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Found 42 results
  1. Content Article
    Incident reports of medication errors are valuable learning resources for improving patient safety. However, key information is often contained within unstructured free text, which prevents automated analysis and limits the usefulness of these data. Natural language processing can be used to structure this free text automatically and retrieve relevant past incidents and learning materials, but this requires a large, fully annotated and validated set of incident reports. This study in Nature used a set of 58,658 machine-annotated incident reports of medication errors to test a natural language processing model. The authors provide access to the validation datasets and machine annotator for labelling future incident reports of medication errors.
  2. Content Article
    The National Coronial Information System (NCIS) is an online repository of coronial data from Australia and New Zealand.
  3. Content Article
    Medication shortages can occur for many reasons, including manufacturing and quality problems, delays and discontinuations. This Food and Drug Administration (FDA) database provides information on drugs with a supply issue. Information is provided to the FDA by manufacturers.
  4. Content Article
    In this video and accompanying transcript, clinical decision support researcher F Perry Wilson looks at the importance of health records and databases indicating whether or not a patient is deceased. If they are not up to date and sharing this information with the right staff and processes, inappropriate messages can be sent to healthcare professionals or the deceased patient's family. He argues that as well as being a waste of resources, sending communications requesting procedures or offering appointments in this situation undermines confidence and trust in health systems, in both staff and members of the public.
  5. Content Article
    The US Department of Health & Human Services was directed in the Patient Safety and Quality Improvement Act of 2005 to create and maintain a Network of Patient Safety Databases (NPSD) to provide an interactive, evidence-based management resource for healthcare providers, Patient Safety Organisations (PSOs) listed by the Agency for Healthcare Research and Quality (AHRQ), and others. AHRQ, the lead agency for patient safety in the USA implements the NPSD. Initially, the NPSD contains non-identifiable data derived from patient safety work product submitted by PSOs from across the country. This rich data source makes it possible to identify and track patient safety concerns for the purpose of learning how to mitigate patient safety risks and reduce harm across healthcare settings nationally. 
  6. Content Article
    This state-of-the-nation report from the National Hip Fracture Database (NHFD) focuses on the period from 1 January to 31 December 2022. It shows that the number of people who died in the month following a hip fracture now stands at 6.2%; down from 10.9% in 2007, when the NHFD was set up. However, the report also finds that it took longer for patients to reach a ward where a hip fracture team can work together (where there is the best chance of recovery) in 2022. It also states that fewer patients received prompt surgery to repair their broken hip by the day after they presented to hospital. There was an improvement in how many people with hip fracture received bone strengthening medicines to avoid future fractures in 2022, but some hospitals continue to report that none of their patients receive such treatment.
  7. News Article
    A trust has discovered 1,800 patients who were removed by mistake from its elective waiting list. Barking, Havering and Redbridge University Hospitals Trust chief executive Matthew Trainer wrote to colleagues in the east London health system today to “apologise for the stress this will have caused those experiencing a delay”. Of the 1,800 patients involved, 600 have been waiting more than a year and roughly 200 have been waiting for more than two years. Mr Trainer’s note explained: “The patients have been waiting to see our specialists in routine clinics in gynaecology, neurology, neurosurgery and ophthalmology.” It continued: “As we have been working through our waiting lists, we have discovered a problem with one of them that was used to deal with the backlog created by the pandemic. “It contained routine referrals that were submitted by GPs who wanted their patients to be seen by a specialist, but for whom there were no appointments available due to covid-19. Unfortunately, these patients were removed automatically from this list before they had been seen.” Read full story (paywalled) Source: HSJ, 26 April 2022
  8. News Article
    A ground-breaking, mandatory national medical device outcome registry has been launched to collate detailed information on all procedures involving high-risk (Class III/IIb) devices, including pacemakers, hip joint replacements and breast implants. Led by NHS England’s Outcomes and Registries programme, and developed in partnership with NEC Software Solutions (NEC), the Medical Device Outcome Registry platform (MDOR) will capture data on over two million medical device procedures and more than 10 million unique devices used on patients each year across the NHS and independent healthcare sector, addressing recommendations from the Cumberlege review and Patterson inquiry. Collecting key details of the procedure, the clinicians involved and devices used, the registry will include clinical observational and patient outcome data, providing a single, comprehensive repository to improve patient safety and outcomes. Scott Pryde, delivery director for the Outcomes and Registries Programme, NHS England, said: “Millions of people receive high-risk medical devices and implants every year. Whereas most procedures are a complete success, when things go wrong it can result in serious harm for the patients affected. The Medical Device Outcome Registry will be responsive to concerns about the safety and outcomes of patients who receive high-risk medical devices, such as implants, and will use the data to actively detect, predict and prevent patient harm, and improve outcomes for patients". “The result will be in a step change in improving patient safety in these procedures, providing clinicians and healthcare teams with secure access to critical information they can use to inform clinical decisions and improve the experience of patients before, during and after their procedures.” Read full story Source: Clinical Services Journal, 31 May 2023
  9. News Article
    Trusts must start submitting full data on surgeries which include a high-risk medical device into a new national registry by December as part of a national push to increase accountability and safety around surgery. NHS England is launching the new mandatory medical device outcome registry this month. The new registry was created in response to Baroness Cumberlege’s “First Do No Harm” review and initial data submissions about surgeries that include a high-risk medical device will begin in June. Details of the launch arrangements have been set out in a draft letter which HSJ has seen and understands is set to be sent to medical directors and other system leaders imminently. Relevant procedures include those, for example, involving either a Class III device, like an implant, or a Class IIb therapeutic device, such as drug-eluting balloon catheter. Read full story (paywalled) Source: HSJ, 16 May 2023
  10. Content Article
    The Patient Safety Database (PSD), previously called the Anesthesia Safety Network, is committed in the delivery of better perioperative care. Its primary goal is to make visible the lack of reliability of healthcare and the absolute necessity to build a new system for improving patient safety. This year, PSD has also been involved in the development of the SafeTeam Academy, an e-learning training platform associated with the Patient Safety Database, which offers video immersive courses using the power of cinema to train healthcare professionals. This is the latest newsletter from PSD, featuring a wide range of content by safety experts across Europe.
