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Showing results for tags 'Patient harmed'.
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News Article
Inquiry into rogue breast surgeon to call for changes to private hospital safety
Patient Safety Learning posted a news article in News
An independent inquiry is expected to call for major changes in the way private hospitals supervise doctors after hundreds of women were put through unnecessary operations by a rogue breast surgeon. Ian Paterson was jailed for 20 years in 2017 after being convicted of 13 counts of wounding with intent and three counts of unlawful wounding. But his surgical malpractice may have harmed more than 750 women over more than a decade. He carried out unnecessary surgery for breast cancer on women who did not have the disease, and put other women who did at risk by using his own unofficial technique, which left behind partial breast tissue. On Tuesday an inquiry chaired by the Bishop of Norwich, the Right Reverend Graham James, will be published and is expected to make recommendations about how doctors are allowed to work across both the NHS and private sector with minimal supervision and oversight. One key area of focus is expected to be a process known as “practising privileges”, where private hospitals allow clinicians to carry out their own activities within the hospital, similar to self-employed contractors. They effectively rent the hospital space for their work. Read full story Source: The Independent, 2 February 2020 -
Content ArticleA review on the extent of medication errors and recommendations to reduce medication-related harm in England. The Short Life Working Group report makes recommendations for a programme of work to tackle medication error and improve medicine safety.
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Content ArticleLinda Millband is the national practice lead for medical negligence at Thompsons Solicitors. She led the team responsible for fighting, and winning, a legal battle on behalf of 650 ex-patients of disgraced breast surgeon Ian Paterson. Ahead of the publication of the Independent Inquiry into Ian Paterson, Linda reflects on how it should be used as a catalyst for positive change in private hospitals.
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News Article
Top hospital downgraded amid safety fears and whistleblowing inquiry
Patient Safety Learning posted a news article in News
The hospital at the centre of a whistleblowing inquiry has been downgraded by the care watchdog and issued with a warning notice amid concerns over leadership and patient safety. West Suffolk Foundation Trust has been rated requires improvement by the Care Quality Commission (CQC) in a damning report having previously been rated outstanding since 2017. The trust, whose Chief Executive Stephen Dunn received a CBE for services to patient safety in 2018, has faced criticism after bosses threatened senior doctors with a fingerprint and handwriting analysis to try and identify a whistleblower. In a new report published today, the CQC inspectors said they had significant concerns about the safety of mothers and babies in the trust’s maternity unit and the criticised the culture of the trust leadership referencing what they called “threatening” actions. In the West Suffolk hospital maternity unit the CQC found staff had not completed key safety training, did not protect women from domestic abuse, and staff did not always report safety incidents. They also found maternity staff were not taking observations and the unit lacked enough staff with the right qualifications to keep women safe. The trust was issued with a warning notice by the trust demanding it make improvements before the end of this month. On the trust leadership the CQC report said: “The style of executive leadership did not represent or demonstrate an open and empowering culture. There was an evident disconnect between the executive team and several consultant specialities." Read full story Source: The Independent, 30 January 2020 -
Content ArticleSidney Dekker says when there has been an incident of harm, we need to know "who is hurt, what do they need, and whose obligation is it to meet that need?" In this blog, commissioned by Patient Safety Learning, Joanne Hughes, hub topic lead, develops our understanding of the needs of patients, families and staff when things go wrong. Using Joanne's expertise and informed by her personal experience and engagement with many others who have suffered second harm, this blog discusses the care needs for harmed patients, their families and for staff when things go wrong. It aims to highlight the chasm between what is needed and what is currently delivered.
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Content ArticleMark Chassin, M.D., president and CEO of The Joint Commission, sat on the Institute of Medicine committee that authored the landmark 1999 report, To Err is Human. In this podcast, he speaks to Nancy Foster, AHA vice president for quality and patient safety, about its impact on health care safety. He speaks about the need to reflect more on the type of culture that exists within zero harm organisations. He also argues that we need to ensure people feel free to speak up and ensure that everyone is accountable for consistently upholding safety processes and standards.
