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Found 1,334 results
  1. News Article
    Hospitals are still promoting a “natural birth is best” philosophy – despite a succession of maternity scandals highlighting the dangers of the approach. A Telegraph investigation has found a number of trusts continuing to push women towards “normal” births – meaning that caesarean sections and other interventions are discouraged. On Saturday, the Health Secretary has expressed concern about the revelation, vowing to raise the matter with senior officials. Guidelines for the NHS make it categorically clear that a woman seeking a caesarean section should be supported in her choice, after “an informed discussion about the options”. Maternity services were last year warned by health chiefs to take care in the language they used, amid concern about “bias” towards natural births. The warning from maternity officials followed concern that women were being left in pain and fear, with their preferences routinely ignored. The findings come 18 months after Dame Donna Ockenden published a scathing report into maternity care at Shrewsbury and Telford NHS Trust, which warned that a focus on natural birth put women in danger. Read full story (paywalled) Source: The Telegraph, 23 September 2023
  2. Content Article
    The 15th annual HSJ Patient Safety Congress brings together more than 1000 attendees with the shared goal of advancing the national agenda for patient safety across health and social care. In this blog, Samantha Warne, the hub's Lead Editor, captures some of the key highlights and messages from day one of HSJ’s Patient Safety Congress.
  3. Content Article
    ‘Compassionate communication, meaningful engagement’ is a handbook for all NHS staff which aims to improve collaboration with patients, their families and carers following a patient safety event. Developed with NHS Trusts across England in partnership with Making Families Count, the guide includes principles of compassionate engagement, roles and responsibilities of healthcare professionals, and information about the processes following an incident. It also brings together a range of signposting information and resources for families and staff.
  4. News Article
    The national director for patient safety in England has cautioned against the ‘false hope’ of trying to achieve ‘zero harm’ from healthcare, describing it as unachievable. Speaking at HSJ’s Patient Safety Congress earlier this week Aidan Fowler told delegates: “The dream of zero harm is appealing. It’s what we all want. But it’s unachievable in reality, it’s unmeasurable [and] it carries risk.” Mr Fowler said what is really meant is eliminating “avoidable harm”, but also described this as “problematic”. He said: “I challenge any one of you to define ‘avoidable’. We start to define a complex system in simplistic terms. We hear, ‘we’ve had no avoidable harm for six hears in our hospital’. And you think, ‘is that real?’” Mr Fowler stressed the ambition should be to reduce harm to minimal levels, but said the notion that any provider could claim they had no harm for period of years was “hard to credit”. He said by pursuing the “zero harm” ambition, the NHS was also “setting unattainable goals to our staff”. “[We are] creating unrealistic expectations and burning them [staff] out and potentially creating moral distress when they’re not achieving something they’re told they should achieve,” he said. Read full story (paywalled) Source: HSJ, 21 September 2023
  5. News Article
    The US Food and Drug Administration (FDA) has sent warning letters to pharmacy chains Walgreens and CVS accusing them of illegally marketing eye care products. The FDA’s warning letters said the products in question, which were falsely labelled as potential treatments for conditions like glaucoma, cataracts, and pink eye, should be modified if the companies and manufacturers that make and distribute them want to avoid legal action. “The FDA is committed to ensuring the medicines Americans take are safe, effective and of high quality,” Jill Furman, Director of the Office of Compliance at the FDA’s Center for Drug Evaluation and Research, said in a statement. “When we identify illegally marketed, unapproved drugs and lapses in drug quality that pose potential risks, the FDA works to notify the companies involved of the violations.” Ms Furman wrote in the letter sent to Walgreens: “Your ‘Walgreens Allergy Eye Drops,’ ‘Walgreens Stye Eye Drops,’ and ‘Walgreens Pink Eye Drops’ products are especially concerning from a public health perspective. Ophthalmic drug products, which are intended for administration into the eyes … pose a greater risk of harm to users because the route of administration for these products bypasses some of the body’s natural defences.” Read full story Source: The Independent, 21 September 2023
  6. News Article
