1. Design of medical equipment should include input from human factors experts at an early stage. The medical equipment procurement process should include human factors assessments.
2. Design of drug ampoules and packaging should incorporate human factors principles to optimise readability and reduce the risk of mis-selection: anaesthetists, pharmacists and procurement departments should ensure that these principles are prioritised during their purchasing processes.
3. Design of safe working environments should incorporate human factors principles. Regu
Witness(es): Emma Murphy, Founder, Independent Foetal Anti-Convulsant Trust (In-FACT); Janet Williams, Founder, Independent Foetal Anti-Convulsant Trust (In-FACT); Kath Sansom, Campaigner, Sling the Mesh Campaign.
Witness(es): Professor Sir Cyril Chantler, Deputy Chair, Independent Medicines and Medical Devices Safety Review; Simon Whale, Review Member and Communications Lead, Independent Medicines and Medical Devices Safety Review; Baroness Julia Cumberlege, Chair, Independent Medicines and Medical Devices Safety Review.
Witness(es): Maria C
The IMMDS Review examined the response of the healthcare system in England to the harmful side effects of three medical interventions: Hormone pregnancy tests, sodium valproate and pelvic mesh implants. These interventions had resulted in a truly shocking degree of avoidable harm to patients over a period of decades, with the Review describing the healthcare system’s response to this as ‘disjointed, siloed, unresponsive and defensive’.
In this report, the Government provides a progress update on the implementation of the Review’s recommendations, which is summarised below:
The World Health Organization states that unsafe care is one of the top ten leading causes of death and disability worldwide, with the NHS estimating that there are around 11,000 avoidable deaths annually due to safety concerns. However, despite a range of international and national initiatives aimed at reducing avoidable harm, it remains a persistent, wide-scale problem.
A key reason for this is the implementation gap, the difference between what we know improves patient safety and what is done in practice. In this report Patient Safety Learning highlights six specific policy areas where
A strong and effective ICS will have a deep understanding of all the people and communities it serves.
The insights and diverse thinking of people and communities are essential to enabling ICSs to tackle health inequalities and the other challenges faced by health and care systems.
The creation of statutory ICS arrangements brings fresh opportunities to strengthen work with people and communities, building on existing relationships, networks and activities.