contract was suspended in June. A helpline has been set up to ensure affected patients are seen by GPs and follow-up treatment can be arranged. Paula Wilkins, Chief Nurse at Kent and Medway Clinical Commissioning Group, said: "In mid-June we suspended most of DMC's dermatology service when we became concerned about patient safety." "I'm very sorry to say, we now know there have been delays in appointments, including for the diagnosis and treatment of cancers, and that has exposed people to the risk of harm." Read full story Source: BBC News, 21 July 2020 -
News Article
Unit put into special measures after ‘inadequate’ rating
Patient Safety Learning posted a news article in News
A low secure unit for people with learning disabilities and autism has been put into special measures after inspectors found the use of restraint and segregation affected the quality of life for some patients. Cedar House, in Barham near Canterbury, houses up to 39 people and had been rated “good” by the Care Quality Commission early last year. But at an inspection in February this year inspectors rated the service – run by the Huntercombe Group — “inadequate,” saying it was not able to meet the needs of many of the patients at the unit. It was issued with three requirement notices. One patient had been subject to prolonged restraint 65 times between September and February. Each time he was restrained by between two and 19 staff, for an average of nearly two hours. On one occasion, this restraint lasted for eight hours. But the inspectors were told that in the six months before the inspection 29 staff had been injured during these restraints, and the hospital had been trying to refer the patients to a more secure environment. “The impact of this inappropriately placed patient was considerable for both the patients and the hospital,” the report said. “The staff who were regularly involved in restraining the patient were tired and concerned about the welfare and dignity of the patient.” Read full story (paywalled) Source: HSJ, 21 July 2020 -
Content ArticleOn Wednesday 8 July 2020 the Independent Medicines and Medical Devices Safety Review published its report First Do No Harm, examining how the healthcare system in England responds to reports about the harmful side effects from medicines and medical devices. Chaired by Baroness Julia Cumberlege, the review focused on looking at what happened in relation to three medical interventions: hormone pregnancy tests, sodium valproate and pelvic mesh implants. In this blog Patient Safety Learning consider the reports findings in more detail, highlighting the key patient safety themes running through this, which are also found in many other patient safety scandals in the last twenty years. It also looks at what needs to change to prevent these issues recurring and asks whether NHS leaders stick with the current ways of working, make a few improvements, or take this opportunity for transformational change.
-
News ArticleThe NHS have duped thousands of women into believing the most common incontinence mesh operation is safe, by not adding loss of sex life into its risk figures, campaigners say. The move keeps figures low so surgeons can reassure women that it is a safe day case operation. The discovery is buried in a report from five years ago, and when questioned on it, the MHRA, tasked with making sure implants are safe for patients, passed the buck and blamed the report authors. The revelation comes after a debate in Westminster, where health minister Jackie Doyle Price said there was not enough evidence to suspend the plastic implants and quoted a risk of 1-3%. However, those figures were blown out of the water just weeks before the debate in a landmark study using the NHS’s own hospital re-admission figures which show TVT mesh tape risk is at least 10%. Campaigners say even that is not a reflection of the true scale of the mesh disaster because it does not take into account women going to doctors for pain medication or those suffering in silence. Read full story Source: Cambs Times, 31 October 201t
-
News ArticleDaniel Mason was born half a century ago without hands, with missing toes, a malformed mouth and impaired vision. From an early age, he and his family had to deal with people asking about his disabilities. The impact on his life has been considerable. Daniel’s mother Daphne long suspected the cause of his problems was a powerful hormone tablet called Primodos that was given to women to determine whether they were pregnant. But when she raised her concerns with doctors, they were dismissed. Now, at last, Daphne has been vindicated with official confirmation this week that her fears were right, in the landmark review by Baroness Cumberlege into three separate health scandals that has exposed a litany of shameful failings by the NHS, regulatory authorities and private hospitals. This damning report shows again the danger of placing a public service on a pedestal, with politicians happy to spout platitudes but scared to tackle systemic problems or confront the medical establishment. But how many more of these inquiries must be held? How many more disturbing reports and reviews must be written? How many more times must we listen to ministerial apologies to betrayed patients? How much more must we hear of ‘lessons being learned’ when clearly they are largely ignored? Read full story Source: Mail Online, 9 July 2020
-
News Article
MHRA's response to the Cumberlege report
Patient Safety Learning posted a news article in News
