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Found 108 results
  1. News Article
    A young woman was left with a retained foreign object, after surgery in an India hospital. A checklist could have avoided her death. The response from the health officials was: “We have issued a show-cause notice to the staff seeking an explanation. We will initiate departmental action based on their replies and finding of our inquiry.” In the fields of healthcare quality and patient safety, such punitive measures of “naming and shaming” have not worked. T.S. Ravikumar, President, AIIMS Mangalagiri, Andhra Pradesh, moved back to India eight years ago with the key motive to improve ac
  2. Content Article
    The COVID-19 pandemic has further amplified the need for radical change in the provision of diagnostic services, but has also provided an opportunity for change. Many beneficial changes in relation to diagnostic pathways, such as increased use of virtual consultations and community services, have already been made. These changes must now be embedded. However, much more now needs to be done in the recovery period to establish new pathways to diagnosis, so that both patients and healthcare professionals can be assured that investigations will be done safely. To deliver the increase in diagn
  3. Content Article
    To improve safety, it is absolutely essential that human factor and design principles are embedded into the specifications for devices and this is what NHS Supply Chain are aiming to achieve through focused engagement with the end users of the products to gain a full understanding around who what where how and when they are used.
  4. Content Article
    We are currently developing the Open Registry infrastructure in South West England, and are bringing together medical device manufacturers (from the world's largest to the smallest) and NHS trusts, with their surgeons that already have relationships with specific manufacturers. Using the system: a patient example Imagine that you are in a consultation with your surgeon, who advises that the mitral valve in your heart needs to be repaired. Your surgeon advises that this procedure can be done with minimally invasive surgery. They recommend using Device-X and you ask, "Why, what evidence
  5. News Article
    Tens of thousands of defibrillators across the UK risk being unusable because 999 call handlers do not know about them. When someone has a cardiac arrest, ambulance staff can only direct bystanders to the nearest defibrillator if it is on a central register. "That could be the difference between life and death," said Adam Fletcher, head of British Heart Foundation Cymru. A campaign to register defibrillators on The Circuit has now been launched. Survival rates are low in the more than 30,000 out-of-hospital cardiac arrests each year in the UK, according to the British Heart
  6. Content Article
    The Coroner highlighted concerns about how the Philips Respironics AF 541 mask connects by tubing to the BIPAP ventilator by means of a 'push on' connection (rather than a fitting involving positive engagement). Evidence taken at the inquest indicated that this connection has come undone on other occasions as well. It was noted that the introduction of a filter at the site of the connection increased the potential for the joint to come apart. The Coroner asks whether a more robust docking system could be installed which is less vulnerable to working loose or being inadvertently pulled apa
  7. Content Article
    While under continual cardiac monitoring from the 6– 8 March 2021, Ann Geraghty experienced two periods of ventricular standstill which were recorded but missed. Had these been detected she would have been admitted into a Critical Care Unit, though the Coroner noted that her subsequent cardiac arrest could not have been prevented. The Coroner raises concerns that: The Philips central monitoring station used by the hospital detected the two periods of ventricular standstill but its alarm notification self-terminated when the heart rhythm had corrected. Following the Trust’s i
  8. News Article
    After three Covid-19 patients died at the make-shift Nightingale Hospital in London following a breathing tube mix-up, NHS trusts in England could be issued tougher ventilation guidance. In each of the cases, filters which prevent the build-up of fluid were not attached to the machines, resulting in dangerous blockages, but it has not yet been determined if these incidents contributed to their deaths. Coroner Nadia Persaud has said the way the machines vary from model to model can be "confusing" and may lead to future deaths, also ruling that the classification and colour coding was "wor
  9. Content Article
    Read the full article: Primodos, Mesh and Sodium Valproate: Recommendations and the UK Government’s response Other articles by this author: Primodos: The next steps towards justice (November 2020) Sodium Valproate: The Fetal Valproate Syndrome Tragedy Mesh: Denial, half-truths and the harms (March 2021) Related reading: A year on from the Cumberlege Review: Initial reflections on the Government’s response (Patient Safety Learning, 23 July 2021) Government response to the report of the Independent Medicines and Medical Devices Safety Review (21 July
  10. Content Article
    The Coroner highlights concerns raised by an independent expert in regards to the non-standardised colour coding used by the manufacturers of the filters on breathing systems of intensive care ventilators, noting that there is widespread confusion among Intensive Care Unit staff about their classification and colour coding. The report states this issue is not confined to Nightingale hospitals, but relates equally to all intensive care settings. It was sent to the Royal College of Anaesthetists and Faculty of Intensive Care Medicine for action and response.
  11. News Article
    Experts have warned that a device used to detect signs of oxygen level drops may not work as well on darker skin. According to NHS England and MHRA, pulse oximeters may sometimes overestimate oxygen levels. Now, NHS England is updating their guidance advising patients patients from black, Asian and other ethnic minority groups to seek advice from their healthcare professional, but to continue using pulse oximeters. "We need to ensure there is common knowledge on potential limitations in healthcare equipment and devices, particularly for populations at heightened risk of life-changi
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