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Found 1,335 results
  1. Content Article
    SHOT is the United Kingdom independent, professionally led haemovigilance scheme.  Since 1996 SHOT has been collecting and analysing anonymised information on adverse events and reactions in blood transfusion from all healthcare organisations that are involved in the transfusion of blood and blood components in the United Kingdom. Where risks and problems are identified, SHOT produces recommendations to improve patient safety. The recommendations are put into its annual report which is then circulated to all the relevant organisations including the four UK Blood Services, the Departments of Health in England, Wales, Scotland and Northern Ireland and all the relevant professional bodies as well as circulating it to all of the reporting hospitals.  As haemovigilance is an ongoing exercise, SHOT can also monitor the effect of the implementation of its recommendations.
  2. News Article
    Delays to follow-up appointments for glaucoma patients leaves them at risk of sight loss, the Healthcare Investigation Safety Branch (HSIB) warns in their new report. The report highlights the case of a 34-year old woman who lost her sight as a result of 13 months of delays to follow-up appointments. Lack of timely follow-up for glaucoma patients is a recognised national issue across the NHS. Research suggests that around 22 patients a month will suffer severe or permanent sight loss as a result of the delays. In HSIB’s reference case, the patient saw seven different ophthalmologists and the time between her initial referral to hospital eye services (HES) and laser eye surgery was 11 months. By this time her sight had deteriorated so badly, she was registered as severely sight impaired. The investigation identified that there is inadequate HES capacity to meet demand for glaucoma services, and that better, smarter ways of working should be implemented to maximise the current capacity. The report makes several safety recommendations focused on the management and prioritisation of appointments. Helen Lee, RNIB Policy and Campaigns Manager, said: “This report has brought vital attention to a serious and dangerous lack of specialist staff and space in NHS ophthalmology services across the country. We know that thousands of patients in England are experiencing delays in time-critical eye care appointments, which is leading to irreversible sight loss for some." “Without immediate action, the situation will only continue to deteriorate as the demand for appointments increases. RNIB urges full and immediate implementation of the recommendations set out in this report to improve the capacity, efficiency and effectiveness of ophthalmology services.” Read full story Source: HSIB, 9 January 2020
  3. Content Article
    Lack of timely follow-up for glaucoma patients is a recognised national issue across the NHS. Research suggests that around 22 patients a month will suffer severe or permanent sight loss as a result of the delays. In this Healthcare Safety Investigation Branch (HSIB) report, the reference case patient saw seven different ophthalmologists and the time between her initial referral to hospital eye services (HES) and laser eye surgery was 11 months. By this time her sight had deteriorated so badly, she was registered as severely sight impaired. The HSIB  investigation identified that there is inadequate HES capacity to meet demand for glaucoma services, and that better, smarter ways of working should be implemented to maximise the current capacity. The report highlights that there are innovative measures implemented by some trusts that have reduced the risk, but this good practice is yet to be implemented more widely.
  4. News Article
    At least 61 women in the UK have been diagnosed with a potentially fatal cancer linked to breast implants, but the type they received continues to be used, with no plans by the regulator to follow France and Australia in banning them. Lawyers for more than 40 of the women, who are bringing legal action against the manufacturers as well as the clinics and doctors who carried out the surgery, say the textured implants linked to anaplastic large cell lymphoma (ALCL) should be withdrawn from the market. Smooth implants are available instead, which have no proven connection to the cancer of the white blood cells. The Medicines and Healthcare Products Regulatory Agency (MHRA) says the disease is very rare, but Sarah Moore, a solicitor at Leigh Day law firm, believes there are more cases than the regulator is aware of. “I think there has been misdiagnosis and under-diagnosis, and I think we have to bear in mind that in the last 18 months there have been 17 more reported cases of ALCL,” she said. The leading manufacturer of textured implants, Allergan, has withdrawn them from worldwide sale. In December 2018 its European kitemark for the implants expired – the French agency that had granted certification had asked for extra safety data that the company said it could not provide in time. They have not been on sale in Europe since then. The US authorities asked the company to recall its textured implants in July 2019 and Allergan took them off the market. France and Australia have since banned the sales of all textured implants, although neither has suggested that women should actively seek to have them removed. In the UK, other brands of textured implants are still in use. Neither NHS England, the NHS Business Services Authority nor the MHRA could say how many had been given to women in the NHS after a mastectomy for breast cancer. Read full story Source: The Guardian, 7 January 2020
  5. Content Article
    Venous thromboembolism (VTE) is a condition in which a thrombus – a blood clot – forms in a vein. Usually, this occurs in the deep veins of the legs and pelvis and is known as deep vein thrombosis (DVT). The thrombus or parts of it can break off, travel in the blood system and eventually block an artery in the lung. This is known as a pulmonary embolism (PE). VTE is a collective term for both DVT and PE.