  11. Content Article
    The Preventable Deaths Tracker was set up to explore concerns raised by coroners to prevent future deaths. The tracker aims to collate data, information and analysis arising from coroners reports and other investigations and make it accessible for all. It hopes to warn against repeat hazards and highlight important lessons, to improve public safety, reduce avoidable harms and prevent premature deaths. The tracker was originally developed with funding from the National Institute for Health Research (NIHR) School for Primary Care Research.
  12. Content Article
    VigiBase is the Uppsala Monitoring Centre (UMC)’s starting-point for the journey from data to wisdom about safer use of medicines and wise therapeutic decisions in clinical practice. It is the driving-force at the heart of the work of UMC and the WHO Programme. The purpose is to ensure that early signs of previously unknown medicines-related safety problems are identified as rapidly as possible. VigiBase is the unique WHO global database of individual case safety reports (ICSRs). It is the largest database of its kind in the world, with over 20 million reports of suspected adverse effects of medicines, submitted, since 1968, by member countries of the WHO Programme for International Drug Monitoring. It is continuously updated with incoming reports.
  13. Content Article
    Pennsylvania is the only state that requires acute healthcare facilities to report all events of harm or potential for harm. With over 3.6 million acute care event reports, the Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest repository of patient safety data in the United States and one of the largest in the world. This report analyses the serious events and incidents from the database.
  14. Content Article
    Richard Armstrong, head of health registries for Northgate Public Services, explains why collecting more data is not a cure-all in a health crisis.
  15. Content Article
    Disclosure UK is the Database on which all pharmaceutical companies abiding by the Association of the British Pharmaceutical Industry (ABPI) Code of Practice must disclose ‘transfers of value’ to healthcare professionals, other relevant decision makers and healthcare organisations in the UK. Where possible, companies do this by naming the individuals and organisations and according to GDPR law, companies must identify an appropriate lawful basis before they process an individual's information. This guidance document by the ABPI is aimed at pharmaceutical companies using Disclosure UK. It explains and promotes the choice of the basis of 'legitimate interests' for disclosure, with the aim of increasing transparency in the relationships between healthcare professionals, other relevant decision-makers and the industry.
  16. Community Post
    I've been posting advice to patients advising them to personally follow up on referrals. Good advice I believe, which could save lives. I'm interested in people's views on this. This is the message I'm sharing: **Important message for patients relating to clinical referrals in England** We need a specific effort to ensure ALL referrals are followed up. Some are getting 'lost'. I urge all patients to check your referral has been received, ensure your GP and the clinical team you have been referred to have the referral. Make sure you have a copy yourself too. Things are difficult and we accept there are waits. Having information on the progress of your referral, and an assurance that is is being clinically prioritised is vital. If patients are fully informed and assured of the progress of their referrals in real-time it could save time and effort in fielding enquiries and prevent them going missing or 'falling into a black hole', which is a reality for some people. It would also prevent clinical priorities being missed. Maybe this is happening, and patients are being kept fully informed in real-time of the progress of their referrals. It would be good to hear examples of best practice.
  17. Content Article
    This guide published by NHS England & Improvement describes the validation rules relating to the LFPSE project, specifically around submitting an Adverse Event via the Adverse Event Application Programming Interface (API). It covers several types of validation rules, which have been split into three sections. Bespoke business validation rules which have been implemented based on the dependencies between responses and extensions that cannot be captured by the FHIR resource validation. FHIR validation responses which may be returned from the API when native FHIR validation checks the submission body against the LFPSE FHIR profiles defined for an adverse event. Invalid operations and similar responses which are external to validation of the submission, including responses pertaining to permissions, personal information and any other responses that do not fit into the two categories above.
