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Found 479 results
  1. Content Article
    This stocktake by NHS Confederation highlights insights from medicines optimisation forums on the experience of ICS medicines optimisation so far: the opportunities that exist, the barriers experienced, the support that is needed, and what the vision for medicines optimisation could achieve.
  2. Content Article
    Probiotics are used for both generally healthy consumers and in clinical settings, but there have been adverse events as a result of their consumption. Concise and actionable recommendations on how to use probiotics safely and effectively are therefore needed, especially as increasing numbers of new strains and products come to market, and probiotic use increases in vulnerable populations. The International Scientific Association for Probiotics and Prebiotics convened a meeting to discuss and produce evidence-based recommendations on potential acute and long-term risks, risks to vulnerable populations, the importance for probiotic product quality to match the needs of vulnerable populations and the need for adverse event reporting related to probiotic use. This paper presents these recommendations to guide the scientific and medical community on judging probiotic safety.
  3. Content Article
    The Global Patient Safety Action Plan was formally adopted at the World Health Assembly on 28 May 2021. It provides a 10-year roadmap and actions to work towards its vision of a world in which no one is harmed in healthcare and every patient receives safe and respectful care. This report provides a snapshot of progress made in achieving the strategic objectives and strategies of the global action plan based on the WHO Member State survey coordinated by the secretariat. This interim report will be replaced by a final Global Patient Safety Report 2023 later in the year.
  4. Content Article
    In February 2023, the government commissioned an independent review to offer recommendations on how to resolve key challenges in conducting commercial clinical trials in the UK and transform the UK commercial clinical trial environment. The review sets out 27 recommendations, including both priority actions to progress in 2023 and longer-term ambitions for UK commercial clinical trials. The review was conducted by Lord James O’Shaughnessy, Senior Partner at consultancy firm Newmarket Strategy, Board Member of Health Data Research UK (HDR UK) and former Health Minister, who was appointed as review Chair. During the review, Lord O’Shaughnessy consulted closely with industry and a wide range of stakeholders across the UK clinical trials sector. The government response welcomes all recommendations from the review, in principle, and makes 5 headline commitments backed by £121 million. An implementation update, setting out progress made against these commitments and a comprehensive response to the remaining recommendations, will be published in the autumn.
  5. Content Article
    This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the investigation into the death of Elizabeth Dixon in respect of the failures of care she received from the NHS.
  6. News Article
    The government has committed “in principle” to creating a public repository of consultants’ practice details that sets out their practising privileges and key performance data, including how many times they have performed a particular procedure and how recently. The commitment was part of the response to an independent national inquiry, launched in 2017, following the malpractice of rogue surgeon Ian Paterson. Now serving a 20 year prison sentence, Paterson had undertaken numerous unnecessary breast operations in both private and NHS practice, causing harm to hundreds of patients. The inquiry, published February 2020, found that Paterson was able to harm patients over more than decade because of the “dysfunctional” healthcare system. It outlined 17 recommendations for the government to respond to, mainly focusing on improving oversight and governance, as well as ensuring greater scrutiny of private providers. At the time, some saw the report as a missed opportunity to tackle the systemic patient safety risks of the private hospital business model, such as financial incentives which can lead to overtreatment. Read full story Source: BMJ, 17 December 2021
  7. News Article