  6. Content Article
    Venous thromboembolism (VTE) is a condition in which a thrombus – a blood clot – forms in a vein. Usually, this occurs in the deep veins of the legs and pelvis and is known as deep vein thrombosis (DVT). The thrombus or its part can break off, travel in the blood system and eventually block an artery in the lung. This is known as a pulmonary embolism (PE). VTE is a collective term for both DVT and PE. With an estimated incidence rate of 1-2 per 1,000 of the population, VTE is a significant cause of mortality and disability in England with thousands of deaths directly attributed to it each year. One in twenty people will have VTE during their lifetime and more than half of those events are associated with prior hospitalisation. At least two thirds of cases of hospital-associated thrombosis are preventable through VTE risk assessment and the administration of appropriate thromboprophylaxis.
  7. Content Article
    Technology is often viewed as either positive or negative. On one hand weight loss apps are usually seen as a positive influence on users. From the sociocultural perspective, on the other hand, media and technology can negatively impact body satisfaction and contribute to eating disorders; however, these studies fail to include weight loss apps. While these apps can be beneficial to users, they can also have negative effects on users with eating disorder behaviours. Yet few research studies have looked at weight loss apps in relation to eating disorders. In order to fill this gap,these researchers conducted interviews with 16 women with a history of eating disorders who use(d) weight loss apps. While findings suggest these apps can contribute to and exacerbate eating disorder behaviours, they also reveal a more complex picture of app usage. Women’s use and perceptions of weight loss apps shift as they experience life and move to and from stages of change. This research troubles the binary view of technology and emphasises the importance of looking at technology use as a dynamic process. This study contributes to the understanding of weight loss app design.
  8. Content Article
    Families of patients who died after medical errors argue that it’s time to abandon the term “second victim” to describe doctors who are involved in a medical error. In an editorial published by The BMJ, Melissa Clarkson at the University of Kentucky and colleagues say that by referring to themselves as victims, “healthcare providers subtly promote the belief that patient harm is random, caused by bad luck, and simply not preventable.” This mindset “is incompatible with the safety of patients and the accountability that patients and families expect from healthcare providers,” they argue.
  9. Content Article
    Adverse events in hospitals constitute a serious problem with grave consequences. Many studies have been conducted to gain an insight into this problem, but a general overview of the data is lacking. The authors of this paper, published in BMJ Quality & Safety, performed a systematic review of the literature on in-hospital adverse events.
  10. Content Article
    Everyday across the NHS, patients, their supporters and the professionals caring for them deal with the aftermath of healthcare harm and, on rare occasions, wrongdoing. Every healthcare system in the world confronts exactly the same problem, but none deal well with the aftermath of harm. In this article published in the Journal of Patient Safety and Risk Management, Anderson-Wallace and Shale introduce a set of standards that aims to make the consequences less devastating for everyone.
  11. Content Article
    The hospital environment is both unique and unusual in that electrical equipment is directly applied to the human body. From this contact either capacitive or resistive coupling may lead to current flow and harm. Surgical diathermy, patient monitoring and imaging, although universal, are often misunderstood, and many clinicians are ignorant of their principles and hazards. Electrical equipment in hospital therefore has the potential to lead to serious injury or death. This article published in Anaesthesia and Intensive Care Medicine outlines the basic physics of electricity, in particular the principles behind diathermy, the hazards posed by it and by other devices and the various measures available to reduce the risk of these.
