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Found 191 results
  1. Content Article
    What happens if a surgeon accidentally drops an instrument on the floor, picks it up and reuses, without it going through a steriliser? Should this be allowed to happen? Well it did! 
  2. Content Article
    This Washington Post article looks at the lack of error and accident reporting in the US reproductive health and fertility industry. Unlike any other area of healthcare, no outside authority or agency regulates Never Events that happen at fertility providers. The authors highlight a case that allowed a glimpse into the industry, when legal action was taken against a San Francisco fertility centre where a storage tank imploded, damaging or destroying 4,000 human eggs and embryos. A jury later found that a manufacturing defect was largely to blame for the disaster but also implicated the actions taken by staff at the centre. The authors also highlight that patients are often asked to sign nondisclosure agreements as part of a legal settlement, which further restricts transparency when something goes wrong.
  3. Content Article
    In this HSJ blog, Ken Jarrold highlights three key things he learned during his ten years as chair of NHS trusts: Focus on the people that matter—service users and frontline staff Keep an appropriate level of contact and relationship with the chief executive Live the values of the trust. He emphasises chairs keeping their focus on the people they serve and ensuring they feel at home interacting with staff and service users, as well as other leaders. He also states his hope that the Leadership Competency Framework for conducting annual appraisals of NHS chairs published by NHS England in February 2024, if applied appropriately, will result in improvements in how chairs serve their organisations.
  4. Content Article
    Medical errors happen all the time. They can be overlooked or they can lead to big lawsuits and settlements. But what they rarely lead to is an apology. However, increasingly, patients, families and healthcare professionals, are calling for a new approach, one that acknowledges the lasting damage that comes from a failure to address medical mistakes. In this report for US media company NPR, a Naomi and Jeff tell their story of losing their daughter Thalia to medical error following planned surgery. They report that concerns they and Thalia raised about their breathing were ignored by healthcare professionals, and Thalia died after her brain was starved of oxygen. The hospital didn't give an explanation or apology for Thalia's death.
  5. Content Article
    This article by the Patient Experience Library summarises the findings of an independent review of services at University Hospitals Sussex Trust by the Royal College of Surgeons. The article highlights that it is a positive sign to see the Trust publishing a sensitive report publicly, noting that in the past other trusts have suppressed reviews of this kind. The review highlighted some concerning findings, including: A high volume of complaints from patients and delays in responding. Consultant surgeons being dismissive and disrespectful towards other members of staff and displaying hierarchical behaviours towards allied healthcare professionals, particularly junior members of staff. Reports of two trainees being physically assaulted by a consultant surgeon in theatre during surgery. A culture of fear amongst staff when it came to the executive leadership team, with instances of confrontational meetings where consultant surgeons were told to 'sit down, shut up and listen'.
  6. Content Article
    This report outlines the findings of an independent investigation into the conduct of a spinal consultant, Doctor F, who formerly worked at Salford Royal NHS Foundation Trust (now part of the Northern Care Alliance NHS Foundation Trust).
  7. Content Article
    Imagine an organisational culture of trust, learning and accountability. In the wake of an incident, a restorative just culture asks: ‘who are hurt, what do they need, and whose obligation is it to meet that need?’ It doesn’t dwell on questions of rules and violations and consequences. Instead, it gathers those affected by an incident and collaboratively addresses the harms and needs created by it, in a way that is respectful to all parties. It holds people accountable by looking forward to what must be done to repair, to heal and to prevent. This film documents the amazing transformation in one organisation —Mersey Care, an NHS mental health trust in the UK. Only a few years ago, blame was common and trust was scarce. Dismissals were frequent: caregivers were suspended without a clear idea of what they might have done wrong. Mersey Care’s journey toward a just and learning culture has repaired and reinvigorated relationships between staff, leaders and service users. It has enhanced people’s engagement, joint ownership and sense of responsibility. It has taken the organization to a place where hurt doesn’t get met with more hurt, but with healing.
  8. Content Article
    As the USA's largest health insurer, the Centers for Medicare & Medicaid Services (CMS) has established quality standards, metrics, and programmes to improve healthcare not just for the 170 million individuals supported by its programmes, but for all Americans. The 2024 National Impact Assessment of CMS Quality Measures Report (Impact Assessment Report) assesses the quality and efficiency impact of measures endorsed by the consensus-based entity and used by CMS.