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Community Post
Restorative justice: can we use it in healthcare to repair harm?
PatientSafetyLearning Team posted a topic in Culture
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Restorative justice brings those harmed by crime or conflict and those responsible for the harm into communication, enabling everyone affected by a particular incident to play a part in repairing the harm and finding a positive way forward. This is part of a wider field called restorative practice. Restorative practice can be used anywhere to prevent conflict, build relationships and repair harm by enabling people to communicate effectively and positively. This approach is increasingly being used in schools, children’s services, workplaces, hospitals, communities and the criminal justice system. What are your thoughts on how this approach would work in a healthcare setting? Does anyone have any experience of using restorative practice?- Posted
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News Article
Justice is being denied to too many families
Patient Safety Learning posted a news article in News
Harry Richford's death underlines the need for the health secretary to bring back the national maternity safety training fund – and there are other issues that require urgent attention – The Independent reports. Harry Richford had not even been born before the NHS failed him. An inquest has concluded he was neglected by East Kent University Hospitals Trust in yet another maternity scandal to rock the NHS. His parents and grandparents have fought a tireless campaign against a wall of obfuscation and indifference from the NHS. In their pursuit of the truth they have exposed a maternity service that did not just fail Harry, but may have failed dozens of other families. As with the family of baby Kate Stanton-Davies at Shrewsbury and Telford Hospitals Trust, or Joshua Titcombe at the University Hospitals of Morecambe Bay Trust, it has taken a family rather than the system to expose what was going wrong. It is known that there are about 1,000 cases a year of safety incidents in the NHS across England, including baby deaths, stillbirths and children left brain damaged by mistakes. Last week, the charity Baby Lifeline, joined The Independent to call on the Department of Health and Social Care (DHSC) to reinstate the axed maternity safety training fund. This small fund was used to train maternity staff across the country. Despite being shown to be effective, it was inexplicably scrapped after just one year. There are other issues that also need urgent attention. The inquest into Harry’s death, which concluded on Friday, lasted for almost three weeks. Without pro bono lawyers from Advocate, Brick Court Chambers and Arnold & Porter law firm, the family would have faced an uphill struggle. At present, families are not automatically entitled to legal aid at an inquest, yet the NHS employs its own army of lawyers who attend many inquests and can overwhelm bereaved families in a legal battle they are ill-equipped to fight. Even the chief coroner, Mark Lucraft QC, has called for this inequality of legal backing to end, but the government has yet to take action. Read full story Source: The Independent, 26 January 2020 -
Content ArticleThe Marmot Review into health inequalities in England was published on 11 February 2010. It proposes an evidence based strategy to address the social determinants of health, the conditions in which people are born, grow, live, work and age and which can lead to health inequalities.
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Content ArticleThe 5th National Audit Project (or NAP5) of the Royal College of Anaesthetists and Association of Anaesthetists was the largest ever study into accidental awareness during general anaesthesia (AAGA). Numerous publications emerged from the project and whereas a comprehensive list of 64 recommendations were made, the full report and associated publications were primarily academic outputs not accessible to all practitioners as a day-to-day ready reference, nor did they provide practical recommendations that individuals could use in their daily practice. The purpose of this publication is to distil and interpret the findings of the 5th National Audit Project into actions that individuals (and organisations) can follow to reduce the risk of accidental awareness.
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Content ArticleThe objective of this study, published in Health Services Research, was to determine whether a communication and resolution approach to patient harm is associated with changes in medical liability processes and outcomes.