    The government has rejected advice from an independent inquiry into the actions of disgraced surgeon Ian Paterson to suspend all healthcare professionals who are suspected of posing a risk to patient safety. The Department of Health and Social Care today published its response to 15 recommendations from the inquiry, which found Mr Paterson, jailed for 20 years in 2017 for 17 offences of wounding with intent, may have conducted up to 1,000 botched and unnecessary operations over a 14-year period. Of its 15 recommendations, the DHSC accepts nine in full, five in principle, rejects one entirely and there is another further point which it is keeping under review. In particular, the inquiry panel members recommended that when a hospital investigates a healthcare professional’s behaviour, including the use of an HR process, any perceived risk to patient safety should result in the suspension of that healthcare professional. DHSC chiefs said they agree practice exclusions and restriction can be necessary, and in some cases immediate exclusion is an appropriate response while an investigation is ongoing. But they added: “However, we do not believe it would be fair or proportionate to impose a blanket rule to exclude practitioners in such cases. “Such a step may inadvertently cause a chilling effect, dissuading healthcare professionals from raising concerns and negatively impacting patient safety.” Read full story (paywalled) Source: HSJ, 16 December 2021
  8. News Article
    In a Letter to the Editor published in The Times yesterday, the All Party Parliamentary Group on First Do No Harm Co-Chair Baroness Julia Cumberlege argues in favour of the work of the Independent Medicines and Medical Devices Safety (IMMDS) Review and its report 'First Do No Harm'. "Inquiries are only as good as the change for the better that results from their work." Read full letter (paywalled) Source: The Times, 5 January 2021
  9. News Article
    NHS guidance ‘too long to read,’ say hospital staff as safety watchdog exposes systemic risks to patients. The Healthcare Safety Investigation Branch (HSIB) revealed some NHS staff had admitted not reading official guidance on how to avoid the ‘never event’ error as part of a new report identifying deeper systemic problems that it said left patients at an increased risk. The independent body warned patients across the NHS remained vulnerable to being injured or even killed by the error that keeps happening in hospitals despite warnings and safety alerts over the last 15 years. HSIB launched a national investigation into the problem of misplaced nasogastric (NG) tubes after a 26-year-old man had 1,450ml of liquid feed fed into his lungs in December 2018 after a bike accident. The patient recovered but the error was not spotted, even after an X-ray. Read full story Source: The Independent, 17 December 2020
  10. News Article
    All NHS trusts in England have been given a deadline of Monday to enact safety improvements in maternity care amid Shropshire's baby deaths scandal. Heath chiefs have told hospitals they must have the 12 "urgent clinical priorities" in place by 17:00 GMT. The move is to address "too much variation" in outcomes for families. It comes during a probe into the maternity care of more than 1,800 families in Shropshire. The inquiry, launched amid concerns of repeated failings at Shrewsbury and Telford Hospital NHS Trust (SaTH), focuses on the experience of 1,862 in total, and includes instances of infant fatality. An interim report published last week found poor care over nearly two decades had harmed dozens of women and their babies. The report called for seven "essential actions" to be implemented at maternity units across England. But that has since been transformed into 12 clinical tasks, including giving women with complex pregnancies a named consultant, ensuring regular training of fetal heart rate monitoring, and developing a proper process to gather the views of families. The directions are revealed in a letter in which NHS England says there is "too much variation in experience and outcomes for women and their families". Read full story Source: BBC News, 15 December 2020
  11. News Article
    Strong leadership, challenging poor workplace culture, and ringfencing maternity funding are key to improving safety. That’s the message from two leading Royal Colleges as they respond to the independent review of maternity services at Shrewsbury and Telford NHS Trust led by Donna Ockenden. The RCOG and the Royal College of Midwives (RCM) have today welcomed the Ockenden Review and its recognition of the need to challenge poor working relationships, improve funding and access to multidisciplinary training and crucially to listen to women and their families to improve learning and to ensure tragedies such as those that have happened at Shrewsbury and Telford NHS Trust never occur again. The Colleges have said that the local actions for learning and the immediate and essential actions laid out in this report must be read and acted upon immediately in all Trusts and Health Boards delivering maternity services across the UK. Commenting, Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, said: “This report makes difficult reading for all of us working in maternity services and should be a watershed moment for the system. Reducing risk needs a holistic approach that targets the specific challenges of fetal monitoring interpretation and strengthens organisational functioning, culture and behaviour." Read press release Source: RCOG, 10 December 2020
