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Found 1,322 results
  1. Content Article
    In 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.
  2. Content Article
    In 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
  3. News Article
    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
  4. Event
    until
    This 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
  5. 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
  6. 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.
  7. 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.
  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. 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.
  11. 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’.
  12. 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.
  13. 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.
  14. News Article
    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
  15. News Article
    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
  16. News Article
    Lip fillers have grown increasingly popular but the industry is "like the wild west", experts warn, with many patients left in pain and embarrassed by their appearance. As Harriet Green left a salon after getting an injection to add volume to her lips, she was reassured the excess swelling would go down. But three months later her lips were still so bloated she could not close her mouth properly. The 22-year-old from Acle in Norfolk needed three corrective procedures - costing a total of more than £700 - to get them back to normal. Dr Saba Raja, a GP who runs her own aesthetics clinic in Norwich, says she is increasingly having to correct treatments which have gone wrong, describing the experience as "really distressing". "Every month I'm getting enquires from young girls who have gone to a non-medical practitioner for lip or tear trough fillers under the eye and had complications. "They often try to contact the practitioner but due to lack of training they are unable to deal with the complications. It is becoming more and more of a problem." Dr Raja describes the industry as "like the wild west", with people injecting patients "out of the back of their cars" and in kitchens. "Anti-wrinkle injections (Botox) are prescription-only but the injector can be anybody who has been on a day course. Dermal filler (for the lips and face) is not even a prescription-only medication, you can buy it off any website," she says. "A lot of non-medical practitioners are buying cheap filler online, with no idea where it has come from. We really need strict regulations and minimum training standards." Read full story Source: BBC News, 9 May 2023
  17. News Article
    Proposals by the Scottish Government to give a licence to unregistered professionals to carry out cosmetic procedures are “fundamentally flawed” and put lives at risk, leading nurses in the field have warned. A consultation has been launched seeking views on plans for a new regulatory regime of non-surgical aesthetic treatments that pierce or penetrate the skin like dermal fillers or lip enhancements. Ministers want to bring non-health professionals under existing legislation allowing them to obtain a licence to perform these procedures in unregulated premises such as beauty salons and hairdressers. The move comes after a UK-wide review carried out in 2013, by then NHS medical director Sir Bruce Keogh, identified that little regulation existed within the cosmetic industry. Since then there has been growing concern that people are coming to physical and psychological harm from treatments gone wrong. Leaders at the British Association of Cosmetic Nurses (BACN) told Nursing Times that they were “totally opposed” to non-medical practitioners carrying out injectable beauty procedures. BACN Chair Sharon Bennett said holding a medical, nursing or dentistry qualification should be a “basic prerequisite” before being accepted to an aesthetics training course. SHe said BACN believed even clinically trained practitioners, including nurses, needed further training in aesthetics before working in this “specialist” area. “[This is] because there is no educational framework, training or statutory provision to establish or task beauty therapists to detect disease, care for patients or carry out medical treatment, so to do so would breach public health safety and endanger lives.” Read full story Source: The Nursing Times, 20 January 2020
  18. News Article
    UK plastic surgeons have released new guidelines to try to make Brazilian Butt Lift (BBL) procedures safer for people who desire a bigger bottom. Some women have died from the operation, which involves sucking out fat from elsewhere - such as the belly - and injecting it into butt cheeks. The British Association of Plastic Surgeons (BAAPS) says the injections should not go very deep to help avoid complications such as dangerous clots. According to the NHS, it has the highest death rate of all cosmetic procedures, and the risk of death from BBL surgery is at least 10 times higher than many other procedures. A major concern is that the injected fat can cause a blockage in a blood vessel in the lungs - called a pulmonary embolism - which can be fatal. This happened to Leah Cambridge, a beautician and mother of three from Leeds. She suffered a massive pulmonary embolism during the operation at a private hospital in Turkey in 2018, a coroner found. BAAPS president Marc Pacifico told the BBC: "Unfortunately we don't know how many people have been going for these risky BBL procedures. We have been recommending against it for a number of years after seeing quite a frightening death rate associated with it. But people have been going abroad to get it done." "Make sure you ask if the surgeon will be using ultrasound for gluteal fat grafting. We are recommending that surgeons should only perform this with real time ultrasound guidance as the only way to ensure the procedure is performed superficially and safely." Read full story Source: BBC News, 10 October 2022
  19. News Article
    People administering Botox or fillers will be required to have a licence under new laws after an “unacceptable” rise in reports of botched cosmetic procedures in the UK. The legislation to protect against rogue practitioners will make it an offence to perform such non-surgical work without a licence after Sajid Javid said “far too many people have been left emotionally and physically scarred” when things have gone wrong. The health secretary recognised that most of those in the aesthetics industry “follow good practice” when it comes to patient safety but said it was time to think about the harm botched cosmetic procedures can have. “We’re doing all we can to protect patients from potential harm, but I urge anyone considering a cosmetic procedure to take the time to think about the impact on both their physical and mental health and ensure they are using a reputable, safe and qualified practitioner,” he said. Maria Caulfield, the minister for patient safety, said the spread of images online via social media has led to a rise in demand for Botox and fillers and there had been a subsequent increase in people suffering the consequences of badly performed procedures. She said: “While these can be administered safely, we are seeing an unacceptable rise in people being left physically and mentally scarred from poorly performed procedures.” Read full story Source: The Guardian, 28 February 2022
  20. News Article
    A cosmetic surgeon who did not have adequate insurance for operations that went wrong has been struck off. Dr Arnaldo Paganelli worked privately for The Hospital Group in Birmingham. The Medical Practitioners' Tribunal Service ruled his actions constituted misconduct. Four women took their case to the body and the tribunal heard evidence about his time at Birmingham's Dolan Park Hospital where he made regular trips from Italy to work. Lead campaigner Dawn Knight, from Stanley, County Durham, said too much skin was removed from her eyes during an eyelift in 2012 and they became "constantly sore". She told BBC Radio 4's You and Yours programme she felt relieved Dr Paganelli "cannot injure anyone else on UK soil" and called for the government to tighten regulation around cosmetic procedures to protect the public. "The process has been long, emotional and exhausting. This situation must never be repeated. After all, when are you more vulnerable than when under aesthetic at the hands of a surgeon who has no insurance?" Read full story Source: BBC News, 12 August 2020
  21. 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
  22. Content Article
    On 18 August 2023, Lucy Letby was found guilty of murdering seven babies and convicted of trying to kill six other infants at the Countess of Chester Hospital. Looking ahead to the forthcoming independent inquiry into this case, Patient Safety Learning, reflecting on the inquiries of the past, sets out some key patient safety themes and issues that should be considered as part of this.
  23. 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
  24. 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
  25. 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.
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