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Content Article
Outpatient hysteroscopy: RCOG patient leaflet
Claire Cox posted an article in Women's health
This leaflet, produced by the Royal College of Obstetricians and Gynaecologists and the British Society for Gynaecological Endoscopy, is for individuals who have been offered hysteroscopy as an outpatient. It may also be helpful if you are a partner, relative or friend of someone who has been offered this procedure. -
News ArticleThe Care Quality Commission (CQC) missed multiple opportunities to identify abuse of patients at a privately run hospital and did not act on the concerns of its own members, an independent review has found. Bosses at the CQC have been criticised in an independent report by David Noble into why the regulator buried a critical report into Whorlton Hall hospital, in County Durham, in 2015. His report published today said the CQC was wrong not to make public concerns from one of its inspection teams in 2015. “The decision not to publish was wrong,” his report said, adding: “This was a missed opportunity to record a poorly performing independent mental health institution which CQC as the regulator, with the information available to it, should have identified at that time.” Read full story Source: The Independent, 22 January 2020
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Content ArticleElisabeth Poorman argues that becoming a doctor means learning that mistakes are not acceptable. From study through to practice, doctors are told in ways big and small, the only way to be a good doctor is to be a perfect doctor. The pressure only intensifies when real harm is on the line. The encouraged response is to study harder, sleep less, and never admit fear.
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News Article
Cosmetic nurse leaders issue warning over Scottish regulation plans
Patient Safety Learning posted a news article in News
Proposals by the Scottish Government to give a licence to unregistered professionals to carry out cosmetic procedures are “fundamentally flawed” and put lives at risk, leading nurses in the field have warned. A consultation has been launched seeking views on plans for a new regulatory regime of non-surgical aesthetic treatments that pierce or penetrate the skin like dermal fillers or lip enhancements. Ministers want to bring non-health professionals under existing legislation allowing them to obtain a licence to perform these procedures in unregulated premises such as beauty salons and hairdressers. The move comes after a UK-wide review carried out in 2013, by then NHS medical director Sir Bruce Keogh, identified that little regulation existed within the cosmetic industry. Since then there has been growing concern that people are coming to physical and psychological harm from treatments gone wrong. Leaders at the British Association of Cosmetic Nurses (BACN) told Nursing Times that they were “totally opposed” to non-medical practitioners carrying out injectable beauty procedures. BACN Chair Sharon Bennett said holding a medical, nursing or dentistry qualification should be a “basic prerequisite” before being accepted to an aesthetics training course. SHe said BACN believed even clinically trained practitioners, including nurses, needed further training in aesthetics before working in this “specialist” area. “[This is] because there is no educational framework, training or statutory provision to establish or task beauty therapists to detect disease, care for patients or carry out medical treatment, so to do so would breach public health safety and endanger lives.” Read full story Source: The Nursing Times, 20 January 2020 -
Community Post
The Patient Safety Incident Response Framework
Jon Holt posted a topic in Investigations, risk management and legal issues
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Hi The new Patient Safety Incident Response Framework is due for publication this month for early adopters and as 'introductory guidance' for everyone else: https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/ I wondered if there is anyone who is involved in an organisation that is an early adopter who can share what has happened so far and also would be willing to share any local learning as the new framework is implemented? Also, more generally wondered if anyone has any initial comments on the proposals which were mentioned in the NHS patient safety strategy and any things in particular which they think will bring benefit or could represent significant challenges or issues?- Posted
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News Article
The FDA is still letting doctors implant untested devices into our bodies
Patient Safety Learning posted a news article in News