  12. News Article
    The death of a premature baby in 2001 led to a "20-year cover-up" of mistakes by health workers, an independent inquiry has found. Elizabeth Dixon, from Hampshire, died due to a blocked breathing tube shortly before her first birthday. The government, which ordered the inquiry in 2017, said the mistakes in her care were "shocking and harrowing". The inquiry report by Dr Bill Kirkup said some of those involved had been "persistently dishonest". Elizabeth, known as Lizzie, died from asphyxiation after suffering a blockage in her tracheostomy tube while under the care of a private nursing agency at home. Dr Bill Kirkup, who was appointed by the government to review the case, said her "profound disability and death could have been avoided". He said: "There were failures of care by every organisation that looked after her, none of which was admitted at the time, nor properly investigated then or later." "Instead, a cover-up began on the day that she died, propped up by denial and deception." Read full story Source: BBC News, 26 November 2020 Patient Safety Learning's statement on the Dixon Inquiry report
  13. News Article
    Expectant mothers are being warned about potentially confusing guidance on consuming caffeine while pregnant, as research suggests energy drinks could have potentially deadly consequences for their babies. A new report by Tommy’s Maternal and Fetal Health Research Centre claims to have established a 27 per cent rise in the risk of stillbirth for each 100mg of caffeine consumed. Researchers compared stillbirths to ongoing pregnancies among 1,000 women across 41 hospitals from 2014 to 2016 as well as interviewing women about their consumption of caffeinated drinks. They adjusted for demographic and behavioural factors, such as age and alcohol consumption, to determine whether stillbirth was linked to caffeine. One in 20 women were found to have increased their caffeine intake while pregnant in spite of evidence some caffeinated drinks put babies lives at risk. However, experts say that calculating precise intake can be difficult, and guidance on limiting caffeine is not consistent The NHS recommends pregnant women keep their daily caffeine intake below 200mg whereas the World Health Organization stipulates 300mg as the safe amount to consume. Tommy’s, a leading baby charity, called for both the NHS and the World Health Organisation to rethink such guidelines, but refused to outline a specific limit - saying it was the NHS and World Health Organisation’s responsibility to decide the recommendations in light of their new study. Professor Alexander Heazell, an author of the study, said: “Caffeine has been in our diets for a long time, and, as with many things we like to eat and drink, large amounts can be harmful – especially during pregnancy. It’s a relatively small risk, so people shouldn’t be worried about the occasional cup of coffee, but it’s a risk this research suggests many aren’t aware of." Read full story Source: The Independent, 18 November 2020
  14. News Article
    Lifting lockdown must be handled better this time round to avoid a surge in Covid that could overwhelm the NHS, doctors say. The British Medical Association has published a blueprint for how it thinks England should proceed with any easing. It includes replacing the "rule of six" with a two-households restriction to reduce social mixing and banning travel between different local lockdown tiers. Government has yet to say if or exactly how England will exit on 2 December. It will decide next week, based on whether cases have fallen enough and how much strain hospitals are under. Read full story Source: BBC News, 18 November 2020
  15. News Article
    Hospital food standards are set to be put on a statutory footing, with trusts held to account by the Care Quality Commission, according to the chair of a government-commissioned review. Philip Shelley, who led the review into hospital food following seven patient deaths from listeria last year, told HSJ the incident was an “absolute condemnation” and that trusts must use the review to improve food standards. The review, published last month, also calls for capital investment to refurbish hospital kitchens and replace old and inefficient equipment, which is likely to cost several hundreds of millions of pounds. The government has accepted the recommendations and Mr Shelley will lead a group of experts to oversee the review’s implementation across the NHS during the next three years. Among the review’s recommendations is the “enhanced role” for the CQC when it inspects NHS trusts. The review states there is currently “very little evidence to prove that food and drink standards are being monitored closely enough” and it therefore recommends placing the standards on a statutory footing from which the CQC can hold trusts to account. Read full story (paywalled) Source: HSJ, 17 November 2020
