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Found 290 results
  1. Content Article
    When Joe Fassler's wife was struck by mysterious, debilitating symptoms, their trip to the ER revealed the sexism inherent in emergency treatment.
  2. News Article
    Mental health patients who were discharged from or admitted to acute mental health services during the first Covid-19 lockdown experienced loneliness and social isolation, according to a new study. Published in the British Journal of Psychiatry Open the 34 patients, carers and clinical staff were interviewed by a team of researchers from The University of Manchester. Mental health service users also reported ‘working harder’ to avoid admission due to fears around environmental safety as a result of COVID-19. “Even before the pandemic, there are lots of safety concerns associated with recent discharge from inpatient mental health services, for example suicide and self-harm,“ said lead author Dr Natasha Tyler, researcher at the GM PSTRC and The University of Manchester. Dr Tyler added: ‘Our patients and carers felt that because of the national need to free-up hospital beds, the quality of discharge and admission planning was compromised at times. “That meant discharging patients from hospitals who were not ready to cope in the community or not admitting patients who needed in-patient care. “The closure of most community support services meant patients had minimal opportunities for accessing care via alternative routes. This worsened their feelings of helplessness and loneliness.” Full article here Source: Greater Manchester Patient Safety Translational Research Centre
  3. Content Article
    For some time now I've been looking to find out more about mental health services in Trieste, Italy. Then I met Vincenzo Passante Spaccapietra, co-host of the Place of Safety? podcast series. This has enabled me to learn more about the closure of the mental institutions in Trieste, Italy, and the work of Franco Basaglia.  I was keen to find out what really took place, what this really means in practice and how we can adopt this model in the UK. We were delighted to have become involved and to have recorded a couple of podcasts. I recommend this resource to everyone interested in safe, compassionate, patient led mental health care.
  4. Content Article
    In my tweets and posts I have suggested that patients themselves need to take more responsibility for the medicines they are prescribed. But what about vulnerable groups who may depend on decisions being made for them, and in their best interests? Whilst there are circumstances where antipsychotic (psychotropic) medicines are an appropriate option for people with autism and learning disabilities, these occasions are limited. In all cases the patient matters most, and any decision to prescribe must be part of a team based, patient-led decision, which is regularly reviewed.
  5. Content Article
    Having stepped down as Chief Executive of the Point of Care Foundation last year, Jocelyn Cornwell reflects on the journey that she and the organisation have made and what she has learnt. This is her personal take on their history, the principles behind the work and achievements plus some reflections on changes that have and have not happened over the last fifteen years. 
  6. Content Article
    This is a guest post for the Hysterical Women website, by Kath Sansom, founder of the Sling the Mesh campaign. Content warning: mention of self-harm.
  7. Content Article
    In this blog by the British Society of Criminology, Sharon Hartles critically examines the journey so far towards the implementation of the remaining eight recommendations set out in the landmark publication of the Medicines and Medical Devices Safety Review First Do No Harm report in July 2020.
  8. Content Article
    Hysteroscopy is a diagnostic gynaecological procedure traditionally requiring administration of general anaesthesia, but more frequently completed using local anaesthesia within a day-case (ambulatory) setting. Advantages associated with this transition include decreased completion times, fewer risks, and lower clinical costs. Numerous services advertise the procedure as being either pain free or low pain; however, it is estimated that 25% of patients report experiencing intense or intolerable pain. For severe pain, local anaesthetic can be administered, but this does not guarantee effective pain management. This research, published in the British Journal of Anaesthesia, found that very few patients feel no pain and a significant number felt pain of greater than 7/10. It also found a disconnect between the patient's experience of pain and the clinician's perception of it. This research paper is paywalled, but can be purchased via the link below.
  9. Content Article
    In this blog, Stephanie O'Donohue, Content and Engagement Manger for Patient Safety Learning, discusses some of the patient safety issues that specifically impact on women. Drawing on recent inquiries, patient testimonials and research, Stephanie focuses on three main issues; consent, patient engagement and bias. She highlights the need for people to work in partnership to understand the barriers to safe care for women and to prevent future harm. 
  10. Content Article
    Hysteroscopy is a procedure used as a diagnostic tool, to identify the cause of common problems such as abnormal bleeding, unexplained pain or unusually heavy periods in women. It involves a long, thin tube being passed into the womb, often with little or no anaesthesia. In recent years, there has been an increased focus on these procedures being performed within outpatient services. The availability of pain relief is much reduced in these settings. There are financial incentives in place to support this move to day surgery.[1] Reflecting on activity to date, Patient Safety Learning discusses the important role that consent, patient engagement and collaborative action is playing in highlighting a serious patient safety concern and in driving the change needed for safe hysteroscopy.
