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Found 479 results
  1. Content Article
    The Royal College of Anaesthetists (RCoA) and the Difficult Airway Society (DAS) have collaborated to create the video resource Capnography: No Trace = Wrong Place.  Presented by Professor Tim Cook, the video shares the important message that during cardiac arrest, if a capnography trace is completely flat, oesophogeal intubation should be assumed until proven otherwise. 
  2. Content Article
    Patient Safety Learning's Chief Executive Helen Hughes, alongside Professor Alison Leary and Professor Sara Ryan, talk on BBC Radio 4 about coroner reports that are specifically designed to help prevent future deaths and question whether it's working in practice. Health researchers warn that lives are at risk because warnings from Coroners are not being acted upon. Analysis of more than 1000 Prevention of Future Death reports has identified five themes that come up time and time again. Patient Safety Learning has written to the Chief Coroner because of their concerns about this. Sara Ryan is a mother who believes lessons from her son's death have not been learned.
  3. Content Article
    Avoidable unsafe care kills and harms thousands of people in the UK each year. When a person dies as a result of a preventable error it is vital that we learn from these tragic events and take action to ensure that this does not reoccur. Coroners' Prevention of Future Deaths (PFD reports) are a crucial resource for this and should be used to make healthcare safer. Are we utilising these to their full extent to improve our safety practice and to achieve their aim, to prevent future deaths?
  4. Content Article
    The No Fault Compensation Review Group were asked by the Cabinet Secretary for Health and Wellbeing to consider the potential benefits for patients in Scotland of a no fault compensation scheme for injuries resulting from medical treatment, and whether such a scheme should be introduced alongside the existing clinical negligence arrangements. This report sets out the approach they adopted together with their findings, conclusions and recommendations which help and inform consideration of what is required to ensure that the compensation scheme in operation in Scotland meets the needs of those involved.  
  5. Content Article
    In this BMJ Opinion article, David Rowland from the Centre for Health and the Public Interest discusses why he thinks the Independent Inquiry into the issues raised by Paterson is yet another missed opportunity to tackle the systemic patient safety risks which lie at the heart of the private hospital business model. David believes that although the Inquiry provided an important opportunity for the hundreds of patients affected to bear witness to the pain and harm inflicted upon them it fundamentally failed as an exercise in root cause analysis.   None of the “learning points” in the final report touch on the financial incentives which may have led Paterson to deliberately over treat patients. Nor do they cover the business reasons which might encourage a private hospital’s management not to look too closely. Yet these concerns about how the private hospital system works and the associated patient risks it produces had been established in a number of previous inquiries.   He suggests that the Inquiry report threw the responsibility for managing patient safety risks back to the patients themselves in two of its main recommendations but that it should be for the healthcare provider first and foremost to ensure that the professions that they employ are safe, competent and properly supervised, and for this form of assurance to be underpinned by a well-functioning system of licensing and revalidation by national regulatory bodies.
  6. News Article
    The Independent Inquiry into the issues raised by Paterson is yet another missed opportunity to tackle the systemic patient safety risks which lie at the heart of the private hospital business model, says David Rowland from the Centre for Health and the Public Interest in a recent BMJ Opinion article. Although the Inquiry provided an important opportunity for the hundreds of patients affected to bear witness to the pain and harm inflicted upon them it fundamentally failed as an exercise in root cause analysis. None of the “learning points” in the final report touch on the financial incentives which may have led Paterson to deliberately over treat patients. Nor do they cover the business reasons which might encourage a private hospital’s management not to look too closely. He suggests that the Inquiry report threw the responsibility for managing patient safety risks back to the patients themselves in two of its main recommendations but that it should be for the healthcare provider first and foremost to ensure that the professions that they employ are safe, competent and properly supervised, and for this form of assurance to be underpinned by a well-functioning system of licensing and revalidation by national regulatory bodies. Read full story Source: BMJ Opinion, 20 February 2020
  7. Content Article
    hub Topic Lead, Eve Mitchell, describes how her passion to change care quality and to put workforce at the centre of every health and social care organisation’s planning processes led her on a journey to create the innovative tech start-up, ‘Establishment Genie’: an online workforce planning, safe staffing and benchmarking tool. 