  16. News Article
    An NHS hospital where a woman bled to death in childbirth has been given an "urgent" deadline to keep patients at its maternity unit safe. A letter seen by the BBC reveals the Care Quality Commission (CQC) found unsafe staffing levels at the unit at Basildon Hospital throughout August. The CQC said the trust that runs it had until next Monday to implement appropriate measures. The trust said it had a "robust improvement plan in place". The seven-page document, sent by the CQC on 7 October, puts the Mid and South Essex NHS Foundation Trust on notice that it has to "implement an effective governance system", among other measures. Consequences for missing the deadline were not stated, but the CQC said it was using its powers under the Health and Social Care Act to impose conditions on the trust's registration. The Act does allow the CQC to temporarily close health services. Read full story Source: BBC News, 3 November 2020
  17. News Article
    Following a damning report by the Care Quality Commission (CQC), the East of England Ambulance Service NHS Trust (EEAST) has been placed into special measures. It comes after inspectors uncovered a culture of bullying and sexual harassment at the trust. As a result of the decision, EEAST will receive enhanced support to improve its services. A statement from NHS England and NHS Improvement outlined that the Trust would be supported with the appointment of an improvement director, the facilitation of a tailored ‘Freedom to Speak Up’ support package, the arrangement of an external ‘buddying’ with fellow ambulance services and Board development sessions. This follows a CQC recommendation to place the trust in special measures due to challenges around patient and staff safety concerns, workforce processes, complaints and learning, private ambulance service (PAS) oversight and monitoring, and the need for improvement in the trust’s overarching culture to tackle inappropriate behaviours and encourage people to speak up. Ann Radmore, East of England Regional Director said, “While the East of England Ambulance Service NHS Trust has been working through its many challenges, there are long-standing concerns around culture, leadership and governance, and it is important that the trust supports its staff to deliver the high-quality care that patients deserve." “We know that the trust welcomes this decision and shares our commitment to reshape its culture and address quality concerns for the benefit of staff, patients and the wider community.” Read full story Source: Bedford Independent, 19 October 2020
  18. News Article
    Endometriosis care across the UK needs urgent improvement and diagnosis times need to be cut in half, a report by MPs says. It found an average wait for a diagnosis was eight years and that has not improved in more than a decade. Endometriosis affects one in 10 women in the UK and causes debilitating pain, very heavy periods and infertility. Nadine Dorries, minister for women's health, said awareness was increasing but there was still a long way to go. More than 10,000 people took part in the All-Party Political Group inquiry which found that 58% of people visited the GP more than 10 times before diagnosis and 53% went to A&E with symptoms before diagnosis. The majority of people also told MPs their mental health, education and careers had been damaged by the condition. About 90% said they would have liked access to psychological support but were never offered it, with 35% having a reduced income due to endometriosis. Helen-Marie Brewster, 28, from Hull, has been told by doctors that her only remaining treatment option is a full hysterectomy. She had symptoms throughout secondary school but was only diagnosed when she left education. "GPs ask me to explain to them what endometriosis is, because they don't know. They're the ones who are meant to help." "Last year I visited the A&E department 17 times trying to find help and pain relief for this condition, even for just a few days so I can keep going. The wait time for diagnosis is so long that in that time it's spreading and doing more damage the longer it is left untreated... We can't carry on like this." Read full story Source: BBC News, 19 October 2020 Read press release
  19. News Article
