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Found 469 results
  1. Content Article
    The Safety Case is a regulatory technique that requires organisations to demonstrate to regulators that they have systematically identified hazards in their systems and reduced risks to being as low as reasonably practicable. It is used in several high-risk sectors, but only in a very limited way in healthcare. This multisite case study in BMJ Quality and Safety examined the first documented attempt to apply the Safety Case methodology to clinical pathways. The study found that the Safety Case approach was recognised by those involved in the Safer Clinical Systems programme as having potential value. However, it is also fraught with challenge, highlighting the limitations of efforts to transfer safety management practices to healthcare from other sectors.
  2. Content Article
    The 15th annual HSJ Patient Safety Congress brings together more than 1000 attendees with the shared goal of advancing the national agenda for patient safety across health and social care. In this blog, Samantha Warne, the hub's Lead Editor, captures some of the key highlights and messages from day one of HSJ’s Patient Safety Congress.
  3. Content Article
    The important issue of a patient’s right to a second medical opinion has recently hit the headlines with Martha’s Rule, which relates to the tragic death of 13-year-old Martha Mills in NHS care and the circumstances surrounding this. There is a groundswell of support for Martha’s Rule, with Health and Social Care Secretary Steve Barclay committed to introducing the rule in England. This is excellent news, but development and implementation must not be rushed writes John Tingle, Dr Dita Wickins-Drazilova and Steve Gulati from the University of Birmingham.
  4. News Article
    Certain spina bifida-related surgeries remain suspended at Children's Health Ireland at Temple Street (CHI) for almost a year amid serious allegations that unlicensed devices made with non-medical parts have been implanted in child patients. In two cases where these devices were used, the implants had to be removed from patients after causing significant harm, while the efficacy of a third is yet to be determined. One senior member at the hospital has raised concerns about the number of repeat operations required on young spina bifida patients and associated rates of reinfection, with disquiet in the hospital eventually leading to first an internal review of operations in October 2022 and later an external probe by US clinicians. In June this year there were 287 children on waiting lists in Ireland for life-changing spinal surgery. Despite a commitment first given by then health minister Simon Harris in 2017 that no child would be on the waiting list for more than four months, there are still more than 120 children waiting more than a year for scoliosis surgery, according to the Ombudsman for Children. CHI has declined to comment on allegations that one of its surgeons has used the unlicensed, failed implants, as well as its decision to cease operations on spina bifida patients. Patient advocate Amanda Santry, who took part in the external review on behalf of Spina Bifida & Hydrocephalus Paediatric Advocacy, has said she has been denied access to the review findings and has also called for a “full investigation” into the allegations of the use of non-medical parts. Read full story Source: The Ditch, 15 September 2023
  5. News Article
    Regulation of managers must not lead to a disbarring process without also introducing ”developmental” and supportive measures, NHS England’s national patient safety director has said. Speaking at HSJ’s Patient Safety Congress, Aidan Fowler was asked whether NHS board members and managers should be regulated, amid calls for this in the wake of the Lucy Letby scandal. He said: “I think there are pros and cons to regulation… What I would say is that you just have to be cautious that you do not lead to a disbarring process without the developmental side of regulation, and the support side of regulation. For staff, to support them to do a good job. “We have seen that there is a gap in patient safety training for boards, which we need to work on, for them to understand and to encourage them to talk about it more. “I think there is a developmental part of regulation, which is really important… in any discussion. I know because we are already having discussions around it. That is a key part to pay attention to.” Read full story (paywalled) Source: HSJ,18 September 2023
  6. News Article
    A national NHS leader has said regulation of managers ‘is coming’, and the service should ‘just go with it and make it as effective’ as possible. Sir Jim Mackey, national director for elective recovery and the chief executive of Northumbria Healthcare Foundation Trust, also told HSJ that regulation could offer better “protection” for management staff if implemented properly. NHS England is considering additional regulation of NHS management after being asked to “revisit” the idea by health and social care secretary Steve Barclay in the wake of the murder of babies by nurse Lucy Letby at the Countess of Chester Hospital. In an interview with HSJ, Sir Jim said: “Honestly, I think it’s coming. So we just need to go with it and make it as effective as it can be. It’s completely understandable in the current context for politicians and the public to want people in these positions to be regulated.” He continued: “There’s potentially some protection for people in being regulated in an effective way, as well as [being subject to] clear rules, clear processes. If somebody makes an allegation and it’s found to be wrong [and] you’ve been through a thorough regulatory process, it’s going to help you to move on and put it behind you.” Read full story (paywalled) Source: HSJ, 18 September 2023
  7. Content Article
    This Newsnight report looks at the case of Rebecca Wight, an advanced nurse practitioner who raised concerns about a colleague at at Manchester’s Christie cancer hospital and felt her treatment by Trust management as a whistleblower was poor. She is now taking The Christie to an employment tribunal for constructive dismissal. The video also features an interview with Helené Donnelly, a nurse who tried to raise the alarm more than 100 times at Mid Staffs and went on to be a key witness in the subsequent Francis inquiry. She calls for failing NHS managers to be struck off, highlighting that a decade on from one of the worst failings in NHS history, those raising concerns were still not being listened to.
