Search the hub
Showing results for tags 'Recommendations'.
Found 479 results
-
News ArticleAt least seven so-called NHS “never events” should be reclassified because the health service has failed to put in place effective measures to stop them from repeatedly happening, safety experts have said. The independent Healthcare Safety Investigation Branch (HSIB) said NHS England should remove the never event incidents from the list of 15 it requires hospitals to report, because they are not “wholly preventable” and the NHS has not adequately recognised the systemic risks that mean they keep happening. The errors include examples such as a 62-year-old man having the wrong hip replaced during surgery and a nine-year-old girl who was given a drug by injection that should have been given by mouth. Other incidents included a woman who had a vaginal swab left inside her following the birth of her first child and a 26-year-old man who had a feeding tube accidentally inserted into his lung rather than his stomach. In a new report, investigators from HSIB carried out a detailed analysis of seven incidents it has investigated which account for the majority of never events recorded by NHS hospitals in 2018-19. NHS England claims there are steps hospitals can take that mean the errors should never happen but HSIB says many of the steps are administrative, such as a checklist, and do not fully take into account the environment staff work in, the nature of the errors or how they happen. Read full story Source: The Independent, 21 January 2021
-
News ArticleIn July last year, the Independent Medicines and Medical Devices Safety Review – chaired by Baroness Cumberlege— published its landmark report, First Do No Harm. It followed a two-year review of harrowing patient testimony and a large volume of other evidence concerning three medical interventions: Primodos, sodium valproate and pelvic mesh. Yesterday, in a written statement to Parliament, the Minister for Patient Safety, Suicide Prevention and Mental Health, Nadine Dorries, gave an update on the government’s response to the recommendations of the Cumberlege Review. In an article in The Times today, Baroness Cumberlege welcomes that the government has now accepted the need for a patient safety commissioner for England and the amendment to the Medicines and Medical Devices Bill, which is being considered in the House of Lords today, which she hopes "will swiftly become law". However, she also states that "... a full response to the review's is still outstanding 6 months after publication. Action is urgently needed to ensure we help those who have already suffered and reduce the risk of harm to patients in future". Read full story (paywalled) Source: The Times, 12 January 2021
-
News ArticleA third of stillbirths at two south Wales hospitals could have been prevented with better care or treatment, an investigation has concluded. It emerged two years ago that more than 60 women suffered the heartbreak of a stillbirth at at the Royal Glamorgan, Llantrisant, and Prince Charles Hospital, Merthyr Tydfil, and that many of these were never reported or investigated. An independent panel set up by the Welsh Government to oversee improvements in these maternity units has now concluded that many of these babies could have been saved. It looked at whether the care provided to women and their babies between January 2016 and September 2018 fell below the standards expected. The failures were split into different levels of severity, known in the report as "modifiable factors". Their investigation looked at 63 stillbirths between January 1, 2016, and September 30, 2018, and discovered that 21 (33%) of them had at least one "major modifiable factor", meaning the stillbirth could potentially have been avoided. More than half (59%) of the 63 had at least one "minor modifiable factor" while in three-quarters (76%) of them "wider learning" was required. In only four of the 63 stillbirths the panel found no modifiable factors. The panel also discovered that "areas for learning" were identified in 59 of the 63 episodes of care reviewed. Read full story Source: Wales Online, 5 October 2021 Read report
-
News Article
Pandemic changes affected maternity care for women who had stillbirths
Patient Safety Learning posted a news article in News
Changes to maternity services during the pandemic, including the mandatory redeployment of midwives and doctors to care for infected patients, may have affected the care given to women who had stillborn babies, a Healthcare Safety Investigation Branch (HSIB) investigation has found. The safety watchdog launched an investigation after the number of stillbirths after the onset of labour increased between April and June 2020. During the three months there were 45 stillbirths compared to 24 in the same period in 2019. The HSIB launched a probe examining the care of 37 cases. Among its findings the watchdog said staffing levels were affected because of the NHS response to the pandemic. In its report it said this “influenced normal work patterns and the consistency and