  12. News Article
    A woman has been awarded $10.5 million (£8m) in damages after medical staff left a sponge inside her body. The sponge – which measured 18-by-18 inches and was left behind during surgery – was inside the woman's body for years before she realised. It had been left in her body after she underwent heart surgery at a Kentucky hospital in 2011. The bypass surgery is said to have gone wrong, leaving a mess – and as nurses rushed to deal with the problems, the sponge was left inside her body. It was not discovered for four years, until she had a CT scan in 2015. In the meantime, the sponge had moved around the woman's body, shifting around her intestines and causing pain as it did so. She had her leg amputated and was left with gastrointestinal issues after the sponge eroded into her intestine. The patient's lawyers said the case should be a reminder to hospitals to ensure that objects such as needles and other sharp objects, as well as sponges, are removed from patients after surgery. Read full story Source: The Independent, 1 January 2020
  13. Content Article
    The authors of this paper, published in Clinica Chimica Acta, argue that in the current health care organisational environment in most hospitals, at least six major changes are required to begin the journey to a culture of safety: We need to move from looking at errors as individual failures to realising they are caused by system failures We must move from a punitive environment to a just culture We move from secrecy to transparency Care changes from being provider (doctors) centred to being patient-centred We move our models of care from reliance on independent, individual performance excellence to interdependent, collaborative, inter-professional teamwork Accountability is universal and reciprocal, not top-down.
  14. Content Article
    This study, published in the BMJ Open, aims to examine individual, situational and organisational aspects that influence psychological impact and recovery of a patient safety incident on physicians, nurses and midwives.
  15. Content Article
    This paper, published by Science Daily, highlights how a multidisciplinary group of leaders established consensus-driven research agenda designed to create a path forward to inform approaches that better support harmed patients and families.
  16. Content Article
    Patients indicate they want and expect explanations and apologies after medical errors and physicians indicate they want to apologise. However, in practice, physicians tend to provide minimal information to patients after medical errors and infrequently offer complete apologies. Although fears about potential litigation are the most commonly cited barrier to apologising after medical error, the author of this article, published in Clinical Orthopaedics and Related Research, argues that the link between litigation risk and the practice of disclosure and apology is tenuous. Other barriers might include the culture of medicine and the inherent psychological difficulties in facing one’s mistakes and apologising for them. Despite these barriers, incorporating apology into conversations between physicians and patients can address the needs of both parties and can play a role in the effective resolution of disputes related to medical error.
  17. Content Article
    Consider these actual patient experiences: A patient is admitted to the hospital for a bowel obstruction from a known malignancy. She calls her cancer specialist about this complication, but he is unavailable. A covering provider reading from her file says ‘your cancer is untreatable’. This is the first time she has heard this. A patient dies in the hospital and the next day the funeral home collects a body from the hospital morgue. After embalming the body, the funeral home is notified by the hospital that they were given the wrong body. Because of this error, it may not be possible to process the correct body in time for the wake the following day. Despite being simultaneously dreadful and familiar to healthcare professionals, cases like these are not systematically identified or addressed in hospital quality improvement programmes. As a result, we have no good way of preventing them and patients inevitably continue to suffer from these unnecessary emotional harms. The authors of this paper, published in BMJ Quality & Safety, argue these cases are examples of preventable harm that are deserving of formal capture, classification and action by the healthcare system.
  18. Content Article
    The Professioan Records Standards Body are a unique collaboration of groups representing those who receive and provide health and social care across the UK, as well as those providing the IT systems that support care. Emma Robertson is the patient lead on the Professional Records Standards Body (PRSB), work to accredit apps and digital health technologies. She speaks to PRSB about why she got involved with the work and the benefits and challenges of using apps to support health and care.
  19. Content Article
    The aim of this article, published in Dental Update, is to inform and update the reader on NHS England patient safety initiatives applicable to dentistry, specifically the development of an example Local Safety Standards for Invasive Procedures (LocSSIPs) for wrong site extraction.
  20. Content Article
    This comprehensive systematic review, produced by the General Medical Council) examined the prevalence, severity and key types of preventable patient harm.