The Medicines and Healthcare products Regulatory Agency (MHRA) has published its response to the Independent Medicines and Medical Devices Safety Review. In its response, the MHRA said: “Today’s publication of the Independent Medicines and Medical Devices Safety Review is of profound importance for the MHRA, since the safety of the public is our first priority." "We therefore take this report and its findings extremely seriously. Throughout the Review’s work we have listened intently to the many distressing experiences of women and their families. We will now carefully study the findings and recommendations of the Report. We recognise that patient safety must be continually protected and that many of the major changes recommended by the Review cannot wait. We are therefore making changes without delay to ensure that we listen to patients and involve them in every aspect of our work. We are already taking steps to strengthen our collaboration with all bodies in the healthcare system and will strive to ensure that, working with these other bodies, the safety changes we advise are embedded without delay in clinical practice. We wholeheartedly commit to demonstrating to those patients and families who have shared their experiences during the Review, and anyone else who has suffered, that we have learned from them and are changing and improving because of what they have told us. We are determined to put patients and the public at the heart of everything we do." Read full statement Source: GOV.UK, 8 July 2020 -
Content ArticleThis Review was announced in the House of Commons on 21 February 2018 by Jeremy Hunt, the then Secretary of State for Health and Social Care. Its purpose is to examine how the healthcare system in England responds to reports about harmful side effects from medicines and medical devices and to consider how to respond to them more quickly and effectively in the future. The Review was asked to investigate what had happened in respect of two medications and one medical device: hormone pregnancy tests (HPTs) – tests, such as Primodos, which were withdrawn from the market in the late 1970s and which are thought to be associated with birth defects and miscarriages; sodium valproate – an effective anti-epileptic drug which causes physical malformations, autism and developmental delay in many children when it is taken by their mothers during pregnancy; and pelvic mesh implants – used in the surgical repair of pelvic organ prolapse and to manage stress urinary incontinence. Its use has been linked to crippling, life- changing, complications; and to make recommendations for the future. The Review was prompted by patient-led campaigns that have run for years and, in the cases of valproate and Primodos over decades, drawing active support from their respective All-Party Parliamentary Groups and the media.
-
News ArticleFormer health secretary Jeremy Hunt has warned ministers not to let the Cumberlege review “gather dust on a shelf”. The chair of the Commons Health and Social Care Committee told The Independent it was vital action was taken to implement the recommendations. Mr Hunt, who made patient safety a key focus of his tenure as health secretary, backed the idea of an independent patient safety commissioner that would be outside the NHS and have powers to advocate for patient issues. Mr Hunt said: “This report should be a powerful wake-up call that our healthcare system is still too closed, defensive and focused on blame rather than learning lessons. It’s truly harrowing to hear of all the women and families who live with permanent anguish because of these medicines and devices, and it has clearly taken too long for their voices to be heard.” “The NHS is one of the safest health systems in the world, and we’re all rightly in awe of our frontline heroes. But in healthcare getting it right ‘most’ times isn’t good enough because the exceptions wreak lifelong devastation on families. So we must not allow this seminal report to gather dust on a shelf: lessons must be learnt once and for all.” Read full story Source: The Independent, 8 July 2020
-
News Article
Lives ruined as damage viewed as 'women's problems'
Patient Safety Learning posted a news article in News
Many lives have been ruined because officials failed to hear the concerns of women given drugs and procedures that caused them or their babies considerable harm, says a review. More than 700 women and their families shared "harrowing" details about vaginal mesh, Primodos and an epilepsy drug called sodium valproate. Too often worries and complaints were dismissed as "women's problems". It says arrogant attitudes left women traumatised, intimidated and confused. June Wray, 73 and from Newcastle, experienced chronic pain after having a vaginal mesh procedure in 2009. "Sometimes the pain is so severe, I feel like I will pass out. But when I told GPs and surgeons, they didn't believe me. They just looked at me like I was mad." The chairwoman of the highly critical review, Baroness Julia Cumberlege, said the families affected deserved a fulsome apology from the government. She said: "I have conducted many reviews and inquiries over the years, but I have never encountered anything like this; the intensity of suffering experienced by so many families, and the fact that they have endured it for decades. Much of this suffering was entirely avoidable, caused and compounded by failings in the health system itself." Read full story Source: BBC News, 8 July 2020 -
Content Article
Premature discharge from hospital (June 2020)
Claire Cox posted an article in Keeping patients safe
This is a report of a qualitative survey that explored unsafe, premature discharge from hospital. The Patients Association has regularly heard from helpline callers that patients believed that they had been discharged too early from hospital,and that as a result they had either suffered harm or been at risk of harm. -
Content Article
The Salford Medication Safety Dashboard (SMASH)
Claire Cox posted an article in Medication administration
The Salford Medication Safety Dashboard (SMASH) was successfully used in general practices with the help of on-site pharmacists. SMASH is a web application that flags up a list of patients who are potentially at risk from medicines they have been prescribed. -
