Search the hub

Recommendations The Government should immediately issue a fulsome apology on behalf of the healthcare system to the families affected by Primodos, sodium valproate and pelvic mesh. The appointment of a Patient Safety Commissioner who would be an independent public leader with a statutory responsibility. The Commissioner would champion the value of listening to patients and promoting users’ perspectives in seeking improvements to patient safety around the use of medicines and medical devices. A new independent Redress Agency for those harmed by medicines and medical devices should be created based on models operating effectively in other countries. The Redress Agency will administer decisions using a non-adversarial process with determinations based on avoidable harm looking at systemic failings, rather than blaming individuals Separate schemes should be set up for each intervention – HPTs, valproate and pelvic mesh – to meet the cost of providing additional care and support to those who have experienced avoidable harm and are eligible to claim. Networks of specialist centres should be set up to provide comprehensive treatment, care and advice for those affected by implanted mesh; and separately for those adversely affected by medications taken during pregnancy. The Medicines and Healthcare products Regulatory Agency (MHRA) needs substantial revision particularly in relation to adverse event reporting and medical device regulation. It needs to ensure that it engages more with patients and their outcomes. It needs to raise awareness of its public protection roles and to ensure that patients have an integral role in its work. A central patient-identifiable database should be created by collecting key details of the implantation of all devices at the time of the operation. This can then be linked to specifically created registers to research and audit the outcomes both in terms of the device safety and patient reported outcomes measures. Transparency of payments made to clinicians needs to improve. The register of the General Medical Council (GMC) should be expanded to include a list of financial and non-pecuniary interests for all doctors, as well as doctors’ particular clinical interests and their recognised and accredited specialisms. In addition, there should be mandatory reporting for pharmaceutical and medical device industries of payments made to teaching hospitals, research institutions and individual clinicians. The Government should immediately set up a task force to implement this Review’s recommendations. Its first task should be to set out a timeline for their implementation. Response from Patient Safety Learning Patient Safety Learning welcomes the publication of the First Do No Harm report today from the Independent Medicines and Medical Devices Safety Review. The Chair of the review, Baroness Julia Cumberlege, highlighted in this that they found the healthcare system to be "disjointed, siloed, unresponsive and defensive" to the patients effected by these issues. She also noted that: ‘The system is not good enough at spotting trends in practice and outcomes that give rise to safety concerns. Listening to patients is pivotal to that’ The report highlighted some key themes consistent with other major patient safety failures: Patients not being engaged in their care: Lacking the information required to make informed choices, awareness of how to report problems and their experiences not being recognised. Ineffective reporting: Data not being utilised to identify and address patient safety issues. Existing reporting systems not being effective enough to capture this information and share learning widely. Blame culture: Persistent failure to acknowledge when things go wrong for fear of blame, reducing the ability to address threats to patient safety. Patient Safety Learning considers that patient safety is currently treated as one of many priorities to be weighed against each other. We think it is wrong that safety is negotiable. Patient safety must be core to the purpose of healthcare, reflected in everything that it does.

Michael was diagnosed with Crohn's disease at the age of 12 and had his first operation at 14. He died last weekend and was the same age as me. Our daughters were in the same year at secondary school together, and we got to know each other that way at first and then through our mutual interest in health care. When he awoke from an operation to discover he had a stoma bag, he didn't wallow. He bought items online to make it a 'smart' stoma bag to be able to get an alert when it was near full and provide useful data to his medical consultants. This was the type of person he was. Whenever I needed help in anything and asked him, he would unconditionally do everything he could to help, and never failed to deliver – I wish I had been able to do more for him. When he realised that thousands of other patients would be able to benefit from his smart ostomy bag, he tried to get innovation funding to develop and manufacture it at scale for the NHS. He tried over 40 times and received over 40 rejections. People on the other side of the Atlantic were able to see what the NHS couldn't, and 11 Health (he was the 11th person to have a bowel transplant) moved to the West Coast of the USA and grew quickly. He was 'patient in residence' at Stanford Medical school, one of the first such roles in the world. With the clinicians at Stanford, they created the Everyone Included programme, a joint initiative between clinicians and patients which as he described it is "a framework for healthcare innovation, implementation and transformation based on principles of mutual respect and inclusivity". He mentioned this and his journey as a patient in his Ted X talk in 2018. In that talk, he calls for a Chief Patient Officer to work with healthcare execs in co-designing new services for patients or improving existing services. Involving patients in this sort of work is a key foundation for safer healthcare systems. This is not a non-exec role, it is not an arms length committee tick box role. It is a role that can have a profound effect on the ways that services are delivered to patients. It is hugely important and no UK care providers has anyone like this on their exec teams. If you know different, please comment on it below. I think it is about time that a movement to appoint Chief Patient Officers into Trusts was started, don't you? See here for a detailed interview with Michael in 2018: https://www.highland-marketing.com/interviews/hm-interview-michael-seres/

Key points Medication errors are the most common type of error affecting patient safety and the most common single, preventable cause of adverse events. Medicines calculations can assist in preventing an inaccurate medicines dose from being administered to the patient, which could result in suboptimal therapeutic benefit and/or possible harm to the patient. It is crucial for IV infusion calculations to be accurate, because these medicines directly enter the venous system and generally have a prompt action. Therefore, there is limited possibility of removing the medicine if an error is made. Individual nurses and healthcare organisations must ensure that medicines calculation skills are developed and maintained in practice.

What can I learn? Practical guidance and examples of best practice in the design of infusion devices How design can be used to change and make safer the use of infusion devices in practice. Principles that can be widely applied to the design of other technologies

The aims of this study were to: eradicate accidental administration of medication into the arterial line and improve arterial line safety estimate the prevalence of wrong route arterial line drug errors conduct primary research implement the NIC in the East of England assess cost effectiveness and the uptake of the NIC in the East of England understand the reasons for barriers to adoption.

The webinar covers: human factors pitfall of hospital procurement usability testing task efficiency examples of good and not so good design.