  8. News Article
    A high-profile government climbdown which legalised a type of cannabis medicine on the NHS five years ago misled patients, campaigners say. It was thought the law change would mean the unlicensed drug, which treats a range of conditions, could be freely prescribed by specialist doctors. But fewer than five NHS patients have been given the medicine, leaving others to either pay privately or miss out. The government says safety needs to be proven before a wider rollout. Legalisation of whole-cannabis medicine was hailed as a breakthrough for patients - giving either NHS or private specialist doctors the option to prescribe it if they believed their patients would benefit. But patients are being turned away, say campaigners, because doctors often do not know about the medicine, which is not on NHS trusts' approved lists. Some specialists who do know about it say there is insufficient evidence of the drug's safety and benefits to support prescribing. Senior paediatric consultant Dr David McCormick, from King's College Hospital in London, says it was "disingenuous" of the government to suggest in 2018 that NHS prescribing was ready to take place. "Parents were clamouring at our door, or phoning all the time, as they believed we were able to prescribe and that was not the case. "The message went out, 'doctors can now prescribe cannabis products' and that put us in a difficult position, because in truth we need to apply for that to be approved by NHS England." Read full story Source: BBC News, 13 September 2023
  9. News Article
    YouTube has launched a verification system for healthcare workers in the UK as it battles disinformation online. In 2022, health videos were viewed more than three billion times in the UK alone on the video-sharing platform. Doctors, nurses and psychologists have been applying for the scheme since June and must meet rigorous criteria set by the tech giant to be eligible. Successful applicants will have a badge under their name identifying them as a genuine, licensed healthcare worker. But YouTubers have warned the system is only meant for education purposes, not to replace medical advice from your GP. Vishaal Virani, who leads health content for YouTube, said it was important simply due to the sheer number of people accessing healthcare information on the video-sharing platform. "Whether we like it or not, whether we want it or not, whether the health industry is pushing for it or not, people are accessing health information online," he told the BBC. "We need to do as good a job as possible to bring rigour to the content that they are subsequently consuming when they do start their care journey online." Read full story Source: BBC News, 8 September 2023
  10. Content Article
    Demand for surgical and non-surgical cosmetic treatments has spiralled in the past ten years among men and women, especially young women in the 18-34 age group, thanks to social media, reality TV and celebrity endorsements. A corresponding increase in ‘botched’ procedures is putting pressure on the NHS to solve problems created by unregistered, unqualified practitioners.  Official advice is to check your practitioner is qualified and has appropriate insurance. This makes sense but it’s not always easy to know where to look. That’s why the Professional Standards Authority have done the hard work for you. The Check a Practitioner service exists for situations like these. You can check if a practitioner is regulated by law or belongs to a reputable Accredited Register.
  11. Content Article
    The government brought forward an amendment to the Health and Care Act 2022 which gives the Secretary of State for Health and Social Care the power to bring into force a licensing scheme in England for non-surgical cosmetic procedures. The purpose of the scheme is to ensure that consumers who choose to undergo a non-surgical cosmetic procedure can be confident that the treatment they receive is safe and of a high standard. Under the proposed scheme, practitioners will need to be licensed to perform specific procedures and the premises from which they operate will also need to be licensed.
  12. News Article
    The government could ban unlicensed providers of cosmetic treatments in England, in what industry bodies say would be the biggest shake-up in a generation. Under the plans, anyone carrying out Botox, breast or butt lift injections would have to be trained and licensed, with their premises also inspected. The proposals have been have been opened up for public consultation. At present, healthcare professionals such as doctors, nurses and dentists carrying out non-surgical cosmetic procedures have to be trained and insured to do them as part of the requirements laid down by their regulatory bodies. But there is no set training for beauty therapists and other non-professionals. Read full story Source: BBC News, 3 September 2023
  13. Content Article
    Rebecca Bauers, Interim Director for People with a Learning Disability and Autistic People, and Chris Dzikiti, Director for Mental Health, talk about CQC’s new cross-sector policy position statement on restrictive practice, what it means for providers, and what people receiving healthcare services have the right to expect. As well as sharing the new policy, they discuss what forms restrictive practices can take, and explain how the use of blanket restrictions diminishes the therapeutic power of person-centred, trauma-informed care.
