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Content ArticleClinical trial documents are complex and may have inconsistencies, leading to potential site implementation errors and may compromise participant safety. This study characterises the frequency and type of administrative and potential patient safety interventions (PPSIs) made during the review of oncology trial documents for clinical trial implementation by centralized clinical content specialists. The study demonstrates a gap in patient safety when assessing trial documents for clinical trial implementation. One solution to address this gap is the utilisation of a centralised team of clinical specialists to preemptively review trial documents, thereby enhancing patient safety during clinical trial conduct.
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Content ArticleThis is guidance for dispensing of valproate-containing medicines in the manufacturer’s original full pack, following amendments to the Human Medicines Regulations (HMRs). These amendments currently apply in England, Scotland and Wales. This guidance should be regarded as good practice by pharmacists in Northern Ireland. The change comes into force in England, Scotland and Wales from 11 October 2023.
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EventuntilLast year, our helpline advisers dealt with an average of two calls a day relating to complaints – could the caller complain about what had happened? How to complain? Who to complain to? This event is for patients and carers who would like answers to some basic questions about complaining about care. Solicitors Chris James and Josh Hughes from law firm Bolt Burdon Kemp will be joining our Chief Executive Rachel Power in this online event. Between them they’ll: Help people understand the NHS complaints process, including its limitations Describe how to get the most out of making a complaint Explain were the distinction can lie between poor service and a claim in negligence. Register
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News Article
Messages revealed healthcare workers were drugging patients
Patient Safety Learning posted a news article in News
Two healthcare workers who exchanged vile texts while needless drugging sick people to ‘keep them quiet’ have been found guilty of ill-treating patients. Senior nurse Catherine Hudson, 54, was found to have regularly tranquillised patients unnecessarily for her own amusement and to have an ‘easy’ shift. While Charlotte Wilmot, 48, an assistant practitioner, wrote vile texts encouraging her to carry out the dangerous acts, with complete disregard for the consequences. Preston Crown Court heard the pair worked on the stroke unit at Blackpool Victoria Hospital and had carried out needless sedations between 2017 and 2018. Restrictions on prescription drugs were so lax in the stroke unit that staff would help themselves and self-medicate or steal drugs to supply to others, the court heard. Drugs such as Zopiclone, a powerful medicine used to treat insomnia, were often stolen and used to drug multiple patients. Police launched an investigation in November 2018 after a student nurse raised concerns about the treatment of patients in the stroke unit. A number of staff members were arrested during the course of the investigation and their mobile devices were seized. Read full story Source: The Independent, 6 October 2023 -
Content ArticleThe protests outside the Scottish Parliament took an alarming turn recently with people wearing hospital gowns spattered with blood. The demonstrators were former patients of neurosurgeon Sam Eljamel, many allegedly harmed by him and still suffering and searching for answers years later. A public inquiry has been announced by the First Minister. As the Patient Safety Commissioner for Scotland Bill makes its way into law, Alan Clamp, chief executive officer of the Professional Standards Authority for Health and Social Care, asks what this means for Scotland and the safety of its patients? See also: Working together to achieve safer care for all: a blog by Alan Clamp
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News Article
Reliance on physician associates risks patient safety, doctors say
Patient Safety Learning posted a news article in News
The use of non-medics in clinical roles is leading to deaths and missed diagnoses, senior doctors have warned. Hundreds of doctors have signed an open letter to the leadership of the Royal College of Physicians (RCP), urging them to take a stand over the rollout of physician associates (PAs). PAs are a newer type of medical role that involves significantly less training than doctors receive. The NHS has used PAs since 2003 but concerns have emerged in recent months about them taking on more advanced work than is appropriate. NHS England set out plans earlier this year to expand their numbers significantly amid ongoing staff shortages. Now an open letter to the RCP’s council, to date signed by 46 fellows of the college and 194 other doctors, sets out concerns ranging from patient safety and liability to the fact that newly qualified PAs can earn more than newly qualified doctors. They say: “There have been several high-profile incidents in which serious illness was missed by a PA when undertaking a role that would normally be filled by a doctor. In some cases, avoidable deaths have resulted. “Given that some of these conditions required more advanced training than the PA had received, the implication is that rare avoidable deaths are a price society must pay for the replacement of medical staff with non-medical staff. We believe this trade-off must be debated widely not just by doctors but also by the lay public.” Read full story (paywalled) Source: The Times, 5 October 2023 -
