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Found 1,318 results
  1. Content Article
    This document describes the results of a study conducted by a Calgary study team who entered into a contract with the Canadian Patient Safety Institute (CPSI) to seek out, assess, and compile related research, approaches, and models to help inform the engagement process with patients/families who had been harmed while receiving care.
  2. Content Article
    This guide, developed by the charity Action Against Medical Accidents (AvMA), aims to provide support for people seeking legal advice about a possible clinical negligence claim. It is intended to provide information about what to expect from a first meeting with a lawyer and how to prepare for this.
  3. Content Article
    A National Patient Safety Alert has been issued on the elimination of bottles of liquefied phenol 80%. The alert has been issued by the NHS England and NHS Improvement National Patient Safety Team, British Orthopaedic Society, The Association of Coloproctology Great Britain and Ireland, and Royal College of Podiatry.
  4. Content Article
    One in 20 patients who undergo a surgical procedure contract an infection afterwards, in the part of the body where the surgery took place. 60% of these are preventable. We’re looking for patients to help raise awareness of the damaging impact these infections can have on people, and guide improvements. Have you ever contracted an infection after surgery? How did it affect you? Would you be happy to share your experience?
  5. Content Article
    Pennsylvania is the only state that requires healthcare facilities to report all events that cause harm or have the potential to cause harm to a patient. These patient safety events are reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS), which is the largest repository of patient safety data in the United States and one of the largest in the world, with over 3.9 million acute care records. This article, published in Patient Safety, shows details of the PA-PSRS acute care data along with longitudinal and categorical insights that can be used to improve patient safety.
  6. Content Article
    This article discusses the prevalence and cost of hospital-acquired conditions (HACs) and patient safety events (PSIs) associated with procedures that may below value, and reports on the prevalence of adverse events associated with potential low-value procedures and the additional hospital length of stay (LOS) and costs. 
  7. Content Article
    Preventable harm during labour can be catastrophic for parents, babies and families, as well as for the staff involved. Reducing avoidable brain injury in childbirth means building on everyone’s experiences and expertise, working together to improve care in labour for all. THIS Institute, in partnership with The Royal College of Midwives and The Royal College of Obstetricians & Gynaecologists, is inviting maternity staff, parents and birth partners from across the UK to contribute their views to their Avoiding Brain Injury in Childbirth (ABC) campaign. The focus is on monitoring and responding to babies’ wellbeing during labour and on managing the emergency complication at caesarean section known as impacted fetal head. The ABC campaign aims to give maternity staff tools and support to be able to provide the highest quality of care when there are concerns about the baby’s wellbeing during labour. It also aims to improve communication with everyone using maternity services and make sure they are listened to and involved in decisions about their care.
  8. Content Article
    In this article, published by the Harm & Evidence Research Collaborative, Sharon Hartles examines the UK Government’s response in relation to the implementation of the recommendations set out in the Independent Medicines and Medical Devices Safety Review, First Do No Harm report. She explores how the Government’s response has impacted on those harmed by the side effects of Primodos, Mesh and Sodium Valproate.
  9. Content Article
    This paper describes the case of a patient who had undergone a Ripstein procedure to address rectal prolapse 6 years before admission to the researchers clinic due to pain and discomfort over a period of 2 years. The researchers document the complications of the mesh implantation for rectal prolapse repair and presents the case of the unusual complication and reviews the relevant literature.
  10. Content Article
    This article, published in JAMA, tells the story of a 6 year-old boy who was initially misdiagnosed, which led to months of agony. Here, his mother, Thalia Margalit Krakower MD, asks that the medical community shift focus from promoting a false sense of perfection to one that embraces humility enough to apologise as essential to the healing process. "A deep cultural shift is needed in medicine to openly acknowledge and understand that imperfection is part of being human – no one knows everything, makes every diagnosis without delay, answers every patient message, or even delivers an apology just right. It is our humanity that makes us vulnerable to make mistakes and also empowers us to connect and heal." Read the article in full Related content Safety of candour: how protected are apologies in open disclosure? When the Duty of Candour becomes personal by Sarah Seddon Mothers Instinct: Reframing Duty of Candour in our hearts and minds – a blog by Joanne Hughes (15 October 2020) AvMA: Regulating the duty of candour. Requires improvement (October 2018) Barts Health NHS Trust: Duty of Candour training film (April 2016) Nursing and Midwifery Council. Openness and honesty when things go wrong: the professional duty of candour (June 2015)
  11. Content Article
    This week the Department of Health and Social Care released the UK Government’s response to the recommendations of the Independent Medicines and Medical Devices Safety Review, sometimes referred to as the Cumberlege Review. In this blog Patient Safety Learning sets out its reflections on this.  
  12. Content Article
    This document presents the National Safety Standards for Invasive Procedures which sets out a standardised framework – key steps - necessary to deliver safe care for patients undergoing invasive procedures.