availability of clinicians.” As an example, in one maternity unit the staffing numbers were short by three midwives due to sickness and redeployment. In another consultant presence was reduced overnight. During the pandemic both the Royal College of Midwives and the Royal College of Obstetricians criticised NHS trusts for redeploying maternity staff when mothers continued to need services regardless of the pandemic. HSIB said none of the women in its report were recorded as having the virus, but it found the pressures and changes as a result of the pandemic may have affected the care they received. The study stressed that the proportion of consultations undertaken remotely was not known and "the impact of remote consultations is not clear from this review". Read full story Source: The Independent, 16 September 2021 -
News Article‘Very heavy-handed, laborious and expensive’ inspections ‘have not been the right way’ of regulating hospitals, according to the Care Quality Commission’s (CQC) former chair. Speaking at a Royal Society of Medicine event on Wednesday, Lord David Prior, who is now the chair of NHS England, said “very few” physicians will have improved their work after reading a report from the regulator. He added that there is a role for the CQC to move in when “things are going wrong” although he is “sceptical” the regulator can actually drive improvement in hospitals. Lord Prior said: “I am highly sceptical as to whether or not CQC or any regulator can really drive improvement and drive the top hospitals to make them better. “And certainly I think there’ll be very few physicians who will say that their clinical work has improved as a result of reading a CQC report. “I think the sadness I have about CQC is that we have not been able, or it has not been able, to develop a series of predictive metrics that could replace these very heavy handed, very laborious and very expensive visits that we used to do.” Read full story (paywalled) Source: HSJ, 9 September 2021
-
News Article
New study develops a 'core outcome set' to make new surgical techniques safer
Patient-Safety-Learning posted a news article in News
A new study has been published focusing on surgical innovation and how it could be made safer. The research set out to develop a 'core outcome set', an agreed minimum set of outcomes to measure and report for safe surgical techniques in all audits, research, and clinical practice. The study, co-led by Dr Kerry Avery, a Senior Lecturer at the University of Bristol and NIHR Bristol Biomedical Research Centre (BRC) has said "It may surprise many people to learn that surgical procedures haven’t traditionally been subject to the kind of regulation we see in other areas of medicine. But to ensure safety and improve efficiency, a core outcome set is an important step". Read full story. Source: University of Bristol, 13 July 2021 -
EventuntilThis Patient Information Forum webinar will share the key findings of our survey on maternity decisions. Our expert panel will share recommendations to help empower women to make informed decisions about the induction of labour. Open to members and non-members. Register
-
Event
Priorities for NICE in health & social care
Patient Safety Learning posted an event in Community Calendar
untilThis Westminister Forum conference will discuss the priorities for NICE within health and social care following the publication of the NICE Strategy 2021 to 2026: Dynamic, Collaborative, Excellent earlier this year, which sets out NICE’s vision and priorities for transformation over the next five years, including: rapid and responsive evaluation of technology, and increasing uptake and access to new treatments flexible and up-to-date guideline recommendations which integrate the latest evidence and innovative practices improving the effective uptake of guidance through collaboration and monitoring providing scientific leadership through driving research and data use to address gaps in the evidence base. It will be an opportunity to discuss the role of NICE in a changing health and social care landscape following the pandemic, as well as the opportunities presented for guidance to keep pace with the development of integrated care, innovative treatments, and data-driven research and technology. Sessions in the agenda include: key priorities for delivering the future vision and transformation of NICE going forward developing evidence-based guidelines in a changing health and social care landscape: flexibility, patient engagement, collaboration, and effective implementation lessons learned from the use of rapid guidelines in response to COVID-19 the opportunities presented for improving the utilisation of data and the future for data-driven evidence and guidelines taking forward new approaches to evaluating health technology - speed, cost-effectiveness, and engagement priorities for industry engagement and improving value and access to innovative health technology supporting the development and adoption of innovative medicines the role of managed access and funding in delivering improved patient access to innovation opportunities for using research and data analytics to meet gaps in the evidence base. Register -