    Hospital bosses fear that further strikes by doctors will push the NHS “close to breaking point” as it struggles to cope with its winter crisis in the months ahead. NHS leaders are concerned that medics’ plans to continue their campaign of stoppages until February will make it even harder for the service to manage what is always its toughest period. Four days of strikes this week in England have included the first-ever 24-hour joint strike over pay on Wednesday by consultants and junior doctors. This latest series of stoppages – two days by consultants and three days by junior doctors – has forced hospitals to reschedule many thousands of outpatient appointments and non-urgent operations because of the lack of staff. “Winter pressures, respiratory illness and rising Covid again mean that the next six months will be exceptionally difficult. Winter always is,” said one hospital trust chief executive, who asked not to be named. “The NHS is effective at absorbing pressure but the industrial action may, at times, take us close to breaking point and often patient harm and the impact on NHS staff is not fully recognised,” he said. Read full story Source: The Guardian, 20 September 2023
  7. News Article
    Certain spina bifida-related surgeries remain suspended at Children's Health Ireland at Temple Street (CHI) for almost a year amid serious allegations that unlicensed devices made with non-medical parts have been implanted in child patients. In two cases where these devices were used, the implants had to be removed from patients after causing significant harm, while the efficacy of a third is yet to be determined. One senior member at the hospital has raised concerns about the number of repeat operations required on young spina bifida patients and associated rates of reinfection, with disquiet in the hospital eventually leading to first an internal review of operations in October 2022 and later an external probe by US clinicians. In June this year there were 287 children on waiting lists in Ireland for life-changing spinal surgery. Despite a commitment first given by then health minister Simon Harris in 2017 that no child would be on the waiting list for more than four months, there are still more than 120 children waiting more than a year for scoliosis surgery, according to the Ombudsman for Children. CHI has declined to comment on allegations that one of its surgeons has used the unlicensed, failed implants, as well as its decision to cease operations on spina bifida patients. Patient advocate Amanda Santry, who took part in the external review on behalf of Spina Bifida & Hydrocephalus Paediatric Advocacy, has said she has been denied access to the review findings and has also called for a “full investigation” into the allegations of the use of non-medical parts. Read full story Source: The Ditch, 15 September 2023
  8. Content Article
    MEG interviews Patient Safety Learning's Chief Executive, Helen Hughes, for this year's World Patient Safety Day. Helen discusses how Patient Safety Learning contributes to improving patient safety, the 'Blueprint for Action', how the new LFPSE service will impact patient engagement and the role leadership plays in patient safety.
  9. Content Article
    Dr Kristin Harris, Research Fellow in the Department of Anaesthesia and Critical Care at Haukeland University Hospital, Bergen, Norway, discusses why patient safety patient involvement personally matters to her and talks about the tool she's currently working on, which are safety checklists specific to surgical patients.
  10. News Article
    It is still unclear how unauthorised metal parts came to be implanted in a number of the 19 children with spina bifida who suffered significant complications after spinal surgery. But it has emerged that one child died and 18 others suffered a range of complications after surgery at Temple Street Children’s Hospital – with several needing further surgery, including the removal of metal parts which were not authorised for use. Parents of the children undergoing complex surgery were left distraught by the disclosures that emerged yesterday, after campaigning for years while the young patients in need of operations deteriorated on waiting lists. Gerry Maguire, of Spina Bifida Hydrocephalus Ireland, said “absolute horror is being visited on parents and their advocates”. He condemned as disturbing the information which is “being drip-fed to his group and “more alarmingly the families concerned”. One mother expressed concern about further delays in surgery and said children are too complex to be taken for care abroad. Read full story Source: Irish Independent, 19 September 2023
  11. Content Article
    Patients’ perspectives and their active engagement are critical to make health systems safer and people-centred, and are key for co-designing health services and co-producing good health with healthcare professionals, and building trust in health systems. This report, which forms part of a series of Organisation for Economic Co-operation and Development (OECD) papers on the economics of patient safety, looks (i) the economic impact of patient engagement for patient safety; (ii) the results of a pilot data collection to measure patient-reported experiences of safety and; (iii) the status of initiatives on patient engagement for patient safety taken in 21 countries, which responded to a snapshot survey.