EventThis conference focuses on improving practice and patient safety to reduce Extravasation Injury, ensuring front line clinicians are aware of the risk of extravasation and how to recognise, treat and escalate extravasation injuries when they do occur. This conference will enable you to: Network with colleagues who are working to reduce Extravasation Injury Learn from outstanding practice in recognizing, treating and escalating extravasation injury Reflect on national developments and learning Ensure vesicants are administered in the safest way Develop your skills in training frontline staff to recognize evolving injuries Understand how you can implement preventative measures Identify key strategies for improvement Educate patients to raise alarm and improve consent procedures Develop protocols to support practice Understand the role and competencies of the NHS trust lead for extravasation Ensure effective treatment, and early intervention in severe wounds Learn from case studies in cancer, maternity, radiology and paediatrics Ensure you are up to date with the latest legal cases Self assess and reflect on your own practice Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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News Article
GP mistakes led to patient suffering a stroke and going blind
Patient Safety Learning posted a news article in News
Doctors missed a man’s stroke which led him to suffer another one and go temporarily blind. The man said that the experience had changed him from ‘an outgoing social person, to a sheltered man living in fear that he is not being looked after competently’. The 75-year-old visited his GP in Darlington complaining of dizziness, light-headedness, and a numb foot. He had experienced a stroke and should have been immediately sent to hospital. But doctors missed the signs, diagnosed him with a ‘dropped foot’ and requested an urgent MRI scan. However, due to an administrative error the referral wasn’t made and the scan never happened. A month after visiting the GP, the man suffered a blinding headache and diminished vision. He saw an ophthalmologist who referred him to a specialist team. He had suffered another stroke. He also paid for a private scan which confirmed the first stroke happened a month earlier. Distressingly, the man lost vision in his right eye, which he was told could be permanent. Fortunately, his sight returned eight weeks later. His daughter, who described the experience as ‘horrendous’, complained to the Parliamentary and Health Service Ombudsman (PHSO) about her father’s care. The PHSO found that the initial symptoms were signs of a problem with nerve, spinal cord, or brain function. Doctors should have suspected a stroke and immediately sent him to hospital. If that had happened, the second stroke and sight loss would likely have been avoided. Ombudsman Rob Behrens said: “Having a stroke and then being told you could be permanently blind must have been incredibly frightening. The impact on the man, and his family who supported him through the ordeal, will have been deep and long-lasting. “Mistakes like these need to be recognised and acted upon so that they are not repeated.” Read full press release Read case file Source: PHSO, 4 October 2023 -
News Article
Strikes now endangering heart and cancer patients, NHSE warns BMA
Patient Safety Learning posted a news article in News
The impact of successive doctors’ strikes is now ‘causing significant disruption and risk to patients’, including to those needing urgent heart and cancer treatment, NHS England leaders have told the BMA in their strongest warnings yet. A letter to the union’s council chair on Tuesday evening, leaked to HSJ, said: “We are increasingly concerned that the cumulative impact of this action is causing significant disruption and risk to patients… “We are extremely concerned that Christmas Day cover is insufficient to ensure appropriate levels of patient safety are being maintained across local health systems. This is particularly the case in the current period of industrial action, with three consecutive Christmas Day levels of service.” Although Christmas Day includes cover for emergency care, the officials said that in practice – with demand above Christmas Day levels, and with successive days and repeated strikes – it was not protecting patients needing urgent care. The letter, signed by NHSE leaders including chief medical officer Sir Steve Powis, and chief nurse Dame Ruth May, goes on: “Secondly, we are becoming increasingly concerned that combined periods of industrial action are impacting on our ability to manage individuals who require time-sensitive urgent treatment, for example cardiac, cancer or cardiovascular patients, or women needing urgent caesarean sections.” Read full story (paywalled) Source: HSJ, 3 October 2023 -