  21. Content Article
    The Health Protection Agency has suggested that one in ten hospital patients experiences an incident that puts their safety at risk, around half of which could be prevented, and the RCN has identified the need to reduce nurses’ paperwork considerably. This article reports a successful project that set out to tackle these two issues by developing a risk-based nursing assessment system that is simple to use, reduces unnecessary paperwork and reduces the risk of harm to patients. It outlines how the initiative was introduced, as well as obstacles encountered during the process. The risk-assessment tool received positive feedback from nursing staff as it reduces paperwork while providing a risk-based assessment of care needs.
  22. News Article
    Health products powered by artificial intelligence, or AI, are streaming into our lives, from virtual doctor apps to wearable sensors and drugstore chatbots. IBM boasted that its AI could “outthink cancer.” Others say computer systems that read X-rays will make radiologists obsolete. Yet many health industry experts fear AI-based products won’t be able to match the hype. Many doctors and consumer advocates fear that the tech industry, which lives by the mantra “fail fast and fix it later,” is putting patients at risk and that regulators aren’t doing enough to keep consumers safe. Early experiments in AI provide reason for caution, said Mildred Cho, a professor of pediatrics at Stanford’s Center for Biomedical Ethics. Systems developed in one hospital often flop when deployed in a different facility, Cho said. Software used in the care of millions of Americans has been shown to discriminate against minorities. And AI systems sometimes learn to make predictions based on factors that have less to do with disease than the brand of MRI machine used, the time a blood test is taken or whether a patient was visited by a chaplain. In one case, AI software incorrectly concluded that people with pneumonia were less likely to die if they had asthma an error that could have led doctors to deprive asthma patients of the extra care they need. “It’s only a matter of time before something like this leads to a serious health problem,” said Steven Nissen, chairman of cardiology at the Cleveland Clinic. Read full story Source: Scientific American, 24 December 2019
  23. Content Article
    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. Restorative practice is increasingly being used in schools, children’s services, workplaces, hospitals, communities and the criminal justice system. Could this be something that we could utilise as a new approach in healthcare?
  24. News Article
    Two people died and hundreds of others were harmed following prescription errors in North East hospitals last year, new figures reveal. Staff at North East health trusts reported 2,375 prescribing mistakes to an NHS watchdog in 2018, including patients being given the wrong drug, failure to prescribe medicine when needed or given the wrong dosage. At County Durham And Darlington NHS Foundation Trust, where 359 errors were found, 103 patients were harmed by prescription mistakes while one person died. City Hospitals Sunderland NHS Foundation Trust was the second worse in the region for patients coming to harm as a result of prescription errors. One person was killed while 56 were harmed. An NHS spokesperson said: “NHS staff dealt with over a billion patient contacts over the last three years, while serious patient safety incidents are thankfully rare, it is vital that when they do happen organisations learn from what goes wrong - building on the NHS’ reputation as one of the safest health systems in the world." “As part of the NHS Long Term Plan a medicines safety programme has been established, meaning more than ever before is been done to ensure safe medicine use, and nearly £80 million been invested in new technology to prescription systems.” Read full story Source: Chronicle Live, 22 December 2019
  25. News Article
    Experts have warned hundreds of “hidden” children who rely on machines to help them breathe at home are at significant risk of harm due to staff shortages, poor equipment and a lack of training. The number of children who rely on long-term ventilation is rising but new research has shown the dangers they face with more than 220 safety incidents reported to the NHS between 2013 and 2017. In more than 40% of incidents the child came to harm, with two needing CPR after their hearts stopped. Other children had to have emergency treatment or were rushed back to hospital. Many parents reported concerns with the skills of staff looking after their children or reported paid carers falling asleep while caring for their child. Families reported having to cover multiple night shifts due to staff shortages, while also having to care for their child during the day. Other patient safety incidents including broken or faulty equipment or information on packaging that did not match the item or incorrect equipment being delivered. Consultant Emily Harrop, who led the study, said it was “easy for the plight of individual complex children to slip down the agenda”. She warned: “This is a very hidden group of very vulnerable children who are at risk without investment in staffing, access to training and good communication." Read full story Source: The Independent, 18 December 2019
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