  12. News Article
    Dozens more children than initially thought have come to “severe” harm following failings in audiology care, HSJ can reveal. Two more trusts have confirmed that, between them, 30 children suffered severe harm – which is defined as ”permanent or long-term harm” – after the failings. Northern Lincolnshire and Goole Foundation Trust said an external investigation had revealed 14 such cases, while Worcestershire Acute Hospitals Trust found 16 more after going through the same process. A total of 36 confirmed or suspected severe harm cases from paediatric audiology failings across six English trusts are now known about. I NHS England wrote to all 42 integrated care boards at the end of August, asking them to ensure the “approximately” 130 paediatric hearing services in England were running safely. Sir David Sloman, then-chief operating officer, and Dame Sue Hill, chief science officer, said the NHSE “review of these trusts has identified root causes that have led to poor service delivery and outcomes… [which include] lack of clinical governance and oversight, poor reporting of data, poor interpretation of results, poor retention of diagnostic data, and lack of accreditation.” The National Deaf Children’s Society called the speed of the NHS’s response “a scandal”. Read full story (paywalled) Source: HSJ, 19 September 2023
  13. News Article
    A man claims he lost his sight in one eye after routine cataract surgery left him in "unbelievable" pain. John Stabler, from East Yorkshire, is set to sue the maker of an artificial lens he had fitted last year and which was later recalled over safety fears. The 63-year-old said he felt like he had been hit "with a sledgehammer" after the operation and had suffered "catastrophic" loss of income. Manufacturer Nidek said it "profoundly regrets" any patient suffering. Mr Stabler is one of 14 patients seeking compensation over the company's EyeCee One Preloaded lens. He said he had suffered permanent nerve damage to his left eye after having the lens fitted at Hull and East Yorkshire Eye Hospital in October last year. He told the BBC: "About two days after, I was getting really bad pain. It was unbelievable. It was like someone was hitting me with a sledgehammer." NHS England issued a safety alert in January 2023 after Nidek announced a "voluntary and precautionary" global product recall of its EyeCee One and EyeCee One Crystal intraocular lenses. UK distributor Bausch + Lomb said there has been "a limited number of reports of elevated intraocular pressure in patients". Read full story Source: BBC News, 19 September 2023
  14. Content Article
    In this blog to mark World Patient Safety Day 2023, Patient Safety Learning sets out the scale of avoidable harm in health and social care, highlights the need for a transformation in our approach to patient safety and considers the theme of this year’s World Patient Safety Day, ‘Engaging patients for patient safety’.
  15. News Article
    The WHO-hosted global conference on patient safety and patient engagement concluded yesterday with agreement across a broad range of stakeholders on a first-ever Patient safety rights charter. It outlines the core rights of all patients in the context of safety of healthcare and seeks to assist governments and other stakeholders to ensure that the voices of patients are heard and their right to safe health care is protected. “Patient safety is a collective responsibility. Health systems must work hand-in-hand with patients, families, and communities, so that patients can be informed advocates in their own care, and every person can receive the safe, dignified, and compassionate care they deserve,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “Because if it’s not safe, it’s not care.” "Our health systems are stronger, our work is empowered, and our care is safer when patients and families are alongside us,” said Sir Liam Donaldson, WHO Patient Safety Envoy. “The journey to eliminate avoidable harm in health care has been a long one, and the stories of courage and compassion from patients and families who have suffered harm are pivotal to driving change and learning to be even safer." The global conference on patient engagement for patient safety was the key event to mark World Patient Safety Day (WPSD) which will be observed on 17 September under the theme “Engaging patients for patient safety”. Meaningful involvement of patients, families and caregivers in the provision of health care, and their experiences and perspectives, can contribute to enhancing health care safety and quality, saving lives and reducing costs, and the WPSD aims to promote and accelerate better patient and family engagement in the design and delivery of safe health services. At the conference, held on 12 and 13 September, WHO unveiled two new resources to support key stakeholders in implementing involvement of patients, families and caregivers in the provision of health care. Drawing on the power of patient stories, which is one of the most effective mechanisms for driving improvements in patient safety, a storytelling toolkit will guide