Event
Veracuity: Innovative approaches to drug safety
Sam posted an event in Community Calendar
Veracuity was conceived out of a recognition that the practice of pharmacovigilance is performed suboptimally. That is because it relies entirely on a voluntary reporting system – one in which consumers and healthcare professionals must devote considerable energy if they were so inclined to notify somebody about a side effect they attribute to a bio-pharmaceutical product. Adverse event reporting is infrequent and cumbersome because stakeholders are only vaguely aware of their responsibility and the current system is neither easy nor fast to use. Nor does it provide reporters with any immediate helpful feedback. With only a very small percentage of adverse drug events ever reaching the attention of manufacturers or regulators, it is easy to conclude that the medical community and the public may be wholly unaware of tremendous risks and liabilities that may be attributed to drug products. This workshop allows participation in insightful conversation on the future of our industry. Program: Fishbein, J: Introduction and closing remarks. Barrett, CP: Implementation of Post-marketing Risk Management Commitment. Laugel, I: The future of pharmacovigilance with the use of artificial intelligence sounds good. Marschler, M: The use of pharmacogenomic methodologies in the pharmacovigilance evaluation of medicinal products. This webinar meets two times. Fri, Jan 29, 2021 12:00 PM - 2:00 PM GMT Fri, Jan 29, 2021 6:00 PM - 8:00 PM GMT Register 2021-workshop-flier.pdf -
Content Article
In this blog Patient Safety Learning considers the safety concerns highlighted by a recent report by the Healthcare Safety Investigation Branch (HSIB) into the administration of high-strength insulin from pen devices in hospitals. This blog argues that without specific and targeted recommendations to improve patient safety in this area, patients will continue to remain at risk from similar incidents. -
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to help improve patient safety in relation to administering high-strength insulin from a pen device to patients with diabetes in a hospital setting. As its ‘reference case’, the investigation uses the experience of Kathleen, a 73 year old woman with type 2 diabetes who received two recognised overdoses of insulin while she was in hospital. On both occasions she became hypoglycaemic, received medical treatment, and recovered. Patient Safety Learning has published a blog reflecting on some of the key patient safety issues highlighted in this report.
-
Content ArticleIn this editorial, published in the British Journal of Hospital Medicine, Dr Paul Grime reviews the report 'Mind the implementation Gap: The persistence of avoidable harm in the NHS', which calls on the government, parliamentarians and NHS leads to take action to address the underlying causes of avoidable harm in healthcare.
- Posted
- 1 comment
-
- (and 7 more)
-
Content ArticleICS Futures is a roundtable series held by the Public Policy Projects ICS Network and chaired by Matthew Swindells, Chair of the North West London Acute Collaborative and former Deputy CEO of NHS England. The Network is made up of senior leaders from across the health and care sectors. The Network convened for three Chatham House roundtables between 16 May and 17 June 2022. The objective of discussions was to highlight challenges and opportunities in integrated care based on real-world examples, to scale best practice and provide ongoing practical advice for system leaders and care providers. Thoughts were also given on key legislative developments, with some national policy recommendations highlighted. This document summarises the key findings and recommendations from each meeting. It is not an exhaustive description of health and care system leaders’ views but rather provides a snapshot into the thoughts and concerns of a specific cohort of senior stakeholders
-
Content ArticleThe maternity services at the Royal Devon and Exeter NHS Foundation Trust share their infographic which informs their staff of the 15 Immediate and Essential Actions from the Ockenden report and the action plan needed to implement these.
-
Content ArticleThis article highlights two written questions tabled in the House of Commons relating to recommendations of the Independent Medicines and Medical Devices Safety (IMMDS) Review concerning surgical mesh implants.
-
Content ArticleDerek Richford shares Harry's Story from last year's HSJ Patient Safety Congress. Derek is grandfather of Harry Richford who died seven days after an emergency delivery at East Kent Hospitals Trust. Derek is joined by Donna Ockenden, Chair of the Independent review of maternity services at Shrewsbury & Telford Hospital, and Sarah-Jane Marsh, Chair of NHS England's Maternity transformation programme, in the 'Actioning recommendations from the Ockenden report' session at the Congress.
