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Content ArticleThis week Nadine Dorries MP, Minister for Patient Safety, Suicide Prevention and Mental Health, provided an update on the Government’s response to the Independent Inquiry into the Issues raised by Paterson.[1] Here, Patient Safety Learning reflects on this statement and the need for the Government to urgently prioritise providing a full response to the Inquiry’s findings.
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Content ArticleIn April 2017, Ian Paterson, a surgeon in the West Midlands, was convicted of wounding with intent, and imprisoned. He had harmed patients in his care. The scale of his malpractice shocked the country. There was outrage too that the healthcare system had not prevented this and kept patients safe. At the time of his trial, Paterson was described as having breached his patients’ trust and abused his power. In December 2017, the Government commissioned an independent Inquiry to investigate Paterson’s malpractice and to make recommendations to improve patient safety. The report, outlining a series of recommendations to avoid future harm, was published in February 2020. On 23 March 2021 Nadine Dorries, Minister for Patient Safety, Suicide Prevention and Mental Health, provided an update on the Government’s response to the Independent Inquiry into the Issues raised by Paterson, accessible through the link below.
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Mesh: Denial, half-truths and the harms (March 2021)
Patient Safety Learning posted an article in Women's health
In this article, Sharon Hartles, a member of the Harm and Evidence Research Collaborative, critically discusses the harmful impacts of mesh medical devices against the backdrop of disempowerment, denial and half-truths. Surgical meshes have been in use since the late 19th century. In the mid-20th century the clinical usage of mesh increased. Now, in the early 21st century, procedures involving mesh implantation are common surgeries that are performed around the world. Despite the frequency and worldwide usage of mesh medical devices, the debate about whether or not the benefits outweigh the alleged harms remains highly contested. Read the full article Further recommended reading: Dangerous exclusions: The risk to patient safety of sex and gender bias Healing after harm: A restorative approach to incidents Analysing the Cumberlege Review: Who should join the dots for patient safety? Findings of the Cumberlege Review: informed consent Findings of the Cumberlege Review: patient complaints -
Content ArticleEvery year, avoidable harm leads to the deaths of hundreds of thousands of patients, each an unnecessary tragedy. Despite many people doing good work to improve patient safety, this remains a persistent problem. At the recent Future of Hospitals event from Health Plus Care Online, Helen Hughes, Patient Safety Learning's CEO, and Donna Prosser, Chief Clinical Officer of the Patient Safety Movement, consider the need for patient safety to be a core purpose of healthcare and how we can best achieve this. They also discuss whether patient safety can become a social movement - uniting clinicians, patients, leaders, policy-makers and communities.
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Content ArticleThis directive alert has been issued on the need to confirm intravenous (IV) lines and cannulae have been effectively flushed or removed at the end of the procedure.
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Content ArticleThis webinar is part of a series of seminars from the Yorkshire Quality and Safety Research Group. Jo Wailing, Registered Nurse, Research Fellow and Facilitator, talks about her work exploring the potential of restorative approaches to support healing following adverse clinical events. Jo draws on the lessons learned from investigations into the use of, and harm caused by, surgical mesh.
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Content ArticleThis was a debate in the House of Lords on the 2 March 2021 concerning the UK Government's plans regarding a redress scheme for those harmed by sodium valproate, stemming from recommendations in the First Do No Harm Report by the Independent Medicines and Medical Devices Safety Review chaired by Baroness Cumberlege (also known as the Cumberlege Review).
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Content ArticleThe Health Information and Quality Authority (HIQA) has published its annual overview report of lessons learned from receipt of statutory notifications of accidental and unintended exposures to ionising radiation in 2020. This report provides an overview of the findings from these notifications and shares learnings from the investigations of these incidents.
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WHO's Framework for Action - The 7x5 Matrix (Infographic)
Patient Safety Learning posted an article in WHO
The WHO's Global Patient Safety Action Plan aims to provide a strategic direction for concrete actions to be taken by countries, partner organisations, care facilities and World Health Organization (WHO). It sets out a vision of a “world in which no patient is harmed in healthcare, and everyone receives safe and respectful care, every time, everywhere” and a goal of achieving the maximum possible reduction in avoidable harm as a result of unsafe care. -
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This competency framework has been developed and updated to support prescribers in expanding their knowledge, skills, motives and personal traits, to continually improve their performance, and work safely and effectively. -
Content ArticleThis 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.
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Content ArticleThis 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.
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Content ArticleA 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.
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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? -
Content ArticlePennsylvania 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.
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Content ArticleThis 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.
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Avoiding Brain Injury in Childbirth (ABC)
PatientSafetyLearning Team posted an article in Maternity
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. -
Content ArticleIn 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.
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Content ArticleThis 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.
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To err is human, to apologize is hard (JAMA, July 2021)
PatientSafetyLearning Team posted an article in Culture
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) -
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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. -
Content ArticleThis 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.
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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) -
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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. -
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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.- Posted
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