  18. Content Article
    In this blog post, Kath Sansom, founder of the Sling the Mesh campaign, looks at the issue of payments being made to doctors and lobby groups by pharma and medical tech companies. She argues that these payments are a patient safety concern as it can lead to doctors displaying bias in advising treatments, with benefits being overstated and risks downplayed. This is especially concerning when industry money is given to consultants or researchers trialling new treatments. Kath highlights an investigation carried out by the Observer into the issue and explains why Sling the Mesh have lobbied the UK Government for a UK Sunshine style payment act, which would allow the public to look up the names of doctors, surgeons and researchers to see if they have taken money from industry.
  19. Content Article
    Disclosure UK is part of a Europe-wide initiative to increase transparency between pharmaceutical companies and the doctors, nurses, pharmacists and other health professionals and organisations it works with. They want to ensure that patients and others have confidence that this relationship is open and transparent and this is why the pharmaceutical industry is taking the lead on disclosing details of payments and other benefits in kind made by industry to healthcare professionals and healthcare organisations. This information will be published on the database - Disclosure UK. 
  20. Content Article
    Pennsylvania is the only state that requires acute care facilities to report all events of harm or potential for harm. The Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest repository of patient safety data in the United States and one of the largest in the world, with over 4.5 million acute care event reports dating back to 2004. Herein, we examine patient safety event reports submitted to the PA-PSRS acute care database in 2022 and compare them to prior years. The authors extracted data from PA-PSRS and obtained data from the Pennsylvania Health Care Cost Containment Council (PHC4). Counts of reports were calculated based on report submission date, and rates were calculated based on event occurrence date and calculated per 1,000 patient days for hospitals or 1,000 surgical encounters for ambulatory surgical facilities (ASFs). The study found there was a decrease in the number of incident reports submitted to PA-PSRS in 2022 and an increase in serious and high harm event reports.
  21. Content Article
    Intrahospital transport is a common occurrence for many hospitalised patients. Critically ill children are an especially vulnerable population who experience preventable adverse events at least once a week, on average. Transporting these patients throughout the hospital introduces additional hazards and increases the risk of adverse events. The transport process can be decomposed into a series of steps, each incurring specific risk. These risks are numerous and few of these risks are specific to the transport process. There is a paucity of literature available on paediatric intrahospital transport and related adverse events. Elliot et al. recently reviewed the Wake Up Safe database, a paediatric anesthesia quality improvement initiative across member institutions to disseminate information on best practices, for paediatric perioperative adverse events associated with anaesthesia-directed transport. The authors present several examples of airway and respiratory events taken from the database and discuss the complexity of the transport process.
  22. Content Article
    Standardised data and integration of systems are vital for full traceability, improving patient safety, and enabling swift action in healthcare incidents. The PIP breast implant scandal was not the first and transvaginal mesh will not be the last. In fact, the next national patient safety scandal is likely manifesting today. “There needs to be better processes to ‘track and trace’ patients who have received a device when a problem arises,” says Professor Sir Terence Stephenson, Nuffield professor of child health at UCL Great Ormond Street Institute of Child Health and chair of the Health Research Authority for England, in the Scan4Safety 2020 report. “Clear strategies and channels are needed to inform patients, the public and clinical professionals to help improve safety.” One common denominator among such incidents is the lack of traceability – limited visibility of the devices used, when and where they are used and, most importantly, in or on which patients. This is where standardised data comes into play. There is no shortage of data in the NHS. However, the ability to standardise and share that data between systems and organisations is something the health service as a whole still lacks. Today, achieving full traceability remains a key challenge for the NHS, with repercussions that continue to have a detrimental effect on patient care.
  23. Content Article
    Should new draft legislation around the use of mesh in women regarding incontinence or prolapse and a new guidance on a national registry meaning every woman choosing mesh in the future must be logged on a database be extended? Haydn Wheeler argues that a broader database is in need.
  24. Content Article
    In England and Wales, coroners are required to write Prevention of Future Deaths reports when a death is deemed preventable so that action is taken to avert similar deaths. Since July 2013, Prevention of Future Deaths reports have been openly available via the Courts and Tribunals Judiciary website (https://www.judiciary.uk/prevention-of-future-death-reports/). However, their presentation to date have been insufficient to identify trends and learn lessons. The authors of this paper designed a web scraper to create the Preventable Deaths Tracker. On 22 June 2022, 4001 PFDs were scraped, analysed, and compared to the Office of National Statistics’ preventable mortality statistics. This commentary, published in Medico-Legal Journal, summarises the key findings and offers recommendations to improve the Prevention of Future Deaths system so lessons can be learnt to avert preventable deaths.
  25. Content Article
    This study in the journal Medical Devices: Evidence and Research aimed to assess health system experiences of implementing Unique Device Identifier (UDI) systems for medical devices. Although the US Food and Drug Administration (FDA formalised the Unique Device Identification System Rule in 2013, parallel regulatory requirement for US health systems to use UDIs is lacking. Through semi-structured interviews, the authors identified barriers to implementing UDI systems and strategies to overcome them.
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