  14. Content Article
    Healthcare is where the "most exciting" opportunities for artificial intelligence (AI) lie, an influential MP has said, but is also an area where the technology's major risks are illustrated. Greg Clark, chairman of the Commons Science, Innovation and Technology Committee (SITC), said the wider adoption of AI in healthcare would have a "positive impact", but urged policy makers to "consider the risks to safety". He said: "If we're to gain all the advantages, we have to anticipate the risks and put in place measures to safeguard against that." An interim report published by the Science, Innovation and Technology Committee sets out the Committee’s findings from its inquiry so far, and the twelve essential challenges that AI governance must meet if public safety and confidence in AI are to be secured.
  15. Content Article
    In this blog, Sling the Mesh founder Kath Sansom highlights the variation in medical treatment depending on where you live in the world. Describing patient safety advocacy as "like a giant game of chess—but a hideous version where innocent people get hurt," she describes recent developments in the use of pelvic mesh globally. New Zealand recently suspended the use of a particular type of pelvic mesh at the same time as a Canadian study recommended its use for stress urinary incontinence (SUI). Kath gives a brief history of mesh sling suspension and argues that patient safety needs joined up thinking to protect women around the world.
  16. News Article
    Amanda Pritchard has said it is time to ‘look again’ at whether NHS England should be given formal powers to disbar managers for ‘serious misconduct’. In an email to regional leaders and some national bodies yesterday, seen by HSJ, the chief executive officer of NHS England said the murder trial of neonatal nurse Lucy Letby has brought the issue of professional regulation for managers back into focus. She has planned an urgent meeting next week to discuss the options. Ms Pritchard said she wanted the meeting to explore; the feasibility of NHSE being given the powers and resources to act as a regulator; who this could apply to and how it could operate; and how a dedicated regulatory body for NHS leaders might fulfil the role. She stressed any new powers would need to be determined by the government, but said the NHS “should contribute proactively and fully, and with an open mind, to this decision-making process”. Read full story (paywalled) Source: HSJ, 25 August 2023
  17. Content Article
    In this anonymous blog, a patient shares their experience of orthodontic treatment which they undertook to reduce overcrowding of their teeth. However, instead of solving the problem, the treatment caused multiple, complex dental issues that have resulted in severe pain and a high financial cost. The patient talks about how their orthodontist has been unwilling to take any responsibility for the issues caused, threatening legal action if the patient pursues any claims against them. They also discuss the reluctance of other orthodontists to get involved in trying to treat the issues they now face, and call for regulators and governments to look into the issue of negligent orthodontic treatment.
  18. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them.  Kath talks to us about why she set up Sling the Mesh and the significant impact that campaigning has on her life. She also highlights the need to establish systems that will identify and prevent avoidable harm, including long term tracking to investigate trends of harm, reporting of industry payments to clinicians and making logging side effects mandatory for healthcare professionals.
  19. Content Article
    In June 2022, General Sir Gordon Messenger and Dame Linda Pollard published their final report on the review of leadership and management in the health and social care sector, as commissioned by the Secretary of State for Health and Social Care in October 2021. This briefing by NHS Providers summarises the key areas covered by the report, grouping recommendations under the following headings: Training  Development Equality, diversity and inclusion  Challenged trusts, regulation and oversight
  20. Content Article
    The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 aimed to: minimise burdens on public, independent and third sector employers and ensure businesses in UK are not placed at competitive disadvantage relative to EU counterparts offer good standards of protection to healthcare workers from risk of sharps injury at work see a fall in sharps injury numbers. This post implementation review (PIR) aimed to assess the success of these objectives. It found that: stakeholder consultation provided evidence of the increasing use of safer sharps across all healthcare sectors. evidence from RCN research and HSE inspections indicates that risks to healthcare workers from sharps injuries remains high. The policy conclusion from this evidence is that the Regulations are still required, and that the Regulations’ objectives cannot be met with a system that imposes less burden to business.