  9. Content Article
    This ethnographic study looked at five local Healthwatch organisations to determine the extent to which they have fulfilled their intended role of fostering co-creation in health and social care in England. The study results demonstrate clear activity and some tangible impacts that have been achieved towards the aim of cocreation. However, the authors also highlight that the positioning of these organisations as 'collaborative insiders' in local governance systems has limited the issues that have been prioritised in co-creative activities. This analysis suggests that the increasing promotion of ideas of co-production in English health and social care has resulted in fertile grounds for localised co-creation. However, the authors highlight that the areas Healthwatch focused on were ones where other agencies in the system recognised their limitations, and where they knew they needed help to avoid socially undesirable outcomes. As a result, the approaches taken to co-creation by Healthwatch were largely conservative and constrained. The authors state that, "Even though they were not explicitly ruled out-of-bounds, Healthwatch officers knew that to be considered legitimate and serious players in the governance of health and social care, they needed to be selective about which issues they brought to the table."
  10. Content Article
    In December 2022, a newly formed group called 'Long Covid Doctors for Action' (LCD4A) conducted a survey to establish the impact of Long Covid on doctors. When the British Medical Association published the results of the survey, the findings were both astonishing and saddening in equal measure.[1] The LCD4A have now decided that enough is enough and that it is now time to stand up and take positive action. They have initiated a group litigation against those who failed to exercise the ‘duty of care’ that they owed to healthcare workers across the UK during the pandemic.  In this blog, I summarise how and why I feel our healthcare workers have been let down by our government and why, if you are one of these healthcare workers whose life has been effected by Long Covid, I urge you to join the group litigation initiative.
  11. Content Article
    The Department of Health and Social Care (DHSC) and Health Services Safety Investigations Body.(HSSIB) share the common objective to improve patient safety. To achieve this, HSSIB and DHSC will work together in recognition of each other’s roles and areas of expertise, providing an effective environment for HSSIB to achieve its objectives through the promotion of partnership and trust, and ensuring that HSSIB also supports the strategic aims and objective of DHSC and wider government as a whole.
  12. Content Article
    "Our #health system in the UK is in a mess. It has failed to modernise (by this I mean to become fully accountable to #patients and the public, and truly patient-led). Instead, the system has become more and more hierarchical, bureaucratic and crony ridden, mostly as a result of constant meddling and pointless reorganisations instigated by politicians. All political parties in government for the past 30 years have had a hand in this decline." This is my view? What is yours? A new Inquiry gives us all an opportunity to have our say. I am proud to have worked in and for the NHS for most of my working life; proud to have been trained in the #NHS and proud of the work being carried out by clinical teams today. Great work which has benefited patients, often not because of the leadership but despite of the leadership. I'm retired so I can say what I like. If I were working and said anything even vaguely like criticism, however constructive it was, I would be out of a job and my career would be blighted for life. I'm speaking from experience here, unfortunately. I urge everyone to respond to the consultation (link below). In your response think forensically and write it as a statement of truth. Acknowledge the successes and areas that have delivered safe and effective services. If you are being critical give examples and say if it is an opinion or back up what you say with evidence. If we work together across boundaries we can develop a truly patient-led NHS.
  13. Content Article
    The leadership and management functions of Patient Safety Incident Response Framework (PSIRF) oversight are wider and more multifaceted compared to previous response approaches. When working under PSIRF, NHS providers, integrated care boards (ICBs) and regulators should design their systems for oversight “in a way that allows organisations to demonstrate [improvement], rather than compliance with prescriptive, centrally mandated measures”. To achieve this, organisations must look carefully not only at what they need to improve but also what they need to stop doing (eg panels to declare or review Serious Incident investigations). Oversight of patient safety incident response has traditionally included activity to hold provider organisations to account for the quality of their patient safety incident investigation reports. Oversight under PSIRF focuses on engagement and empowerment rather than the more traditional command and control. 
  14. Content Article
    Boards and leaders of healthcare organisations are legally responsible for the performance of their organisation and must take definitive responsibility for improvements, successful delivery and failures in the quality of care. Board effectiveness relies on the ways in which board members translate their knowledge and information into quality and safety plans with measurable goals, maintain oversight on progress towards these goals and hold the chief executive accountable for these goals. This resource by the Canadian Patient Safety Institute lists tools available to boards and board members to allow them to understand their legislative responsibilities for quality and safety, conduct self-evaluation and understand the competencies needed to lead on quality and patient safety.
