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Showing results for tags 'Recommendations'.
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Content ArticleThis is the Government’s formal response to the recommendations made by the Health and Social Care Committee in its report, ‘The Safety of Maternity Services in England’. The Committee’s inquiry examined evidence relating to the safety of maternity services. It builds upon current investigations following incidents at East Kent Hospitals University Trust and Shrewsbury and Telford Hospitals NHS Trust, as well as the inquiry into the University Hospitals of Morecambe Bay NHS Trust. The inquiry also considered whether the clinical negligence and litigation processes need to be changed to improve the safety of maternity services and explored the impact of blame culture on learning from incidents.
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Content ArticleNICE 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 National Institute for Health and Care Excellence (NICE) in its 5-year strategy.
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Content ArticleCOVID-19 placed unprecedented pressure on the health and care system. Improvement, which offers systematic approaches that can help adapt to change, would be expected to be a useful asset in the response to the pandemic. Q members, a community of over 4,000 people skilled in improvement, were asked about the role of improvement tools, methods, approaches and mindsets in supporting change during COVID-19. This paper summarises their responses and shares key findings and recommendations for action.
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Content ArticleFollowing a lengthy consultation, the National Institute for Health and Care Excellence (NICE) has published new guidelines on chronic pain in over 16s. In the new guidelines, NICE made some recommendations for people whose chronic pain has no known cause, including the use of acupuncture. Dr Alice Howarth takes a closer look at the guidelines.
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Content ArticleNew NICE guidelines recommend exercise, rather than medication, for those suffering with chronic pain. Writer Grace Holliday explains why movement alone isn’t enough to help those dealing with symptoms in an article for Stylist.
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Content ArticleThe ISMP Targeted Medication Safety Best Practices for Hospitals (TMSBP) were developed to identify, inspire, and mobilise widespread, national adoption in the US of consensus-based best practices for specific medication safety issues that continue to cause fatal and harmful errors in patients, despite repeated warnings in ISMP publications. The best practice recommendations presented in this guidance document are based on error reports received through the ISMP National Medication Errors Reporting Program (ISMP MERP) and have been reviewed by an external expert advisory panel and approved by the ISMP Board of Trustees. This initiative was first launched in 2014 and is updated with additional best practices, as needed, every two years. While targeted for the hospital-based setting, some best practices are applicable to other healthcare settings. Facilities can focus their medication safety efforts on these Best Practices, which are realistic and have been successfully adopted by numerous organisations.
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Content ArticlePeople with severe food allergies should carry two adrenaline autoinjector pens with them at all times, according to new guidance. Updated advice from The National Institute for Health and Care Excellence (NICE) says healthcare professionals should always offer people with severe allergies a prescription for two adrenaline auto-injectors (AAIs), which deliver potentially life-saving doses of the hormone to treat anaphylaxis, before being discharged from hospital after emergency treatment. They should also advise patients to always carry two devices with them, the guidance states.
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Content ArticleIn this article for NHSManagers.Net, Peter Carter, former General Secretary and chief executive of the Royal College of Nursing, questions why the First Do No Harm report didn't attract the publicity it warranted and urges the Government to address the issues raised in it as a matter of some urgency.
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Content ArticleThe Health Information and Quality Authority (HIQA) has published its annual overview report of lessons learned from receipt of statutory notifications of accidental and unintended exposures to ionising radiation in 2020. This report provides an overview of the findings from these notifications and shares learnings from the investigations of these incidents.
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Content ArticleThe number of intrapartum stillbirths referred to the Healthcare Safety Investigation Branch (HSIB) between April and the end of June 2020 increased compared to the same time in the previous year. The data initiated a HSIB national learning report, which explores the findings from their maternity investigations during this time. They investigated intrapartum (labour) stillbirths after 37 weeks, where a baby was thought to be alive at the start of labour and was born with no signs of life.
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Content ArticleThe Royal College of Obstetricians and Gynaecologists reviewed maternity care at two hospitals: The Royal Glamorgan hospital Prince Charles hospital The report makes recommendation on improvements to ensure the safety of mothers and babies. "During interviews and in group sessions the assessors were repeatedly and consistently told by staff of a reluctance to report patient safety issues because of a fear of blame, suspension or disciplinary action." "The assessors found little evidence among staff at all levels and professional backgrounds, of a coherent approach towards patient safety, or an understanding of their roles and responsibilities towards patient safety beyond the care they provided for a specific woman or group of women. This perception extended to senior members of midwifery and medical staff."
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WHO's Framework for Action - The 7x5 Matrix (Infographic)
Patient Safety Learning posted an article in WHO
The WHO's Global Patient Safety Action Plan aims to provide a strategic direction for concrete actions to be taken by countries, partner organisations, care facilities and World Health Organization (WHO). It sets out a vision of a “world in which no patient is harmed in healthcare, and everyone receives safe and respectful care, every time, everywhere” and a goal of achieving the maximum possible reduction in avoidable harm as a result of unsafe care. -
Content ArticleThis document sets out guidelines for recommended nurse/midwife to patient ratios in the Kingdom of Saudi Arabia. It describes the rationale for introducing national regulations for safe staffing ratios, considers concerns and challenges in this respect, and then outlines specific ratios in different areas of care. This has been produced by the Saudi Patient Safety Center, in collaboration with the Saudi Commission for Health Specialties and the Saudi Nurses Association.