    The government has been told it is ‘not sustainable’ to continue to delay its response to a major review on patient safety as ‘babies are still being damaged’. The Independent Medicines and Medical Devices Safety Review spoke to more than 700 people, mostly women who suffered avoidable harm from surgical mesh implants, pregnancy tests and an anti-epileptic drug, and criticised “a culture of dismissive and arrogant attitudes” including the “unacceptable labelling of many symptoms as “attributable to ‘women’s problems’”. The review’s author Baroness Julia Cumberlege told HSJ that “time is marching on” for the Department of Health and Social Care to implement the recommendations of her July report, which include setting up a new independent patient safety commissioner. The Conservative peer said pressure was building on government to adopt the findings of the review, since it had been endorsed by Royal Colleges and has already been adopted by the Scottish government. She said the government had given “evasive” answers in parliament on the issue. In an exclusive interview with HSJ, Baroness Cumberlege said: There is a crowded field of regulators but “there’s a void” for a service that listens and responds to patients’ safety concerns. She feels “diminished” that women’s concerns are still being dismissed by clinicians, but said young doctors are a cause for hope. She is “very optimistic” report will be implemented – but the NHS has to have the will to make changes. Read full story (paywalled) Source: HSJ, 13 October 2020
  20. News Article
    NICE will speed up patients’ access to the latest and most effective treatments, and dynamic guideline recommendations will be put in the hands of healthcare professionals more quickly under plans unveiled by NICE in its 5-year strategy launched on Monday (19 April 2021). NICE will transform key elements of its approach to ensure efficiency and speed while maintaining robust, trusted methods. The COVID-19 pandemic has reaffirmed the need to place science and evidence at the heart of health and care decision making and improve outcomes for all patients across the healthcare system. Ensuring the organisation is more proactive and engaged with the life science industry earlier in the innovation pathway will allow patients to access new treatments faster. Professor Stephen Powis, NHS England medical director, said: “Since its creation the NHS has always adapted quickly in response to new innovations, from world first transplants to more recently new cancer drugs and treatments during the pandemic which are enabling patients to get the care they need from the comfort of their own home." “At the heart of the NHS Long Term Plan is a commitment to rollout the latest treatments to patients as soon as they are approved and so we welcome NICE’s new strategy to speed up approvals of the latest and most effective treatments.” Read full story Source: NICE, 19 April 2021
  21. News Article
    New guidance from health officials on the treatment of chronic pain could be devastating for women already struggling to get doctors to take their pain seriously, write Sarah Graham, The guidelines, published last week by the National Institute for Health and Care Excellence (NICE), say that patients suffering from chronic pain that has no known underlying cause (known as chronic primary pain) should not be prescribed painkillers. Instead, it suggests, these patients should be offered exercise, antidepressants, talking therapies and acupuncture. This has huge implications for the future treatment of anyone living with unexplained chronic pain – the majority of whom are women – and runs the risk of patients being viewed as hysterical until proven otherwise. Read full story Source: iNews, 7 April 2021
  22. News Article
    A previously secret report into children’s services at a scandal-hit NHS hospital has revealed concerns over the safety of services including care of seriously ill babies were raised with managers back in 2015. A report by the Royal College of Paediatrics and Child Health (RCPCH) raised serious concerns over children’s services at East Kent Hospitals University Trust in 2015 including senior consultants refusing to work beyond 5pm and a shortage of nurses and junior doctors. It also found the neonatal intensive care unit was being staffed by general paediatric doctors instead of specialist neonatal consultants. The confidential report was given to The Independent and posted on the trust’s website this week after being mentioned in the terms of reference for an independent inquiry examining dozens of baby deaths at the trust. It had never been published by the trust, which three years later had its children’s services rated inadequate. A second major report by the Royal College of Obstetricians and Gynaecologists in 2016 highlighted concerns that were not acted on and later featured in the avoidable death of baby Harry Richford, in 2017 which sparked the scandal into dozens more deaths and brain injuries. Bill Kirkup, who is leading the inquiry into East Kent’s maternity services, previously recommended Royal College reviews be registered with the CQC and shared openly by NHS trusts. In its report, the RCPCH said there was “resistance from some consultants to work extended hours” across the trust’s different services with signs of clinicians worked in silos at the different hospitals run by the trust. It warned that paediatric consultants were “spread too thinly across the service” and consultants were providing specialist clinics based on their interests rather than local need. There was “insufficient middle grade doctors to cover both sites” and there were “too few skilled nurses on the wards.” Read full story Source: The Independent, 24 March 2021