patients and families through the process of sharing their experiences, especially those related to harmful events within health care. The Global Knowledge Sharing Platform, created as part of a strategic partnership with SingHealth Institute for Patient Safety and Quality Singapore, supports the exchange of global resources, best practices, tools and resources related to patient safety, acknowledging the pivotal role of knowledge sharing in advancing safety. “Patient engagement and empowerment is at the core of the Global Patient Safety Action Plan 2021–2030. It is one of the most powerful tools to improve patient safety and the quality of care, but it remains an untapped resource in many countries, and the weakest link in the implementation of patient safety measures and strategies. With this World Patient Safety Day and the focus on patient engagement, we want to change that”, said Dr Neelam Dhingra, head of the WHO Patient Safety Flagship. Read full story Source: WHO, 14 September 2023
  16. News Article
    Women are being "failed at every stage" when it comes to maternity care, say campaigners, as they call for more support for those experiencing traumatic births. Mumsnet found 79% of the 1,000 women who answered their questionnaire had experienced some form of birth trauma, with 53% saying it had put them off from having more children. And according to the snapshot of UK mothers, 44% also said healthcare professionals had used language implying they were "a failure or to blame" for what happened. Conservative MP Theo Clarke is leading calls for more action after her own experience, where she thought she was "going to die" after suffering a third degree tear and needing emergency surgery. Now, she has set up an all party parliamentary group on birth trauma. She said: "[It is] clear that more compassion, education and better after-care for mothers who suffer birth trauma are desperately needed if we are to see an improvement in mums' physical wellbeing and mental health. "It is vitally important women receive the help and support they deserve." Chief executive of Mumsnet, Justine Roberts, said the trauma had "long-lasting effects", adding: "It's clear that women are being failed at every stage of the maternity care process - with too little information provided beforehand, a lack of compassion from staff during birth, and substandard postnatal care for mothers' physical and mental health." Read full story Source: Sky News, 15 September 2023
  17. Content Article
    The Association of Ambulance Chief Executives (AACE) has published a new report charting the major increase in the frequency and length of hospital handover delays over the past ten years, calling for an even greater focus on improvements that will reduce and eradicate delays, prevent more patients from coming to significant harm and stop the drain on vital ambulance resources.
  18. News Article
    Children have suffered severe harm at two further hospital trusts as a result of failures in paediatric audiology, HSJ has revealed. HSJ reported in July that three children at Croydon Health Service Trust may have come to “severe harm” – meaning they may have suffered permanent damage – following failures in the trust’s processes in audiology. Now East and North Hertfordshire Trust and North West Anglia Foundation Trust have also confirmed a small number of cases of severe or serious harm; while some trusts have yet to confirm findings from case reviews they have carried out. Major problems emerged earlier this year, initially in Scotland, of poor quality checks missing children with hearing problems who should have received support, and of a failure to inspect the services. NHS England ordered a review of data from the national newborn screening programme which, alongside other review work, identified six English trusts as having likely failures in their service: Croydon, East and North Herts, North West Anglia, Warrington and Halton Hospitals, North Lincolnshire and Goole, and Worcestershire Acute Hospitals. Read full story (paywalled) Source: HSJ, 14 September 2023
  19. Content Article
    NHS England is undertaking an audit of NHS specialised hospital services for patients with complications of mesh inserted for urinary incontinence and vaginal prolapse (Mesh Centres) and would like to hear from women who have had Mesh implanted. They'd like to hear from women who have had, or have considered having treatment for their Mesh complications, both surgical (mesh removal) and non-surgical treatment (including physiotherapy and pain management, for example). As part of the audit, Sally Cavanagh who works for NHS England was asked to team up with Kath Sansom from Sling The Mesh and Paula Goss from Rectopexy Mesh Victims & Support, to develop the survey. It is designed to capture feedback about how women reached the decision to seek, or not seek surgical Mesh removal, how they made their treatment decision and their experiences with health services and health staff involved in their treatment for complications of Mesh. The deadline to submit the survey is midnight Wednesday 11 October 2023.