  8. Content Article
    The independent inquiry into how the rogue breast surgeon Ian Paterson was able to inflict harm on patients over more than decade described the UK healthcare system as “dysfunctional at almost every level.” In this BMJ analysis, Gareth Iacobucci summarises the findings of the inquiry.
  9. Content Article
    Dr Matt-Inada-Kim, National Clinical Lead for Sepsis and Deterioration, shares the proforma he has developed to document management and treatment for the deteriorating patient for the new CQUIN, coming soon. This proforma ensures that all the CQUIN data is captured when it comes to audit. He has shared his accompanying slide set explaining about the CQUIN.  
  10. News Article
    An NHS trust has been criticised for advising pregnant women to stay at home for as long as possible during labour to increase the chances of a “normal birth”. University Hospitals Bristol NHS Trust also suggested mothers should avoid having epidurals or inductions and should try to have a home birth. The advice has been described as “shocking” by experts, who said the guidance was contrary to evidence and could be “dangerous” for mothers and babies. Others criticised the language used by the trust which suggested women who needed medical help were somehow “abnormal”. Earlier this month, the Bristol trust paid out £5.8m in compensation to the family of a six-year-old boy after he was left brain damaged at birth following complications during labour. After being contacted by The Independent, the trust deleted the childbirth advice from its website and accepted it was “outdated”. Read full story Source: The Independent, 13 February 2020
  11. Content Article
    The Independent Inquiry into the Issues raised by Paterson, published on Tuesday 4 February 2020, was prompted by the case of Ian Paterson, a breast surgeon who was convicted of wounding with intent some of the 11,000 patients he treated and jailed for 20 years in 2017. More than 200 patients and family members gave evidence as part of the Inquiry and it is estimated that he could have harmed more than 1000 patients.[1] The Inquiry gave those involved an opportunity to be heard and to learn how this happened, in both the NHS and the independent sector. It found that this “is the story of a healthcare system which proved itself dysfunctional at almost every level when it came to keeping patients safe, and where those who were the victims of Paterson’s malpractice were let down time and time again”.[2] At Patient Safety Learning we have reflected on some of the key patient safety themes that have emerged from this Inquiry and the actions required these issues. You can read Patient Safety Learning's full response here.
  12. Content Article
    This inquiry looked at the current and future scale of the shortfall of nursing staff and whether the Government and responsible bodies have effective plans to recruit, train and retain this vital workforce. It assessed the impact of new routes into nursing (including student funding reforms, the Apprenticeship Levy, Nurse First and nursing associates). In particular, the inquiry examined the effect of changes to funding arrangements for nurse training, including the withdrawal of bursaries, and consider alternative funding models and incentives.
  13. News Article
    The toxicity of a commonly prescribed beta blocker needs better recognition across the NHS to prevent deaths from overdose, a new report warns today. The Healthcare and Safety Investigation Branch (HSIB) report focuses on propranolol, a cardiac drug that is now predominately used to treat migraine and anxiety symptoms. It is highly toxic when taken in large quantities and patients deteriorate quickly, making it difficult to treat. The investigation highlighted that these risks aren’t known widely enough by medical staff across the health service, whether issuing prescriptions to at risk patients, responding to overdose calls or carrying out emergency treatment. Dr Stephen Drage, ICU consultant and HSIB’s Director of Investigations, said: “Propranolol is a powerful and safe drug, benefitting patients across the country. However, what our investigation has highlighted is just how potent it can be in overdose. This safety risk spans every area of healthcare – from the GPs that initially prescribe the drug, to ambulance staff who respond to those urgent calls and the clinicians that administer emergency treatment." The report also emphasises that there is a link between anxiety, depression and migraine, and that more research is needed to understand the interactions between antidepressants and propranolol in overdose. Read full story Source: HSIB, 6 February 2020
  14. Content Article
    This Healthcare and Safety Investigation Branch (HSIB) report explores the under recognised toxicity of propranolol in overdose. Propranolol is used to treat a number of medical conditions, including migraine, cardiovascular problems and the physical effects of anxiety. The case that prompted the investigation was Emma, a 24-year old woman, took an overdose of both propranolol and citalopram (an antidepressant). She called an ambulance, but her condition quickly worsened. Despite resuscitation efforts from both paramedics and medical staff in the hospital she was transferred to, Emma sadly died. There has been a steady rise in the number of propranolol prescriptions issued to NHS patients. Between 2012 and 2017 there was a 33% increase in the number of deaths reported as being linked to propranolol overdose, with 52 deaths recorded as having been linked to propranolol overdose in 2017.