  23. News Article
    The Royal College of GPs has called for an independent review of the link between poor Care Quality Commission (CQC) inspection ratings and the ethnicity of GP partners. The college called for the regulator to commission the work in particular for those rated “requires improvement” and “inadequate” over the past five years, including practices which have since closed down. This will assess “if there is an association between the outcomes of inspections and ethnicity or country of qualification of the GP partners”, according to the RCGP. In addition, the RCGP wants to work with the regulator to discuss how the availability and transparency of this information can be improved to ensure minority ethnic GPs’ experiences are heard. Minority ethnic GPs shared their experiences of CQC inspections at an RCGP council meeting last week, where council members voted to support the above actions. Dr Howsam said: “The college’s BAME action plan commits us to delivering positive change for all our Black, Asian and minority ethnic members and we will continue to work constructively with the CQC towards an improved system of inspection that is supportive of GPs and keeps patients safe as we move away from the immediate crisis of the pandemic and into recovery.” Read full story (paywalled) Source: HSJ, 1 March 2021
  24. News Article
    Pregabalin may be associated with serious breathing problems in patients with compromised respiratory systems, according to a drug safety alert from the medicines regulator. Elderly patients, patients with neurological disease, renal impairment and those who are taking antidepressant medication are also at increased risk of breathing problems from the drug, the Medicines Healthcare Regulatory Agency (MHRA) said (18 February). Pregabalin is a medication that has increasingly been prescribed to treat chronic pain, however, it is also used to treat epilepsy, fibromyalgia, restless leg syndrome, and generalised anxiety disorder. The use of pregabalin combined with central nervous system depressants such as opioids has been associated with an increased risk of respiratory failure, coma, and deaths since 2018, said the MHRA. However, a recent review of the safety of the drug has found that the use of pregabalin alone can also cause ‘severe’ respiratory depression. "The review identified a small number of worldwide cases of respiratory depression without an alternative cause or underlying medical conditions. In these cases, respiratory depression had a temporal relationship with the initiation of pregabalin or dose increase. Other cases were noted in patients with risk factors or underlying medical history. The majority of cases reviewed were reported in elderly patients," the alert said. Health professionals have been advised to consider adjustments in dose or dosing regimen are necessary for patients at higher risk of respiratory depression. The alert also told them to report suspected adverse drug reactions associated with the use of pregabalin via the Yellow Card website. Existing advice asks healthcare professionals to check the patient for a history of drug abuse before prescribing pregabalin and to observe patients who have been prescribed the drug for signs of drug abuse and dependence. Read full story Source: Pulse, 23 February 2021
  25. News Article
    Failures to follow national guidelines to prevent group B Strep infections in newborn babies is leading to a postcode lottery of care and opportunities to stop deadly infections being missed, a new report has found. Nearly 90% of hospitals in the UK are not using the recommended test for GBS carriage – which costs around £11- despite clear guidance issued by the Royal College of Obstetricians and Gynaecologists (RCOG) and Public Health England (PHE) that the test can significantly decrease false-negative results. Group B Strep is the UK’s most common cause of severe infection in newborn babies, causing sepsis, pneumonia, and meningitis. Approximately 800 babies a year in the UK develop group B Strep infection in their first 3 months of life, 50 babies will die, with another 70 survivors left with life-changing disabilities. Most of these infections could be prevented. Only a tiny number of NHS Trusts are following the key new recommendations around giving pregnant women information on group B Strep, offering testing to some pregnant women, and following Public Health England guidelines on testing for group B Strep. As a result, pregnant women face a postcode lottery, potentially receiving significantly different care from recommended practice. Read full story Source: Group B Strep Support, 1 February 2021
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