News ArticleMore than 1 in 10 sexual harassment complaints against doctors are not investigated by the General Medical Council because of an “arbitary” rule, the Observer has revealed. According to data obtained under the Freedom of Information Act, 13% of sexual misconduct complaints made between the years 2017-18 and 2021-22 were closed without investigation because the GMC is prevented from considering alleged incidents more than five years after the event. As part of the council’s remit to protect patient safety and improve medical education and practice across the UK it investigates any kind of complaint against doctors. The figures show the GMC refused to investigate 170 complaints relating to sexual assault, attempted rape, and rape in the period analysed. In 22 of those cases the five-year rule was cited. It received 566 sexual harassment complaints in the same period. Anthony Omo, the GMC’s general counsel and director of fitness to practise, told the Observer: “We can and do waive the five-year rule where there are grave allegations involving sexual assault or rape. In many cases involving sexual allegations, the GMC’s position will be that such serious misconduct is incompatible with continued registration.” A government consultation in February heard that the five-year-rule was “arbitrary” and “a barrier to public protection” as it allowed doctors who may be guilty of inappropriate behaviour to continue practising. However, despite commitments from the Department of Health and Social Care to scrap the limitation as a “top priority”, no date has been set. Read full story Source: The Guardian, 30 September 2023
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Content ArticleIn anticipation of an increase in patients requiring a temporary tracheostomy due to the huge surge in patients placed on ICU ventilation at the peak of the COVID-19 pandemic, the NHS England National Patient Safety Team launched a National Patient Safety Improvement programme to rapidly support the NHS to provide safe tracheostomy care.
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Content ArticleIn this article, Sharon Hartles highlights the high-profile legal battle involving numerous Primodos-affected claimants against pharmaceutical companies and the government. The court ruled against the claimants, dismissing their claims related to hormone pregnancy tests and foetal harm. This decision led to disappointment and criticism from advocates, MPs, and academics involved in the Primodos scandal. Sharon Hartles is affiliated with the Risky Hormones research project, which is an international collaboration in partnership with patient groups. Additionally, she is a member of the Harm and Evidence Research Collaborative at the Open University. Related reading on the hub: Primodos 2023: The fight for justice continues for the Association for Children Damaged by Hormone Pregnancy Tests Primodos, mesh and sodium valproate: Recommendations and the UK Government’s response Primodos: The next steps towards justice Patient Safety Spotlight interview with Marie Lyon, chair of the Association for Children Damaged by Hormone Pregnancy Tests
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News Article
Primodos: Pregnancy test damages claims thrown out by judge
Patient Safety Learning posted a news article in News
Claims for damages by more than 170 people who say they were affected by hormone-based pregnancy test drugs have been thrown out by a High Court judge. The drugs, including Primodos, were given to women to test if they were pregnant from the 1950s to 1970s and alleged to have caused birth defects. But the judge ruled there was no new evidence linking the tests with foetal harm and "no real prospect of success". Campaigners say they are "profoundly disappointed" with the judgement. Legal action had been brought against three drug companies - Bayer Pharma, Schering Health Care, Aventis Pharma - as well as the government in a bid for compensation. However, they argued there was no evidence of a "causal association" between the hormone pregnancy tests and the harm suffered by the claimants. Marie Lyon, chair of the Association for Children Damaged by Hormone Pregnancy Tests, said she was "profoundly disappointed" with the judgement. "We do not accept the defendants' claim that our evidence did not provide sufficient scientific evidence and look forward to the additional scientific evidence, to support our original argument, which is due to be published shortly," she added. Read full story Source: BBC News, 28 May 2023 Further reading on the hub: Patient Safety Spotlight interview with Marie Lyon, chair of the Association for Children Damaged by Hormone Pregnancy Tests -
Event
Patient safety – How to lead the way
Patient Safety Learning posted an event in Community Calendar