News ArticleA GP surgery that had been told it required improvement has been shut down after an inspection found patients could be at "risk of harm". Hampshire's Brockhurst Medical Centre had already been due to close on 31 December. However, the Care Quality Commission (CQC) suspended its registration with "immediate effect" following an unannounced inspection on Monday. Patients are expected to be transferred to other practices on Saturday. In September, a CQC assessment of the practice, on Brockhurst Road in Gosport, rated it overall as "requires improvement". The issues highlighted in the report included that the practice "did not have systems for the appropriate and safe use of medicines" and "there was a risk that some patients were not receiving the care and treatment they needed". Following Monday's inspection, Garry Higgins, of the CQC, said it had taken "urgent action" to suspend the registration of the GP surgery. "We took the action because we believe if we didn't people using the service may be exposed to the risk of harm," he added. Read full story Source: BBC News, 5 December 2020
-
News Article
Private provider’s contract suspended pending safety review
Patient Safety Learning posted a news article in News
An independent provider’s NHS contract has been suspended, and a harm review is to be carried out on patients who have faced a long wait. Kent and Medway Clinical Commissioning Group suspended DMC Healthcare’s contract to provide dermatology services in north Kent “to ensure patient safety” on Friday. It said it had showing some patients had been on waiting lists longer than they should have been. It is unable to say how many patients are likely to be involved in the harm review, but it is expected to focus on those who have waited longer than they should or where harm is suspected. Read full story (paywalled) Source: HSJ, 24 June 2020 -
Content ArticleIn the past 10 years, rates of Obstetric Anal Sphincter Injury (OASI) have increased in England. Experiences in some maternity units have shown that some of the underlying problems related to this rise in OASI include:Inconsistencies in approaches to preventing OASIsInconsistencies in training and skillsLack of awareness of risk factors and long-term impact of OASIsVariation in practice between health professionalsIn light of this, the OASI care bundle team have developed and piloted an intervention package, including a care bundle and guide, a multidisciplinary skills development module for health care professionals, and campaign materials (such as leaflets and newsletters designed to raise awareness).This scaling up programme is a collaboration between the Royal College of Obstetricians and Gynaecologists (RCOG), Croydon Health Services NHS Trust, the Royal College of Midwives (RCM) and the London School of Hygiene and Tropical Medicine (LSHTM), with funding provided by The Health Foundation.
-
News Article
CQC plan to restart inspections needed like ‘hole in head’, says Confed
Patient Safety Learning posted a news article in News
The Care Quality Commission (CQC) has issued a plan for re-starting routine inspections — but has been warned by the NHS Confederation that the health service needs this “like a hole in the head”. The organisation said there would be a “managed return” of “routine inspections” in the autumn. It also stated in a statement today: ”Inspectors are now scheduling inspections of higher risk services to take place over the summer.” But the CQC later insisted to HSJ that this was not a change to its current policy, in place since the beginning of the UK COVID-19 peak, as it would only be inspecting in response to information it receives which raises “serious concerns”. The CQC suspended its routine inspections in March – and has instead been calling healthcare providers and only physically attending where there are serious concerns about harm, abuse or human rights breaches. The new approach to regulation, which the CQC called its “emergency support framework”, was criticised by 11 older people’s and disabled groups, which said the decision not to carry out routine inspections broke human rights and equalities laws. Read full story Source: HSJ, 17 June 2020 -
News Article
‘Independent review of NHS’ ahead of second wave
Patient Safety Learning posted a news article in News
There should be independent reviews of the NHS’ readiness for a potential second major outbreak of coronavirus in the UK, senior doctors are arguing. The Royal College of Anaesthetists said a series of reviews should be carried out, overseen by an independent group formed from clinical royal college representatives, independent scientists and academics. It would encompass investigation of what happened to care quality during the peak of infection and demand through March, April and May — there are major concerns that harm and death was caused by knock of effects, with some health services closed and people being afraid to use others. Hospitals were unable to provide many other services as staff, including most anaesthetists, were redeployed to help with critical care. Ravi Mahajan, president of the Royal College of Anaesthetists, told HSJ areas such as capacity, workforce and protective equipment were key issues to be reviewed. He said: “We can’t wait for [the pandemic] to finish and then review. [The reviews] have to be dynamic, ongoing, and the sooner they start the better. Read full story Source: HSJ, 17 June 2020 -
News Article
Children 'self-harming in hospital' after family visits banned
Patient Safety Learning posted a news article in News