  15. News Article
    The new executive must act urgently if it is to "divert the current mental health epidemic among young people", Northern Ireland's children's commissioner has said. Koulla Yiasouma said progress in implementing recommendations in a report on children and young people's mental health services, produced 12 months ago, had been "too slow". The stark read captured the scale of youth mental health problems in Northern Ireland. The report found that young people are waiting too long to ask for help and even longer to access the right support. Health Minister Robin Swann said his aim was that young people do not wait longer than nine weeks to see a CAMHS (child and adolescent mental health services) professional."I take the mental health and wellbeing of our children and young people very seriously and I am committed to working with my colleagues in a new executive working group on mental well-being, resilience and suicide prevention," he said. Read full story Source: 6 February 2020
  16. News Article
    Shipman, Mid Staffordshire, Morecambe Bay, and now Ian Paterson, the breast surgeon that performed botched and unnecessary operations on hundreds of women. The list of NHS-related scandals has got longer. It's tempting to say the health service has not learned lessons even after a string of revelations and reviews. But is that fair? asks BBC Health Editor Hugh Pym. The inquiry, chaired by Bishop Graham James, makes clear there were failings at every level of a dysfunctional health system when it came to patient safety. The public and private health systems did not compare notes about suspicious behaviour by a consultant. Staff working with Paterson thought that his surgical methods were unusual but, perhaps cowed by being ignored after raising concerns, kept their heads down. Add to that the power and status of a surgeon in the medical world and, in the words of the report, Paterson was "hiding in plain sight". So could it happen again? James says it's clearly impossible to eliminate the activities of determined criminals in any profession. He acknowledges that some improvements have been made on policing. But he says that a decade on from the Paterson scandal, he is not convinced that medical regulators, with a combined budget of half a billion pounds a year, are doing enough collectively or collaboratively to make the system safe for patients. The review chair notes tellingly that while regulators spoke of major improvements which should identify another Paterson, some doctors and nurses had told the inquiry that it was "entirely possible that something similar could happen now". Read full story Source: BBC News, 4 February 2020
  17. Content Article
    In 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 this independent Inquiry to investigate Paterson’s malpractice and to make recommendations to improve patient safety. This report presents the Inquiry’s methodology, findings and recommendations. More importantly, it tells the story of the human cost of Paterson’s malpractice and the healthcare system’s failure to stop him, and something of the enduring impact this has had on the lives of so many people.
  18. News Article
    A culture of "avoidance and denial" allowed a breast surgeon to perform botched and unnecessary operations on hundreds of women, an independent inquiry has found. The independent inquiry into Ian Paterson's malpractice has recommended the recall of his 11,000 patients for their surgery to be assessed. Paterson is serving a 20-year jail term for 17 counts of wounding with intent. One of Paterson's colleagues has been referred to police and five more to health watchdogs by the inquiry. The disgraced breast surgeon worked with cancer patients at NHS and private hospitals in the West Midlands over 14 years. His unregulated "cleavage-sparing" mastectomies, in which breast tissue was left behind, meant the disease returned in many of his patients. Others had surgery they did not need - some even finding out years later they did not have cancer. Patients were let down by the healthcare system "at every level" said the inquiry chair, Bishop of Norwich the Rt Revd Graham James, who identified "multiple individual and organisational failures". One of the key recommendations from the report is that the Government should make patient safety a the top priority, given the ineffectiveness of the system identified in this Inquiry. Read full story Source: BBC News, 4 February 2020
  19. Content Article
    The European Medicines Agency (EMA) has published an PDF icon overview of its key recommendations in 2019 on the authorisation and safety monitoring of medicines for human use. Innovative medicines are essential to advancing public health as they bring new opportunities to treat certain diseases. In 2019, EMA recommended 66 medicines for marketing authorisation. Of these, 30 had a new active substance which had never been authorised in the EU before. The infographic includes a selection of medicines that represent significant progress in their therapeutic areas.  Once a medicine is authorised by the European Commission and prescribed to patients, EMA and the EU Member States continuously monitor its quality and benefit-risk balance and take regulatory action when needed. Measures can include a change to the product information, the suspension or withdrawal of a medicine, or a recall of a limited number of batches. An overview of some of the most notable recommendations is also included in the document.