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HSIB maternity programme year in review 2020/21 (August 2021)
Mark Hughes posted an article in HSSIB investigations
This report provides a review of the Healthcare Safety Investigation Branch (HSIB) maternity investigation programme during 2020/21, including an overview of activity during this period, themes arising from investigations and plans for the future. It is intended for healthcare organisations, policymakers and the public to understand the work HSIB have undertaken. -
Content ArticleIn this article, published by the Harm & Evidence Research Collaborative, Sharon Hartles examines the UK Government’s response in relation to the implementation of the recommendations set out in the Independent Medicines and Medical Devices Safety Review, First Do No Harm report. She explores how the Government’s response has impacted on those harmed by the side effects of Primodos, Mesh and Sodium Valproate.
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This week the Department of Health and Social Care released the UK Government’s response to the recommendations of the Independent Medicines and Medical Devices Safety Review, sometimes referred to as the Cumberlege Review. In this blog Patient Safety Learning sets out its reflections on this. -
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This report is from the Patient Reference Group established to provide advice, challenge and scrutiny to work to develop the government response to the Independent Medicines and Medical Devices Safety (IMMDS) Review, sometimes referred to as the Cumberlege Review. -
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This report from the Department of Health and Social Care sets out the Government's response to the recommendations of the Independent Medicines and Medical Devices Safety (IMMDS) Review, sometimes referred to as the Cumberlege Review. -
Content ArticleThis study looks at patients experiences of surgical site infections (SSIs) with the aim of improving clinical practice. The researchers conducted 17 narrative interviews with patients who had SSIs and then performed a thematic content analysis. Results found patients were not fully informed about SSIs and the nature surrounding them, with 7 patients saying they did not know they even had SSIs which may have been due to staff not informing the patients appropriately. Among the authors' conclusions, they suggest that if patients were more aware of SSIs, it may be able to help them adhere to preventative measures.
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Content ArticleThis article discusses a new consultation that has been launched by Robert Francis QC regarding the terms of reference for an independent study into the infected blood scandal. The article covers the suggested scope, the approach and the rationale behind the research and what it won't do, such as run through evidence already heard by the Inquiry.
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Content ArticleThis article describes how Never Events (NE) are serious clinical incidents that cause harm to patients. The authors analysed data from NHS England to categorise themes and identify common NE. Their results revealed 51 common NE themes in four main categories out of a total of 3247 between 2012 and 2020, identifying wrong-site surgery as the most common category. The authors conclude that with this research, awareness may help to reduce the amount of incidences in the future.
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In December 2020, Ockenden Report: Emerging findings and recommendations from the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust, was published. The report set out seven immediate and essential actions for Trusts under the following themes: Enhanced safety Listening to women and families Staff training and working together Managing complex pregnancy Risk assessment throughout pregnancy Monitoring fetal wellbeing Informed consent The below infographic, produced by the University of Southampton NHS Foundation Trust, sets out their plans against each of the seven actions. -
Content ArticleThis is the transcript of a backbench debate in the House of Commons regarding the implementation of the recommendations of First Do No Harm report, published by the Independent Medicines and Medical Devices Safety Review on the 8 July 2020, chaired by Baroness Cumberlege (also known as the Cumberlege Review).
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Content Article
WHO Global Patient Safety Action Plan 2021–2030 (Final version)
Mark Hughes posted an article in WHO
The Global Patient Safety Action Plan aims to provide a strategic direction for concrete actions to be taken by countries, partner organisations, care facilities and World Health Organization (WHO). It sets out a vision of a “world in which no patient is harmed in healthcare, and everyone receives safe and respectful care, every time, everywhere” and a goal of achieving the maximum possible reduction in avoidable harm as a result of unsafe care. -
Content ArticleThe UK government and devolved administrations, along with the emergency services and other local responders, have clear responsibilities for identifying, assessing, preparing for and responding to emergencies, as well as supporting affected communities to recover. The government has risk management processes in place that aim to identify risks, to ensure that plans are drawn up to mitigate risks and prepare for shocks, and to prevent risks from being overlooked despite short-term pressures. Cabinet Office guidance states that preparedness is the preparation of plans that are flexible enough both to address known risks and to provide a starting point for handling unforeseen events. This report sets out the facts on: the government’s approach to risk management and emergency planning the actions the government took to identify the risk of a pandemic like COVID-19 the actions the government took to prepare for a pandemic like COVID-19 recent developments. The report sets out central government’s risk analysis, planning, and mitigation strategies prior to the arrival of the COVID-19 pandemic, with the aim of drawing out wider learning for the government’s overall risk management approach.
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