  15. Content Article
    In this blog, Scott Ellner, a general surgeon from the US, describes the case of a surgeon colleague who unintentionally harmed a patient, Sarah, during surgery. Sarah ended up in the surgical intensive care unit from septic shock due to a missed bowel injury. Her recovery from what should have been a straightforward procedure was long and complicated. Scott recalls how the surgeon was shocked by the way Sarah's husband responded to him when he explained what had happened—instead of an anger and blame, Sarah's husband expressed compassion for the doctor and reiterated his trust in him. Scott highlights the importance of creating a Just Culture in healthcare systems and outlines challenges to this in the current climate, referring to the case of nurse RaDonda Vaught. He also outlines the impact patient safety incidents and medical errors can have on healthcare professionals, calling on the healthcare community to embrace shared humanity. All of us come with imperfections, vulnerabilities and the capacity for healing and growth.
  16. Content Article
    This blog by the British Society for Rheumatology (BSR) shares highlights of the evidence given to a House of Lord's inquiry into homecare medicines services' governance and accountability. The witness sessions heard evidence on levers for accountability, performance and safety, e-prescribing and workforce. The blog looks at challenges faced by providers, the need for improved regulation and accountability and lack of data and KPIs. It also describes a desktop investigation being undertaken by NHS England to understand the range of arrangements that are in place and how homecare medicines services are held to account.
  17. Content Article
    In a recent report, the Professional Standards Authority (PSA) for Health and Social Care sets out its view on the biggest challenges affecting the quality and safety of health and social care. In this blog, Alan Clamp, PSA's chief executive, summarises these challenges and the possible solutions. You can also read Patient Safety Learning's reflections on the PSA report here.
  18. Content Article
    In this article, Sharon Hartles highlights the high-profile legal battle involving numerous Primodos-affected claimants against pharmaceutical companies and the government. The court ruled against the claimants, dismissing their claims related to hormone pregnancy tests and foetal harm. This decision led to disappointment and criticism from advocates, MPs, and academics involved in the Primodos scandal. Sharon Hartles is affiliated with the Risky Hormones research project, which is an international collaboration in partnership with patient groups. Additionally, she is a member of the Harm and Evidence Research Collaborative at the Open University. Related reading on the hub: Primodos 2023: The fight for justice continues for the Association for Children Damaged by Hormone Pregnancy Tests Primodos, mesh and sodium valproate: Recommendations and the UK Government’s response Primodos: The next steps towards justice Patient Safety Spotlight interview with Marie Lyon, chair of the Association for Children Damaged by Hormone Pregnancy Tests
  19. News Article
    Patient safety will be harmed and victims of medical negligence denied justice because of flaws in the government’s health and care bill, the NHS ombudsman has told the Guardian. Rob Behrens, the parliamentary and health service ombudsman, fears he and his staff will not be able to get to the bottom of clinical blunders because under the bill he will be denied potentially vital information collected by the NHS’s Healthcare Safety Investigation Branch (HSIB). The ombudsman said the legislation would allow the HSIB to “operate behind a curtain of secrecy” and undermine his own investigations into lapses in patient safety and could deny grieving families the full truth about why a loved one died. Behrens has spoken out because he is concerned about government plans for NHS staff involved in an incident to give evidence about mistakes privately in a “safe space” to the HSIB, which cannot be shared with anyone else except coroners. His exclusion from seeing material gathered in that way could force him to take the agency to the high court to access it, he said. “If the ‘safe space’ provisions become law as drafted there is a real risk to patient safety and to justice for those who deserve it. This is a crisis of accountability and scrutiny,” he said. Julia Neuberger, a crossbench peer who chairs University College hospitals NHS trust, has tabled an amendment to the bill in the House of Lords seeking to give the ombudsman access to information obtained via “safe space” processes. Unless ministers rethink the plan “there could be serious consequences for members of the public who use the ombudsman service”, she recently told a Lords debate. “If the ombudsman is unable to investigate robustly all aspects of complaints about the NHS, except with the permission of the high court, patients may find it harder to get access to justice. The NHS may well become less accountable for its system failings,” she said. Peter Walsh, chief executive of patient safety charity Action Against Medical Accidents, backed Behrens. “The so-called safe space is a red herring with serious unintended consequences. There is no evidence staff do not take part in investigations for fear of information being known. It is bullying employers and over-zealous regulators that staff fear. Denying people their right to have the ombudsman investigate properly does nothing to address that.” Read full story Source: The Guardian, 28 February 2022
  20. News Article