  11. Content Article
    The Campaign Against Painful Hysteroscopy is a campaign group raising awareness of the safety flaws that exist within the processes surrounding hysteroscopy procedures for women.  On 20 October 2020, they wrote to Matt Hancock MP, Secretary of State for Health and Social Care and Nadine Dorries MP, Minister for Patient Safety, Suicide Prevention and Mental Health. In their letter they used both empirical data and the personal stories of women to illustrate the prevalence and seriousness of the issue. 
  12. Content Article
    Dr Richard Harrison is a pain researcher employed at the University of Reading and affiliated with the School of Psychology and Clinical Language Sciences (SPCLS) and Centre for Integrative Neuroscience and Neurodynamics (CINN). His research focuses predominately on pain, examining psychological processes underlying how pain is processed, as well as individual differences in the ability to modulate (or control) the experience of pain. In this blog, Richard reflects on his recent research on pain experience and assessment during hysteroscopy procedures, published recently in the British Journal of Anaesthesia. "The dangers of advertising hysteroscopy as a mildly painful procedure are many. Firstly, this stands to put women off engaging with a very useful diagnostic test for the identification of serious medical conditions, such as ovarian cancer or endometriosis. But secondly, it is highly plausible that the resulting prediction error stands to make the experience even more painful than if patients were appropriately warned."
  13. News Article
    Vulnerable patients at a major NHS hospital at the centre of England’s coronavirus second wave have been left without help to eat or drink because wards are so dangerously understaffed, The Independent can reveal. Dozens of safety incidents have been reported by doctors and nurses at the Liverpool University Hospitals Trust since April, citing the lack of nurses as a key patient safety risk. Across several wards, just two registered nurses per ward were being expected to look after dozens of sick patients – a ratio of nurses to patients far below recommended safe levels. On one ward there were 36 patients to two registered nurses – with the nurse in charge of the ward having only qualified six months earlier. The safety concerns also include a diabetic patient – where there was no evidence nurses had monitored their blood glucose levels and insulin medication, which if left unchecked could prove fatal. Other patients have been forced to eat food and drink which has gone cold by the time staff are ready to help them. The hospital is among the worst affected by the surge in coronavirus cases in the north of England. It’s medical director warned on Friday that it was at 100 per cent capacity and unable to maintain standards of care. Read full story Source: The Independent, 5 November 2020
  14. Content Article
    Authors of this commentary published in the Canadian Medical Association journal argue that many patients suffer from a specific adverse event on a daily basis: pain. It is never reported as an adverse event and corrective action is often not taken.
  15. Content Article
    This blog, published in the BMJ, sets the context for an Evidence Based Nursing (EBN) Twitter Chat that took place on 18 March 2015. The chat focused on whether mismanaged (undertreated) pain should be considered an adverse event. The Twitter Chat was hosted by Dr Alison Twycross who is editor of EBN and has also done lots of work in the area of paediatric pain management. This blog provides some context for the chat. The examples given relate to paediatric pain but the principles apply to pain in patients of all ages.
  16. Content Article
    Elderly people in care homes in Cornwall were abused and neglected while failings led to reports of concerns not being investigated, a new Safeguarding Adults Review has found. The Morleigh Group, which operated seven homes in Cornwall and has since shut down, was exposed in a BBC Panorama investigation in 2016. A new Safeguarding Adults Review which was commissioned as a result of the TV show has been published making a number of recommendations to all agencies which were involved in the case. The review was completed in April 2019 but has only just been made public - Rob Rotchell, Cornwall Council Cabinet member for adult social care said that this was due to the number of agencies being involved.
  17. Content Article
    The Cornwall and Isles of Scilly Safeguarding Adults Review into The Morleigh Group has found elderly people in care homes in Cornwall were abused and neglected while failings led to reports of concerns not being investigated. The Morleigh Group operated seven homes in Cornwall and has since shut down. The review was completed in April 2019 but has only just been made public - Rob Rotchell, Cornwall Council Cabinet member for adult social care said that this was due to the number of agencies being involved.