  13. Content Article
    More and more women are coming forward to share their stories of a painful IUD procedure. In this blog for the BMJ Opinion, Stephanie O’Donohue (Content and Engagement Manager for Patient Safety Learning) argues that healthcare services need to get better at recording these experiences. The ripples of trauma caused by severe pain during IUD procedures If you have had an IUD fitted and would like to share your experience, please visit our community forum and share your views.  Related reading  The pain of my IUD fitting was horrific…and I’m not alone The normalisation of women’s pain Through the hysteroscope: Reflections of a gynaecologist Improving hysteroscopy safety (Patient Safety Learning, November 2020)
  14. Content Article
    This report is from the Patient Reference Group established to provide advice, challenge and scrutiny to work to develop the government response to the Independent Medicines and Medical Devices Safety (IMMDS) Review, sometimes referred to as the Cumberlege Review.
  15. Content Article
    Parkinson’s is the fastest growing neurological condition in the world. It affects young or old, and in the UK, around 145,000 people are living with the condition. With population growth and ageing, this figure is estimated to increase by 20%, within the next ten years. Currently there is no cure for Parkinson’s, but medication plays a vital role in managing symptoms and preventing deterioration. In this blog, Laura Cockram, Head of Policy and Campaigning at Parkinson's UK talks about: The serious health implications of delayed medication Evidence of a widespread safety issue The challenges and barriers Potential solutions How Parkinson’s UK are campaigning for change. 
  16. Content Article
    This report from the Department of Health and Social Care sets out the Government's response to the recommendations of the Independent Medicines and Medical Devices Safety (IMMDS) Review, sometimes referred to as the Cumberlege Review.
  17. Content Article
    Jacqui Shaw, 54, underwent surgery for pelvic organ prolapse during which surgical mesh was inserted. She assumed the operation would improve her quality of life. Instead, her days are now blighted by agonising pain and despair.  In this video, published on the Mail+, Jacqui bravely shares her story, and her uncertainty for the future. She describes how she found the support group Sling the Mesh, and subsequently many others who were also experiencing devastating consequences of surgical mesh.
  18. Content Article
    This video, produced in conjunction with Royds Withy King Solicitors, provides a quick overview of AvMA’s services and how volunteers help them to deliver the vital support people need after experiencing medical harm.
  19. Content Article
    Baroness Julia Cumberlege, produced the First Do No Harm report that looked into two drugs and a medical device which caused women or their babies harm. In this episode of Women's Hour, she joins host Emma Barnett to talk about her anger and frustration at the lack of progress made since the report was published a year ago. The report made a list of nine recommendations to support victims and prevent future, avoidable damage. Eight of these have seen no action. Listen from 31:20
  20. Content Article
    This is the transcript of a backbench debate in the House of Commons regarding the implementation of the recommendations of First Do No Harm report, published by the Independent Medicines and Medical Devices Safety Review on the 8 July 2020, chaired by Baroness Cumberlege (also known as the Cumberlege Review).
  21. Content Article
    Diagnostic errors can result in avoidable harm when undiagnosed conditions remain untreated or when patients undergo unnecessary (or harmful) tests. This study seeks to estimate the incidence and origins of avoidable harm from diagnostic errors in English general practice. It defines diagnostic errors as missed opportunities to make a correct or timely diagnosis based on the evidence available. The authors conclude that although missed diagnostic opportunities (MDOs) occurred in fewer of 5% of the investigation consultations they analysed, high numbers of primary care contacts nationally suggest that several million patients are potentially at risk of avoidable harm from MDOs each year.
  22. Content Article
    This is the report of an inquiry conducted by the Health and Social Care Select Committee in 2020/21 which examined the ongoing safety concerns with maternity services and the action needed to improve safety for mothers and babies. It suggests that improvements to maternity services have been too slow to date and recommends several changes, including increasing in the budget for maternity services and reforming existing to litigation processes.
  23. Content Article
    This article describes how the Care Quality Commission has charged The Dudley Group Foundation Trust with the deaths of Kaysie-Jane Robinson (14) and Natalie Billingham (33) who were found to have died as a result of safety failures. The Dudley Group Foundation Trust pleaded guilty to the charges in court on 2 July 2021, however, only the death of Ms Robinson was accepted by the trust as a result of their care failures.
  24. Content Article
    In this blog, Consultant Neurologist Jane Alty, talks about a patient with Parkinson's who was cared for in their trust for a period of time, during which there were frequent occasions on which his Parkinson's medications were delayed or not given. This sadly contributed to a deterioration in his swallowing and overall condition, and lengthened his time in hospital.  Inspired by a letter from his wife, Jane and colleagues started the 'Improving care of patients with Parkinson’s quality improvement project' at Leeds Teaching Hospitals NHS Trust. Here she talks about the journey, the successes and challenges, and the value of involving staff from across the organisation and carers to make services better.
  25. Content Article
    In this article, Sodium Valproate: The Fetal Valproate Syndrome Tragedy, Sharon Hartles, member of the Open University’s Harm and Evidence Research Collaborative, reflects upon the use of Sodium Valporate, marketed as Epilim, to treat patients at risk of epilepsy and the subsequent harms in fetal development and birth defects that arose from its use. 
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