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Showing results for tags 'Patient harmed'.
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EventThis conference focuses on reducing medication errors and resulting harm in line with the WHO Medication without Harm Programme goal to reduce the level of severe, avoidable harm related to medications by 50% over the next five years. The conference focuses on prioritising high risk medications and high risk patient groups to enable your interventions to have the highest impact on patient care and reduction in patient harm. The conference which aims to bring together clinicians and pharmacists, managers, and medication safety officers and leads will reflect on medication safety issues that hav
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News ArticleNHS England has ordered an independent review into patient safety and governance concerns at an acute trust which had been resisting calls to take this step, HSJ has learned. The intervention at University Hospitals of Morecambe Bay Foundation Trust comes after pressure from staff and local MPs, who believe more extensive investigation is required into cases of patient harm within the trauma and orthopaedics division. The broad issues were first revealed by HSJ in November, with documents suggesting several patients were harmed after leaders failed to act on multiple concerns being r
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EventuntilThere are many sources of variation in healthcare that can affect the flow of patients through care systems. Reducing and managing variation enables systems to become more predictable and easier to manage so allowing improvement of quality and safety. To effect successful service improvements, you need to understand the source of variation and use a range of tools to reduce and manage it. This pandemic has provoked the best of human compassion and solidarity, but those who manage our health systems still face extraordinary challenges responding to COVID-19. Looking beyond the crisis, our
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Transvaginal Mesh Case Record Review
PatientSafetyLearning Team posted an article in Women's health
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ECRI: Wrong-site surgery (14 December 2020)
Patient Safety Learning posted an article in Surgery
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Content ArticleIn May 2019, the World Health Assembly recognised patient safety as a key health priority, acknowledging the need to “take concerted action to reduce patient harm in healthcare settings”.[1] They asked the World Health Organization (WHO) to formulate an action plan to help improve patient safety, resulting in the first draft Global Patient Safety Action Plan 2021-2030, published for consultation in August 2020.[2] Patient Safety Learning is pleased to have contributed to the development of this global initiative, with our Chief Executive, Helen Hughes, having attended the initial consulta
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Content ArticleHSIB's national learning reports can be used by healthcare leaders, policymakers, and the public to: Aid their knowledge of systemic patient safety risks. Understand the underlying contributing factors. Inform decision making to improve patient safety.
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Content ArticleAvMA’s services General information Making a complaint about NHS or private healthcare Accessing medical records Serious incident reports Brain injuries at birth Help with an inquest Raising concerns about a healthcare worker Making a legal claim for compensation Understanding legal claims Complaining about your solicitor.
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Content ArticleIn August last year, WHO published the first draft Global Patient Safety Action Plan 2021-2030.[1] It outlined the scale of the patient safety challenge we face globally, with WHO estimating that unsafe care is one of the 10 leading causes of death and disability worldwide.[2] The Action Plan set out a goal of achieving the maximum possible reduction in avoidable harm as a result of unsafe care, accompanied by actions required from WHO, governments, healthcare organisations and key stakeholders over 2021-2030 to help achieve this. We responded to WHO with our feedback.[3] As part of its o
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Content ArticleNational guidance for the investigation of any patient safety incidents identified as either a Serious Incident (SI) or No Surprises/Sensitive Issue relating to the provision of digital health care services in Wales
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Community PostWhat is your experience of having a hysterscopy? We would like to hear - good or bad so that we can help campaign for safer, harm free care. You can read Patient Safety Learning's blog about improving hysteroscopy safety here. You'll need to be a hub member to comment below, it's quick and easy to do. You can sign up here.
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Content ArticleConcerns about painful hysteroscopy Hysteroscopy is a procedure used as a diagnostic tool to identify the cause of common problems, such as abnormal bleeding, unexplained pain or unusually heavy periods in women. It involves a long, thin tube being passed into the womb, often with little or no anaesthesia. In a blog late last year, we reflected on some key patient safety concerns relating to these procedures in the NHS: Despite a significant number of women who undergo this procedure and experience high levels of pain, in many cases their remains little or no access to pain relief. R
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Content ArticleIn this study, Kim et al. analysed 1,189 patient safety event reports using a safety science and resilience engineering approach, which focuses on identifying processes to discover errors before they reach the patient so these processes can be expanded. They analysed the general care processes in which wrong-patient errors occurred, the clinical process step during which the error occurred and was discovered, and whether the error reached the patient. For those errors that reached the patient, they analysed the impact on the patient, and for those that did not reach the patient, we analysed ho
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News ArticleIn July last year, the Independent Medicines and Medical Devices Safety Review – chaired by Baroness Cumberlege— published its landmark report, First Do No Harm. It followed a two-year review of harrowing patient testimony and a large volume of other evidence concerning three medical interventions: Primodos, sodium valproate and pelvic mesh. Yesterday, in a written statement to Parliament, the Minister for Patient Safety, Suicide Prevention and Mental Health, Nadine Dorries, gave an update on the government’s response to the recommendations of the Cumberlege Review. In an article in
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News ArticleIn a Letter to the Editor published in The Times yesterday, the All Party Parliamentary Group on First Do No Harm Co-Chair Baroness Julia Cumberlege argues in favour of the work of the Independent Medicines and Medical Devices Safety (IMMDS) Review and its report 'First Do No Harm'. "Inquiries are only as good as the change for the better that results from their work." Read full letter (paywalled) Source: The Times, 5 January 2021
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Content ArticleAs an additional option to the text below, you might like to watch the following short video from Helen Hughes, Patient Safety Learning's Chief Executive. Using our voice to help create awareness and change Part of how we work towards our goals at Patient Safety Learning is by responding to official reports, using our independent voice for patient safety to help raise awareness of key issues and make the case for change. In July, we set out our analysis of the Cumberlege Review, a week after it was first published. We considered the review’s findings and highlighted the key
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News ArticleAn Independent Patients' Commissioner is set to be appointed to act as champion for people who have been harmed by medicines or medical devices. Baroness Cumberlege, who recommended the new role in a landmark report earlier this year, announced that the government had budged on the issue after initial resistance. She welcomed the move saying: "Had there been a patient safety commissioner before now, much of the suffering we have witnessed could have been avoided." But she added "the risk still remains" and further urgent action is needed to protect patients from potentially h