Young people with learning disabilities are being driven to self-harm after being prevented from seeing their families during the coronavirus lockdown in breach of their human rights, a new report finds. The Joint Committee on Human Rights warned that the situation for children and young people in mental health hospitals had reached the point of “severe crisis” during the pandemic due to unlawful blanket bans on visits, the suspension of routine inspections and the increased use of restraint and solitary confinement. The report concluded that while young inpatients' human rights were already being breached before the pandemic, the coronavirus lockdown has put them at greater risk – and called on the NHS to instruct mental health hospitals to resume visits. It highlighted cases in which young people had been driven to self-harm, including Eddie, a young man with a learning disability whose mother, Adele Green, had not been able to visit him since 14 March. “When the lockdown came, it was quite quick in the sense that the hospital placed a blanket ban on anybody going in and anybody going out,” said Ms Green. “Within a week, with the fear and anxiety, he tried to take his own life, which really blew us away. We were mortified.” The Committee is urging NHS England to write to all hospitals, including private ones, stating they must allow visits unless there is a specific reason relating to an individual case why it would not be safe, and said the Care Quality Commission (CQC) should be responsible for ensuring national guidance is followed. Read full story Source: The Independent, 12 June 2020 -
Content ArticleIn order to obtain compensation for harm arising out of medical treatment received within the NHS in Scotland, the elements needed to establish negligence under the law of delict must be satisfied. The Scottish government has expressed the view that a no-fault compensation scheme in relation to clinical negligence claims made against the NHS in Scotland could be simpler than the existing litigation system and could support the development of the concept of a mutual NHS, as well as a positive feedback and learning culture. With this in mind, the government considers that such a scheme is the favoured way forward for the NHS in Scotland. This report reviews and analyses existing no-fault schemes in a number of countries/jurisdictions: New Zealand (NZ); Nordic countries (Sweden, Finland, Denmark, Norway); and the schemes operating in Virginia and Florida (United States) for birth-related neurological injury.
-
Content ArticleA "Fair and Just Culture" supports learning from unsafe acts that result in potential or real harm as a way to prevent future errors. A fair and just culture strikes a balance between a punitive culture and a blame free culture. Differentiating acceptable from unacceptable behaviour associated with harmful events requires a consistent approach to determine culpability of individuals against system flaws that contribute to unsafe acts. More than one unsafe act by more than one individual can contribute to an event. For optimal learning and fair treatment of staff, each act should be considered individually using the same structured approach.
-
News Article
Johnson and Johnson pays hundreds of women in Scotland harmed by mesh implants
Patient Safety Learning posted a news article in News
The pharmaceutical giant Johnson and Johnson has agreed to pay an undisclosed sum to settle a legal action by hundreds of Scottish women who claimed they suffered serious injuries from the company’s pelvic mesh implants. The settlement came as four lead cases brought by women who suffered pain and other serious side effects from the implants, made by Johnson and Johnson subsidiary Ethicon, were about to reach court in Edinburgh. Read full story (paywalled) Source: BMJ, 2 June 2020 -
News Article
ECT depression therapy should be suspended, study suggests
Patient Safety Learning posted a news article in News
The use of electroconvulsive therapy (ECT) to treat depression should be immediately suspended, a study says. ECT involves passing electric currents through a patient's brain to cause seizures or fits. Dr John Read, of the University of East London said there was "no place" for ECT in evidence-based medicine due to risks of brain damage, but the Royal College of Psychiatrists said ECT offers "life-saving treatment" and should continue in severe cases. The National Institute for Health and Care Excellence (NICE) currently recommends the use of ECT for some cases of moderate or severe depression as well as catatonia and mania. However, peer-reviewed research published in the journal Ethical Human Psychology and Psychiatry concludes "the high risk of permanent memory loss and the small mortality risk means that its use should be immediately suspended". In response to the study, the Royal College of Psychiatrists said ECT should not be suspended for "some forms of severe mental illness". Dr Rupert McShane, chair of the college's Committee on ECT and Related Treatments, said there was evidence showing "most people who receive ECT see an improvement in their condition". "For many, it can be a life-saving treatment," he said. "As with all treatments for serious medical conditions - from cancer to heart disease - there can be side-effects of differing severity, including memory loss." Read full story Source: BBC News, 3 June 2020 -
Content ArticleEarly warning scores are widely used prediction models that are often mandated in daily clinical practice to identify early clinical deterioration in hospital patients. In this paper published in the BMJ, Gerry et al. carried out a systematic review and critical appraisal of early warning scores for adult hospital patients. The results found that many early warning scores in clinical use had methodological weaknesses.The study's authors concluded that the early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care. “Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice.”