When Kathleen Yaremchuk, Chair of the department of otorhinolaryngology (ear, nose and throat) at Henry Ford Hospital in Detroit, began getting calls about mysterious cases of respiratory distress, she launched a study to figure out what was going on. All these patients, it turned out, had a small device implanted in the top of their spines to relieve pain. The object, used to hold a protein that stimulates bone growth, was cleared for sale by the Food and Drug Administration in 2003 without clinical testing in humans. When Yaremchuk and her colleagues reviewed the records of all 260 patients implanted with the device at Henry Ford Hospital between 2004 and 2009, they found that a significant number developed airway obstruction, trouble swallowing and respiratory failure, in some cases leading to death. The neck implant is just one of the products associated over the past decade with 1.7 million injuries and more than 80,000 deaths. A searing global investigation last year by the International Consortium of Investigative Journalists places much of the blame on significant failings in the FDA’s oversight. The agency’s laissez faire attitude has resulted in artificial hips that cause cobalt poisoning (which can damage the heart and brain); surgical mesh that cuts through flesh and organs, causing infections and haemorrhage; and defibrillators that repeatedly shock patients beyond human endurance. Safety problems have led to recalls of devices implanted in hundreds of thousands of people. And the devices can be difficult or impossible to remove if they go bad No wonder many patient advocates cheered when the FDA announced in November that it planned to make “transformative” changes in the way more than 80% of medical devices are cleared for sale in the United States. But the promised transformation is mere window dressing. Two key loopholes still exist, allowing most products to be approved for sale without clinical trials in humans. Read full story (paywalled) Source: The Washington Post, 4 January 2019 -
Content ArticleMedication errors may cause harm, including death, and increase use of health care services. This project aims to summarise the evidence on the burden of medication error, namely the number of errors occurring in the NHS in England, the costs of those errors to the NHS and the health losses due to medication error. This involves two systematic reviews, one on the incidence and prevalence of medication errors, and the other on the costs of health burden associated with errors. Additionally, economic modelling estimates the number of errors occurring in the NHS in England each year, their costs and health consequences.
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Content ArticleChildren admitted to paediatric and neonatal intensive care units may be at high risk from medication errors (MEs) and preventable adverse drug events. In this systematic review published in Drug Safety, Alghamdi et al., reviewed empirical studies examining the prevalence and nature of MEs and preventable adverse drug events in paediatric and neonatal intensive care units. They found that medication errors occur frequently in critically ill children admitted to paediatric and neonatal intensive care units and may lead to patient harm. Important targets such as dosing errors and anti-infective medications were identified to guide the development of remedial interventions.
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News Article
Hernia mesh implants used 'with no clinical evidence'
Patient Safety Learning posted a news article in News
"Too many" types of hernia mesh implants are being used on NHS patients with little or no clinical evidence, the BBC has been told. New data shows more than 100 different types of mesh were purchased by NHS Trusts from 2012 to 2018 in England and Scotland, leading to fears over safety. The meshes can cut into tissue and nerves, leaving some people unable to walk, work or care for children. Currently, hernia mesh devices can be approved if they are similar to older products, which themselves may not have been required to undergo any rigorous testing or clinical trials in order to assess their safety or efficacy. In England, around 100,000 such operations are performed each year, the majority using mesh. Many go well. But the Victoria Derbyshire programme has heard from nearly 300 people who have experienced complications - including chronic pain, infections and organ perforations. International guidelines estimate one in 10 patients will experience "significant chronic pain" following a mesh repair. The director of devices at the Medicines and Healthcare products Regulatory Agency (MHRA), Graeme Tunbridge, told the BBC: "The benefits and risks of using mesh for hernia repair have been considered in detail by clinicians and the professional bodies who represent them. We continue to monitor and review evidence as it becomes available and will take any appropriate action on that basis." Mr Tunbridge said he recognised the system "does need strengthening" and said new legislation on medical devices would take effect from May 2020. Read full story Source: BBC News, 15 January 2020 -
News Article
Urologists support New Zealand MOH report recommendations on surgical mesh
Patient Safety Learning posted a news article in News
The Urological Society of Australia and New Zealand (USANZ) supports recommendations in the Hearing and Responding to Stories of Survivors of Surgical Mesh report released by the New Zealand Ministry of Health in response to complications resulting from the use of surgical mesh in a range of operations, including for stress incontinence and pelvic organ prolapse. The Ministry of Health commissioned the review, in which New Zealand urologists participated alongside a wide range of consumer and other health groups, to provide a plan “to minimize future risk to consumers and support those harmed by it”. “The Urological Society acknowledges that complications from the use of mesh for treating stress urinary incontinence and pelvic organ prolapse has caused considerable physical and psychological harm in some patients, which we feel is unacceptable, said USANZ President, Dr Stephen Mark. "We also acknowledge and accept findings that there were deficiencies in technical and communication skills of some surgeons. We recognise the distress caused to these patients and want to be part of the solution in helping these people, as well as ensuring no patients are harmed in future." “Further research is necessary to achieve best practice outcomes and help us understand why, when, and in which patient complications may occur. For this reason, USANZ supports participation with Australia in a mesh registry. By collaborating with Australian researchers, we can be part of a substantial database that would underpin ongoing research in the interests of patient safety." Read full story Source: New Zealand Doctor, 13 January 2020 -