    The bodies of people who died with Covid were treated like "toxic waste" and families were left in shock, a bereaved woman has told the inquiry. Anna-Louise Marsh-Rees said her father Ian died "gasping for breath" after catching the virus while in hospital. Ms Marsh-Rees, who leads Covid-19 Bereaved Families for Justice Cymru, said he was "zipped away", and his belongings put in a Tesco carrier bag. Ian Marsh-Rees died after catching the virus while in hospital, aged 85. His daughter said finding information regarding his care in hospital and how he became infected was "almost like an Agatha Christie mystery". She said no GP ever suggested he might have Covid, although she now knows his discharge notes said he had been exposed to Covid. "It wasn't until we saw his notes some months later that we saw the DNA CPR (do not attempt CPR) placed on him, and this was without consultation with us," she said. "It kind of haunts us all that… people used to say 'well they're in the right place' when they go to hospital. I'm not sure they would say that any more," Ms Marsh-Rees said. She now wants to change the way deaths are handled by health boards. She said it was important to prepare families before and support them after the death of a loved one, from palliative care to dignity in death. Read full story Source: BBC News, 18 July 2023
  21. News Article
    German public research funder Deutsche Forschungsgemeinschaft (DFG) is conducting an audit of the clinical trials it has supported in the past. The audit was announced in response to a request from TranspariMED asking DFG for a list of all its trials completed between 2009 and 2017, to which DFG replied that it currently has no such comprehensive dataset. DFG stated that it is "currently preparing an evaluation of its clinical trials programme. In the framework of this evaluation the data you requested will be collected and analysed, as the outcomes of trials supported by DFG is of high interest including for DFG itself." TranspariMED, an organisation which aims to end evidence distortion in medicine, sees this development as a good opportunity for DFG to check whether and when clinical trials were registered and their results made public. Previous research has shown that nearly a third of German academic trials never make their results public. This not only wastes public money, but also harms patients because it leaves gaps in the evidence base on the efficacy and safety of drugs, medical devices, and non-drug treatments. Due to gaps in German law, there is still no legal obligation to make the results of many German clinical trials public. Read full story Source: TranspariMed, 20 December 2022
  22. News Article
    A week after Donna Ockenden published her damning report on the catastrophic failures in maternity services at Shrewsbury and Telford Hospital NHS Trust in March last year, she was contacted by families in Nottingham asking her to investigate how dozens of babies had died or been injured in their city hospitals. Six months later, Ockenden — herself a senior midwife — was put in charge of another inquiry by the government and yet again she is finding a culture of cover-ups and lies in maternity care. “Of the families that I have met in Nottingham to date, some of them have expressed concerns to me that the trust were not truthful in discussions around their cases,” she tells the Times Health Commission. “We have all the systems and structures in place that should be able to spot maternity services in difficulty and here we are again. Families are having to fight to get answers.” The woman who has done more than anyone to highlight the problems with maternity care is reluctant to use the word “crisis” but she warns: “I think that without urgent and rapid action, from central government downwards — on funding and workforce and training — mothers and their babies are not going to be able to receive the safe, personalised maternity care that they deserve and should expect". Read full story (paywalled) Source: The Times, 21 April 2023
  23. Content Article
    This short blog highlights the situations where patients, carers, parents and relatives are failed by healthcare systems and by the leadership. They are left to stand alone against powerful institutions, because when staff speak up and 'blow the whistle' it often results in retaliation. Investigating and resolving the patient safety issue then becomes buried under an employment issue.
  24. Content Article
    This video published by the Irish Health Service Executive (HSE) tells the story of Pat, whose bowel cancer diagnosis was missed, resulting in his premature death. His daughter Patricia talks about the two investigations that took place into her father's death and how the hospital's internal investigation failed to acknowledge that a staff member had raised concerns about Pat's initial colonoscopy on five occasions, but this had not been followed up. She describes the impact of these events on her father and the rest of the family and calls on medical professionals to "trust us (families) more and fear solicitors less."
  25. Content Article
    In this article for NHS Confederation, Sir Chris Ham reflects on progress made against his recommendations on the conditions ICSs need to succeed and on next steps for the Hewitt review. He argues that progress has been made in acting on some of the recommendations in the report Governing the Health and Care System in England. This can be seen in plans to create a new NHS England (NHSE), reduce staffing at the centre and regions and co-produce the operating framework. However, he highlights that more work is needed to reduce the number of national NHSE programmes, ensure greater consistency in how these programmes work and bring an end to constant bidding for funds tied to specific priorities. He recommends that high priority be given to an organisational development (OD) programme to support the development of collaboration, mutual respect and trust and determine how peer support, shared learning and improvement collaboratives can play a bigger part in improving performance in future. Sir Chris highlights that the Hewitt review offers an opportunity for these and other issues to be addressed with priority being given to ensuring that planning guidance for 2023/24 is short and focused on a small number of national priorities, leaving scope for ICSs to add local priorities. Leaders in the DHSC and NHSE must recognise the exceptional pressures facing the health and care system and set out what a realistic set of medium-term objectives for ICSs looks like under current circumstances.
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