  21. Content Article
    Increasing adverse events, hospital-associated infections, and other harm to patients have compounded and now fuel the call for the formation of a national patient safety board in the USA. But, with so many established health entities already within the government, will adding one create more complexities than it will oversight? A bill introduced in the House in December 2022 proposes such a body loosely modelled off the National Transportation Safety Board. The group behind the efforts for the board's creation note in a document that it still would not be the "sole solution" needed to properly address patient safety issues nationally, but rather is designed to "augment" the work of other federal agencies and patient safety organisations.  The bill proposes that it would not be necessary to identify providers in reports that the board would investigate, and some patient safety experts say this is not the right approach, noting that it would not provide the accountability necessary — particularly since the board would be nonpunitive to begin with. But others argue that this structure could help promote voluntary reporting for more data collection.  Three patient safety professionals shared their takes in Becker's Hospital Review.
  22. News Article
    In September last year, Ebrima Sajnia watched helplessly as his young son slowly died in front of his eyes. Mr Sajnia says three-year-old Lamin was set to start attending nursery school in a few weeks when he got a fever. A doctor at a local clinic prescribed medicines, including a cough syrup. Over the next few days, Lamin's condition deteriorated as he struggled to eat and even urinate. He was admitted to a hospital, where doctors detected kidney issues. Within seven days, Lamin was dead. He was among around 70 children - younger than five - who died in The Gambia of acute kidney injuries between July and October last year after consuming one of four cough syrups made by an Indian company called Maiden Pharmaceuticals. In October, the World Health Organization (WHO) linked the deaths to the syrups, saying it had found "unacceptable" levels of toxins in the medicines. A Gambian parliamentary panel also concluded after investigations that the deaths were the result of the children ingesting the syrups. Both Maiden Pharmaceuticals and the Indian government have denied this - India said in December that the syrups complied with quality standards when tested domestically. It's an assessment that Amadou Camara, chairperson of the Gambian panel that investigated the deaths, strongly disagrees with. "We have evidence. We tested these drugs. [They] contained unacceptable amounts of ethylene glycol and diethylene glycol, and these were directly imported from India, manufactured by Maiden," he says. Ethylene glycol and diethylene glycol are toxic to humans and could be fatal if consumed". Read full story Source: BBC News, 21 August 2023
  23. News Article
    The Care Quality Commission (CQC) has published a report on Stoke Mandeville Hospital, part of Buckinghamshire Healthcare NHS Trust following a recent inspection in June. CQC carried out a focused inspection of the trusts children’s emergency department in response to concerns raised about the safety and quality of the service. Inspectors found children and young people received safe care. However, the trust needs to review its systems to make sure potential serious incidents are managed in a way that allows any lessons learned to be shared, to reduce the risk of them happening again. Link to the full report (opens in a new browser window)
  24. News Article
    Drug companies are systematically funding grassroots patient groups that lobby the NHS medicines watchdog to approve the rollout of their drugs, the Observer has revealed. An investigation by the Observer has found that of 173 drug appraisals conducted by the National Institute for Health and Care Excellence (NICE) since April 2021, 138 involved patient groups that had a financial link to the maker of the drug being assessed, or have since received funding. Often, the financial interests were not clearly disclosed in NICE transparency documents. Many of the groups that received the payments went on to make impassioned pleas to England’s medicines watchdog calling for treatments to be approved for diseases and illnesses including cancer, heart disease, migraine and diabetes. Others made submissions appealing NICE decisions when medicines were refused for being too expensive. In one case, a small heart failure charity that gave evidence to a NICE committee arguing for a drug to be approved received £200,000 from the pharmaceutical company, according to the maker’s spending records. In another case, a cancer patient group supplied evidence relating to drugs made by 10 companies – from nine of which it had received funding. Read full story Source: The Guardian, 22 July 2023
  25. News Article
    Britain’s health regulator has partly suspended the manufacturing licence of Sciensus, a private company paid millions by the NHS to provide vital medicines, after the death of a cancer patient who was given the wrong dose of chemotherapy. The Medicines and Healthcare products Regulatory Agency (MHRA) said it had taken “immediate” action under regulation 28 of the Human Medicines Regulations 2012 law “where it appears to the MHRA that in the interests of safety the licence should be suspended”. The MHRA found “significant deficiencies” in standards at Sciensus during an investigation triggered by the death of one patient and the hospitalisation of three others. All four patients were administered “incorrect” doses of an unlicensed version of cabazitaxel, a licensed chemotherapy used to treat prostate cancer, according to people familiar with the matter. Read full story Source: The Guardian, 25 July 2023
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