-
Content ArticleThe Belfast Health Trust failed to intervene quickly enough in the practice of a doctor which led to Northern Ireland's largest ever patient recall, the Independent Neurology Inquiry has found. More than 5,000 former patients of neurologist Michael Watt were invited to have their cases examined for possible misdiagnoses. Among the conditions being treated were stroke, Parkinson's disease and multiple sclerosis (MS). The inquiry found "numerous failures". The Independent Neurology Inquiry concluded that the combined effect of the failures ensured that patterns in the consultant's work were missed for a decade.
-
Content ArticleThis study by Sir Robert Francis QC looks at options for a framework for compensation for the victims of the infected blood tragedy. Sir Robert will give evidence about his work to the Infected Blood Inquiry in July. Before then, it is important that the Inquiry, and recognised legal representatives of its infected and affected core participants, have an opportunity to consider his work.
-
Content Article
The Messenger review is a con (HSJ, 9 June 20220
Patient Safety Learning posted an article in National/Governmental
The Messenger review may be full of well-meaning and often well-judged sentiments – but the recommendations were either peripheral (a five-day course for middle managers) or so vague as to be virtually worthless (proposals to make equality, diversity and inclusion everyone’s business). Lord Rose, Sir Ron Kerr, Tom Kark and indeed Sir Robert Francis all made similar recommendations about ensuring the quality of NHS leadership, but the Messenger review has a slightly different thrust. It aimed to review health and social care leadership. By this measure, the review has failed to do what it set out to achieve. Social care and indeed primary care are an afterthought, with the focus on the acute sector, writes Alastair McLellan and Annabelle Collins for the HSJ. -
Content ArticleIn October 2021 the government announced a review into leadership across health and social care, led by former Vice Chief of the Defence Staff General Sir Gordon Messenger and supported by Dame Linda Pollard, Chair of Leeds Teaching Hospital Trust. The results of the review have now been published and recommendations made.
-
Content ArticleMore must be done to avoid harm to patients while waiting for treatment. The backlog for planned care is one of the biggest challenges for the NHS in Wales. Waiting times targets have not been met for many years. This backlog has been made much worse due to the pandemic. In February 2022, there were nearly 700,000 patients waiting for planned care, a 50% increase since February 2020. Over half of the people currently waiting have yet to receive their first outpatient appointment which means that they may not know what they’re suffering from and their care cannot be effectively prioritised. Modelling shows it could take up to seven years or more to return waiting lists to pre-pandemic levels. This report makes five recommendations based on what the Welsh Government needs to do as it implements its national plan.
-
Content ArticleIn this Editorial for the journal Midwifery, maternity experts come together to respond to the Ockenden review and discuss what went wrong and what needs to happen now.
-
Content ArticleFollowing the publication of the Independent Medicines and Medical Devices and Safety (IMMDS) Review in July 2022, the UK Government accepted a recommendation to appoint a Patient Safety Commissioner responsible for promoting safety in the context of the use of medicines and medical devices. At the Health Plus Care conference on the 19 May 2022, Patient Safety Learning's Chief Executive Helen Hughes and Marie Lyon, Chair of the Association for Children Damaged by Hormone Pregnancy Tests, considered the key challenges that will faced by the new Patient Safety Commissioner and the importance of implementing in full the recommendations of the IMMDS Review. See attached their presentation slides.
- Posted
- 1 comment
-
1
-
- (and 4 more)
-
Content ArticleThis is an Early Day Motion tabled in the House of Commons on 18 May 2022, which calls on the Government to implement the recommendations of the Independent Medicines and Medical Devices Safety Review in full, including paying compensation to people disabled by sodium valproate.
-
Content ArticleIn May 2022, the National Steering Committee for Patient Safety (NSC) issued the Declaration to Advance Patient Safety to urge health care leaders across the continuum of care to recommit to advancing patient and workforce safety. The NSC called for immediate action to address safety from a total systems approach, as presented in the National Action Plan to Advance Patient Safety, and implored leaders to adopt safety as a core value and foster collective action to uphold this value.