News Article
JAMA editorial blasts FDA's reporting of medical device problems
Patient Safety Learning posted a news article in News
The US Food and Drug Administration (FDA) needs to do more to quickly and substantially reform its system for reporting adverse events caused by medical devices, two researchers wrote in an Editorial published in JAMA Internal Medicine. The editorial notes several instances where information on a medical device was withheld from the public or not reported fully. The current adverse events reporting system relies on device makers to voluntarily report adverse events, which the authors say does not place patient safety as a priority. The editorial specifically highlights a study involving Medtronic's Insync III model 8042 heart failure pacemaker, which the authors said caused a "high burden of serious adverse events (including death)." The authors said it took the FDA 19 months to recall the device after the first instance of the device failing was reported. The FDA also decided to classify the recall as Class II, which signifies a low probability of serious adverse events. "This long unexplained delay before the recall and the inappropriate recall classification raise concerns about patient harms that could have been prevented by speedier and stronger regulatory actions," the authors wrote. Read full story Source: Becker's Hospital Review, 10 January 2020 -
Content ArticleAn ideal surveillance system for medical device safety would comprehensively collect data on adverse events across the life span of a device, discusses Salazar and Redberg in an Editorial in JAMA Internal Medicine. They suggest that the system should be integrated into electronic health records to allow seamless identification, tracking, and real-time reporting of device-associated adverse events. It would be able to take adverse events and detect substantial safety signals and underperforming devices. Such a system would also allow implementation of corrective actions quickly.
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Content Article
Safety-II in practice (June 2017)
Claire Cox posted an article in Recommended books and literature
Safety-I is defined as the freedom from unacceptable harm. The purpose of traditional safety management is therefore to find ways to ensure this ‘freedom’. But as socio-technical systems steadily have become larger and less tractable, this has become harder to do. Resilience engineering pointed out from the very beginning that resilient performance – an organisation’s ability to function as required under expected and unexpected conditions alike – required more than the prevention of incidents and accidents. This developed into a new interpretation of safety (Safety-II) and consequently a new form of safety management. Safety-II changes safety management from protective safety and a focus on how things can go wrong, to productive safety and a focus on how things can and do go well. For Safety-II, the aim is not just the elimination of hazards and the prevention of failures and malfunctions but also how best to develop an organisation’s potentials for resilient performance – the way it responds, monitors, learns, and anticipates. That requires models and methods that go beyond the Safety-I toolbox. This book introduces a comprehensive approach for the management of Safety-II, called the Resilience Assessment Grid (RAG). It explains the principles of the RAG and how it can be used to develop the resilience potentials. The RAG provides four sets of diagnostic and formative questions that can be tailored to any organisation. The questions are based on the principles of resilience engineering and backed by practical experience from several domains. Safety-II in Practice is for both the safety professional and academic reader. For the professional, it presents a workable method (RAG) for the management of Safety-II, with a proven track record. For academic and student readers, the book is a concise and practical presentation of resilience engineering. -
News ArticleA quarter of children referred for specialist mental health care because of self-harm, eating disorders and other conditions are being rejected for treatment, a new report has found. The study by the Education Policy Institute warns that young patients are waiting an average of two months for help, and frequently turned away. It follows research showing that one in three mental health trusts are only accepting cases classed as the most severe. GPs have warned that children were being forced to wait until their condition deteriorated - in some cases resulting in a suicide attempt - in order to get to see a specialist. Read full story Source: The Telegraph, 10 January 2020