  20. Content Article
    Chemotherapy is strong medicine, so it is safest for people without cancer to avoid direct contact with the drugs. That’s why oncology nurses and doctors wear gloves, goggles, gowns and, sometimes, masks. When the treatment session is over, these items are disposed of in special bags or bins. After each chemotherapy session, the drugs may remain in your body for up to a week. This depends on the type of drugs used. The drugs are then released into urine, faeces and vomit. They could also be passed to other body fluids such as saliva, sweat, semen or vaginal discharge, and breast milk. Some people having chemotherapy worry about the safety of family and friends. There is little risk to visitors, including children, babies and pregnant women, because they aren’t likely to come into contact with any chemotherapy drugs or body fluids.
  21. Content Article
    This report from the Action against Medical Accidents (AvMA), authored by Dr David Cousins, reveals serious delays in NHS trusts implementing patient safety alerts, which are one of the main ways in which the NHS seeks to prevent known patient safety risks harming or killing patients. The report identifies serious problems with the system of issuing patient safety alerts and monitoring compliance with them. Compliance with alerts issued under the now abolished National Patient Safety Agency and NHS England are no longer monitored – even though patient safety incidents continue to be reported to the NHS National Reporting and Learning System.  The report recommends a number of urgent actions to address these risks to patients.
  22. News Article
    The failure to pass a damning report about a scandal-hit hospital trust to the care watchdog has been criticised by the man who led the inquiry into baby deaths at Morecambe Bay. On Friday, a coroner ruled that the death of baby Harry Richford in 2017 resulted from neglect in the maternity unit of East Kent Hospitals NHS Trust. A report by the Royal College of Obstetrics and Gynaecologists (RCOG) completed a year earlier had warned of issues that contributed to Harry’s death, including senior doctors not showing up for their shifts. However, the report was never passed on to the Care Quality Commission (CQC), despite the recommendation of the Morecambe Bay inquiry in 2015 that relevant external reviews should be passed on to the watchdog. Bill Kirkup, who chaired the inquiry into deaths of mothers and babies at Furness General Hospital in Barrow-in-Furness, told The Independent: “When there is sufficient concern about a service to prompt an external review, the report must be available immediately to those responsible for assuring the quality of the service. That was the reason for the recommendation of the Morecambe Bay investigation, and it is disappointing that the Care Quality Commission apparently had no sight of this report until now.” Read full story Source: 26 January 2020
  23. Content Article
    The Health Foundation commissioned the Institute of Health Equity to examine progress in addressing health inequalities in England, 10 years on from the landmark study Fair Society, Healthy Lives (The Marmot Review). Led by Professor Sir Michael Marmot, the review explores changes since 2010 in five policy objectives: giving every child the best start in life enabling all people to maximise their capabilities and have control over their lives ensuring a healthy standard of living for all creating fair employment and good work for all creating and developing healthy and sustainable places and communities. For each objective the report outlines areas of progress and decline since 2010 and proposes recommendations for future action, setting out a clear agenda at a national, regional and local level. 
  24. Content Article
    The government response to the care failures at the Mid Staffordshire NHS Foundation Trust led to the policy imperative of ‘regular interaction and engagement between nurses and patients’ in the NHS. The pressure on nursing to act resulted in the introduction of the US model, known as ‘intentional rounding’, into nursing practice. This is a timed, planned intervention that sets out to address fundamental elements of nursing care by means of a regular bedside ward round. This study, published by Health Services and Delivery Research, aimed to examine what it is about intentional rounding in hospital wards that works, for whom and in what circumstances.
  25. Content Article
    This study, published in Health Services and Delivery Research, identified five key themes that help explain how patient experience data work could lead to quality improvements in acute hospital trusts.
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