  20. News Article
    A grandfather who went into hospital with stomach problems needed both of his legs and his left hand amputating after contracting a life-threatening infection. Stephen Hughes, from Edmondstown, had been admitted to the Royal Glamorgan Hospital in Llantrisant, in March 2022, with gallstones and aggressive stomach inflammation. This led to pancreatitis corroding a hole in the duodenum which caused a significant bleed into his gut. The 56-year-old's condition deteriorated and he was transferred to the ICU at the University Hospital of Wales as a patient in critical condition. Whilst at UHW, his family said that the NHS staff worked tirelessly to stop the internal bleeding he was suffering. His gallbladder was removed on September 8th, 2022, and stents were placed along his arteries. Although these operations were successful, his family claims that Mr Hughes caught sepsis from the feeding tube in his neck on 11 September 2022 whilst recovering. Stephen’s body prioritised sending blood to his vital organs which resulted in his outer limbs being deprived of blood and oxygen. Stephen then had to have life-altering operations, which resulted in both of his legs being amputated towards the end of September, and his left hand being amputated at the start of October. He was later discharged on 31 October. A spokesperson for Cardiff and Vale University Health Board said: “As a Health Board we are unable to comment on individual patient cases, however we appreciate how life altering operations are particularly distressing for the individual and also their loved ones. Read full story Source: Wales Online, 9 September 2023
  21. News Article
    A hospital review of mesh operations by a surgeon who left dozens of patients in agony is now looking into another type of procedure he carried out. Tony Dixon, who used mesh surgery to treat bowel problems, has always maintained he did the operations in good faith. Now it has emerged that other patients who had their rectum stapled are also being written to. Spire Hospital Bristol said its "comprehensive" review remains ongoing. Mr Dixon pioneered the use of artificial mesh to lift prolapsed bowels and a review of the care he gave patients receiving Laparoscopic ventral mesh rectopexy has already concluded. Now the Spire has contacted patients who underwent a Stapled Transanal Rectal Resection (STARR operation) with Mr Dixon. Many of the affected patients have told the BBC they did not give informed consent for the procedure and are in chronic pain. Read full story Source: 11 September 2023
  22. News Article
    A public inquiry will be held into the disgraced brain surgeon Sam Eljamel, the Scottish government has confirmed. Eljamel harmed dozens of patients at NHS Tayside, leaving some with life-changing injuries. He was head of neurosurgery at Ninewells Hospital in Dundee until December 2013, when he was suspended. Health Secretary Michael Matheson said he was persuaded of the need for the inquiry after reading a damning due diligence review into NHS Tayside. It follows a long-running campaign which saw almost 150 former patients of the surgeon calling for the inquiry. Mr Matheson said he had concluded that a public inquiry was "the only route to get to the bottom of who knew what and when, and what contributed to the failures described by NHS Tayside". The health secretary said he also wanted to see individual cases reviewed independently of NHS Tayside in a "person-centred, trauma-informed" manner. Read full story Source: BBC News, 7 September 2023
  23. Content Article
    Healthcare professionals prescribing fluoroquinolone antibiotics (ciprofloxacin, delafloxacin, levofloxacin, moxifloxacin, ofloxacin) are reminded to be alert to the risk of disabling and potentially long-lasting or irreversible side effects. Do not prescribe fluoroquinolones for non-severe or self-limiting infections, or for mild to moderate infections (such as in acute exacerbation of chronic bronchitis and chronic obstructive pulmonary disease) unless other antibiotics that are commonly recommended for these infections are considered inappropriate. Fluoroquinolone treatment should be discontinued at the first signs of a serious adverse reaction, including tendon pain or inflammation.
  24. Content Article
    In this article in the Scotsman, former whistle blower, Iain Kennedy, writes about the culture of fear and blame in Scotland's NHS and how NHS staff must feel free to speak up about problems that affect patient safety.
  25. Event
    until
    World 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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