untilThis webinar is open to DoF's/CFOs and deputies only. On average 11,000 deaths a year are classed as avoidable with that number probably tripling in the years following the pandemic. Patient Safety Learning is a charity and independent voice for improving patient safety. They harness the knowledge, enthusiasm and commitment of healthcare organisations, professionals and patients for system-wide change and the reduction of preventable harm. They provide a wealth of free resources on the hub and they are on a mission to align leadership and frontline delivery of care; ensuring that patient safety is a core purpose in the development of integrated care. ICSs present a significant opportunity to drive improvements in patient safety in local health systems across the NHS. However, patient safety remains the ‘elephant in the room’ in the development of ICS roles and responsibilities. Helen will bring a unique perspective to this session as an ex-NHS finance director, she understands the pressure and conflicting priorities faced by NHS leaders. But with between 13 – 15% of yearly spending being attributed to patient safety issues. Not only morally is this an issue that needs to be addressed but getting it right can also have a big impact on the bottom line. This is the second webinar running as part of the HFMA Connect network. Join this supportive community dedicated to assisting NHS finance leaders like you, being run in collaboration with the HFMA Hub partnership. This new network facilitates knowledge sharing and looks to assist directors of finance, chief finance officers and deputies as they navigate the current challenges facing the NHS. Register -
News ArticleHospitals 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
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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. -
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.
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Content ArticleMEG 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.
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Content ArticleDr 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.
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Content ArticlePatients’ 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.
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Content Article
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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’. -
Content ArticleThe 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.
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Content ArticleNHS 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.
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News Article
Complaints about non-surgical butt lifts ‘rising at alarming rate’ in UK
Patient Safety Learning posted a news article in News
Complaints about non-surgical Brazilian butt lifts and breast enhancements have risen at an “alarming” rate, up from fewer than 5 to 50 in a year, an industry body has revealed. Save Face, a national, government-approved register of accredited non-surgical treatment practitioners, is calling for the procedures to be banned, while the Local Government Association has asked Westminster to take urgent action. Ashton Collins, the director of Save Face, said the organisation had noted an “alarming” increase in complaints about these enhancements, which she said should be banned. Collins said: “No reputable healthcare professional would offer these treatments as they are very high risk. “It’s a new and incredibly dangerous trend which has emerged from social media, a trend people think is a cheaper, risk-free alternative to the surgical counterparts. All the cases reported to us have been carried out by non-healthcare practitioners who have prioritised profits ahead of the safety and wellbeing of their clients. “These treatments are incredibly risky, and we have helped people who have contracted sepsis and have had to undergo surgery to remove the filler. In 2021, we had fewer than five complaints about these treatments. That figure has increased tenfold in the past year alone and we are getting more and more complaints each week.” Read full story Source: The Guardian, 2 June 2023 -
News Article
‘Black market’ Botox scars women for life
Patient Safety Learning posted a news article in News
Practitioners with no professional medical qualifications use social media to target women and girls, an investigation by undercover Times reporters has found. The medicines regulator has begun an investigation after undercover Times reporters found beauticians offering to inject women with “black market” Botox, putting them at risk of being disfigured for life. Practitioners with no professional medical qualifications used social media to target women and girls, suggesting the treatments were safe and would enhance their looks. Many used products that have not gone through safety checks in Britain. Reporters confirmed that at least three practitioners advertising facial injections on social media sites were using cheap versions of Botox that are not licensed in the UK. Campaigners say they are receiving increasing reports of disfigurements such as permanent facial scarring and large sores caused by injections with unlicensed versions of Botox, often carried out in people’s homes and at beauty salons. The Medicines and Healthcare products Regulatory Agency (MHRA) said it was reviewing the findings and would “take appropriate regulatory action where any non-compliance is identified”. Sajid Javid, the health secretary, said the practices uncovered were “totally unacceptable” and officials were looking into whether legal changes were needed “to ensure no one is harmed”. Read full story (paywalled) Source: The Times, 2 February 2022
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