  18. News Article
    As she lay dying in a Joliette, Que., hospital bed, an Atikamekw woman clicked her phone on and broadcast a Facebook Live video appearing to show her being insulted and sworn at by hospital staff. Joyce Echaquan's death on Monday prompted an immediate outcry from her home community of Manawan, about 250 kilometres north of Montreal, and has spurred unusually quick and decisive action on the part of the provincial government. The mother of seven's death will be the subject of a coroner's inquiry and an administrative probe, the Quebec government said today. A nurse who was involved in her treatment has been dismissed. But that dismissal doesn't ease the pain of Echaquan's husband, Carol Dubé, whose voice trembled with emotion as he told Radio-Canada his wife went to the hospital with a stomach ache on Saturday and "two days later, she died." Echaquan's relatives told Radio-Canada she had a history of heart problems and felt she was being given too much morphine. In the video viewed by CBC News, the 37-year-old is heard screaming in distress and repeatedly calling for help. Eventually, her video picks up the voices of staff members. One hospital staff member tells her, "You're stupid as hell." Another is heard saying Echaquan made bad life choices and asking her what her children would say if they saw her in that state. Dubé said it's clear hospital staff were degrading his wife and he doesn't understand how something like this could happen in 2020. Read full story Source: CBC News, 29 September 2020
  19. Content Article
    Sarah Seddon's son (Thomas) was stillborn in May 2017. The lack of candour following Thomas’ death and the conduct of the serious incident investigation impacted significantly on Sarah and her family. The local investigation was followed by a Fitness to Practise (FtP) investigation where Sarah experienced how damaging, dehumanising and traumatic FtP processes can be for patients who are required to be witnesses. Here she reflects on the impact of being a witness in a Fitness to Practise (FtP) hearing had on her.
  20. Content Article
    Authors of this article, previous argued that inadequately managed pain in children should be considered an adverse event, a harmful patient outcome. They argued that inadequately managed pain meets the definition of an adverse event and further hypothesised that treating pain as an adverse event may improve care by raising health care administrators and quality improvement experts’ awareness of this issue.  In this article, published in the Journal of Child Care Health five years on, they reflect on the progress made in both moving this proposition forward and testing out the concept. They then move on to look at what still needs to be done to ensure that children’s pain is managed effectively.
  21. Content Article
    Chaired by Baroness Julia Cumberlege, the Independent Medicines and Medical Devices Safety Review report, First Do No Harm, examines how the healthcare system in England responds to reports about the harmful side effects from medicines and medical devices. In this blog, Patient Safety Learning reflects on one of the key patient safety themes featured in the Review – informed consent. 
  22. Content Article
    In this blog, intensive care doctor Jake Suett draws on his personal journey and that of others to highlight the prolonged and frightening symptoms many patients with confirmed or suspected COVID-19 are experiencing. Jake outlines his concerns and sets out recommendations for future action to address the needs of these 'Long COVID' patients. Included is an example letter that can be adapted by others to call on MPs to raise awareness of those suffering persisting symptoms of COVID-19. 
  23. News Article
    Many lives have been ruined because officials failed to hear the concerns of women given drugs and procedures that caused them or their babies considerable harm, says a review. More than 700 women and their families shared "harrowing" details about vaginal mesh, Primodos and an epilepsy drug called sodium valproate. Too often worries and complaints were dismissed as "women's problems". It says arrogant attitudes left women traumatised, intimidated and confused. June Wray, 73 and from Newcastle, experienced chronic pain after having a vaginal mesh procedure in 2009. "Sometimes the pain is so severe, I feel like I will pass out. But when I told GPs and surgeons, they didn't believe me. They just looked at me like I was mad." The chairwoman of the highly critical review, Baroness Julia Cumberlege, said the families affected deserved a fulsome apology from the government. She said: "I have conducted many reviews and inquiries over the years, but I have never encountered anything like this; the intensity of suffering experienced by so many families, and the fact that they have endured it for decades. Much of this suffering was entirely avoidable, caused and compounded by failings in the health system itself." Read full story Source: BBC News, 8 July 2020
  24. Content Article
    In this interview, Dr Jake Suett talks about his experience of persisting and debilitating symptoms after he was suspected to have contracted COVID-19. Additional reading: Patient safety concerns for Long COVID patients (6 July 2020) Press release: Patient Safety Learning calls for urgent action to ensure Long COVID patients are heard and supported (6 July 2020) My experience of suspected 'Long COVID' (6 July 2020) Dismissed, unsupported and misdiagnosed: Interview with a COVID-19 ‘long-hauler’
  25. Content Article
    An increasing number of people with confirmed or suspected COVID-19 are continuing to struggle with prolonged, debilitating and sometimes severe symptoms months later.[1] Many were never admitted to hospital and have instead been trying to manage their symptoms and recovery at home. These patients are sometimes referred to as the ‘long-haulers’ or described as having ‘post-acute’, ‘chronic’ or ‘long-term’ COVID-19. Here, we will use the term ‘Long COVID’. With social distancing restrictions still in place, patients in the UK and across the world have been turning to social media support networks[2] to connect with others who are experiencing similar challenges. These patients have raised very credible concerns about the care they are receiving[3] and the uncertainties they face. Their concerns are revealing many implications for patient safety. We have recently shared on the hub the story of Dr Jake Suett[4], one of the many people experiencing symptoms of Long COVID. When we conclude this article, we will return to his story and highlight the changes that he is calling for. However, first, we will focus on the patient safety aspects of Long COVID, highlighting key areas of concern and action needed (a full list of actions can be found summarised here).
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