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Found 1,321 results
  1. News Article
    A man who suffered a psychotic episode which lasted for weeks was not fully informed about potential extreme side-effects of taking steroids medication, England’s health service Ombudsman has found. Andrew Holland was prescribed steroids in early January 2022 by Manchester Royal Eye Hospital after losing vision in his left eye and suffering a severe infection in his right eye. The 61-year-old from Manchester was given the medication as treatment for eye inflammation, but soon began suffering from disrupted sleep and severe headaches. These side-effects developed into more serious ones, including becoming aggressive, psychotic, and inexplicably wandering the street at different times of the day and night. After several hospital visits due to his symptoms, Andrew attended Manchester University NHS Foundation Trust’s emergency department in mid-January with a severe headache and later became an inpatient. He was diagnosed with steroid induced psychosis, with symptoms including hallucinations, insomnia and behaviour changes. Though no failings were found with Manchester University NHS Foundation Trust in prescribing Andrew with steroids for the eye condition, the Ombudsman discovered a missed opportunity to fully inform him of potential extreme side-effects. He was therefore unable to make a fully informed decision about whether to take them or not. The Trust apologised for an ‘unsatisfactory experience’. However, the Ombudsman found relevant guidelines were not followed. Moreover, there had been no acknowledgement of mistakes in communication about the side-effects. Nor was any attempt made to correct them. Read full story Source: PSHO, 10 April 2024
  2. Community Post
    *Trigger warning. This post includes personal gynaecological experiences of a traumatic nature. What is your experience of having a hysteroscopy? 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.
  3. Content Article
    Richard von Abendorff, an outgoing member of the Advisory Panel of the Healthcare Safety Investigation Branch (HSIB), has written an open letter to incoming Directors on what the new Health Services Safety Investigations Body (HSSIB) needs to address urgently and openly to become an exemplary investigatory safety learning service and, more vitally, how it must not contribute to compounded harm to patients and families. The full letter is attached at the end of this page.
  4. News Article
    Kara Dilliway was just three years old when she came down with a common ear infection in October 2022. She recovered quickly, as was expected, but just days after the infection cleared her parents found she was struggling to hear and talk. “We’d noticed she’d just started to say yes and no to things, that’s when we thought something is going on,” says her mother Sam Dilliway, a 41-year-old community care worker from Basildon, Essex. Doctors said she could have glue ear, a common condition in children – fluid build-up had started to cause problems with her hearing, and would need draining. But what should have been a minor ailment has turned into a never-ending ordeal for the family. What was a simple case of glue ear could now leave her with hearing loss for up to two years as she awaits routine treatment. It comes after data released in January found that over 10 million people have been left on NHS waiting lists for basic ear care services. Dr Aymat says that the long-term effects of such conditions being left untreated in children can be severe. While glue ear is unlikely to leave permanent damage, there is always a small risk of permanent hearing loss. However, the developmental effects are far more likely and potentially long-lasting. Read full story Source: The Independent, 1 April 2024
  5. Content Article
    Health Services Research (HSR) conceptual models examine the complexity and “basic science” of patient safety. HSR methods can help quantify patient safety problems, enhance their understanding, and develop and test solutions. However, preventable harm persists and even worsened during the pandemic. One reason is inadequate attention and investment in patient safety over the past two decades. Significant investments are still needed to measure the burden of different patient safety events across settings and to address emerging safety threats. Solutions need to be developed, evaluated, and implemented through rigorous research to ensure widespread, effective adoption. Multidisciplinary strategies are required both to mitigate safety threats before they lead to patient harm, and to close the implementation gap. Outside of AHRQ and VA funding, patient safety research in the United States is underfunded. Efforts to translate HSR to patient care, policy, and clinical practice is essential for patient safety improvements. These efforts require health services researchers to go beyond publishing a paper; they must work closely with healthcare organizational leaders, clinicians, policymakers, and patients to ensure their findings are acted upon, and to help propose and test solutions. The National Center for Patient Safety (NCPS) offers an excellent model to do so by funding dedicated patient safety centres of inquiry (PSCIs) nationally. PSCIs focus on research and implementation activities that promote organization-wide learning. The PSCI model adds significant value to creating a learning health system for safety that invests in patient safety data gathering, analysis, learning, and actionable improvements.
  6. News Article
    A senior mental health nurse suffered “degrading and humiliating” treatment while she languished for 10 days on an unsuitable NHS ward during a mental health crisis, The Independent has been told. Rachel Luby, 36, was admitted to Basildon Hospital A&E in Essex on 5 January this year after attempting to take an overdose of over-the-counter medicine following a traumatic assault. This, she claimed, was the start of weeks of horrific care she endured while waiting for a mental health bed. It culminated in her being restrained and forced into a caged van “like an animal”. She revealed her story after The Independent reported on a warning from top emergency doctors that self-harming and suicidal patients who go to A&E are not being treated with compassion because staff are overwhelmed. Ms Luby, an award-winning nurse, said she waited more than a week and a half in a general hospital before she was moved to a bed on a mental health ward. Ms Luby was able to leave the ward and find medication to overdose again, despite staff allegedly assessing her as a risk. In a second incident, she went to the bathroom and attempted to take her own life. She told The Independent: “I feel that this is something I will not recover from. I will not ever reach out for help in the future. “If this is the treatment that I’m getting as a nurse, then what the heck is happening to those that don’t have the voice or education that I have? It horrifies me to think what is happening to people that are far more vulnerable than me.” Read full story Source: The Independent, 27 March 2024
  7. Content Article
    Anti-choking devices are intended to alleviate choking incidents after Basic Life Support protocols have been attempted and failed. There are numerous counterfeit and unbranded anti-choking devices being sold in the UK online which do not have a valid UKCA or CE mark and may pose a significant risk of worsening choking if used. These devices should not be used in the event of a choking emergency and should be disposed of once identified as counterfeit or non-compliant.
  8. Content Article
    Imagine an organisational culture of trust, learning and accountability. In the wake of an incident, a restorative just culture asks: ‘who are hurt, what do they need, and whose obligation is it to meet that need?’ It doesn’t dwell on questions of rules and violations and consequences. Instead, it gathers those affected by an incident and collaboratively addresses the harms and needs created by it, in a way that is respectful to all parties. It holds people accountable by looking forward to what must be done to repair, to heal and to prevent. This film documents the amazing transformation in one organisation —Mersey Care, an NHS mental health trust in the UK. Only a few years ago, blame was common and trust was scarce. Dismissals were frequent: caregivers were suspended without a clear idea of what they might have done wrong. Mersey Care’s journey toward a just and learning culture has repaired and reinvigorated relationships between staff, leaders and service users. It has enhanced people’s engagement, joint ownership and sense of responsibility. It has taken the organization to a place where hurt doesn’t get met with more hurt, but with healing.
  9. Content Article
    The Patient and Client Council’s role with respect to health and social care services is to: represent the interests of the public promote the involvement of the public; assist people making or intending to make a complaint through advocacy; promote the advice and information by HSC bodies to the public about the design, commissioning and delivery of services; undertake research into the best methods and practices for consulting and engaging the public.
  10. Content Article
    The Northern Ireland Public Services Ombudsman investigates unresolved complaints about public bodies in Northern Ireland.   Before you make a complaint to us you should normally have: Complained directly to the organisation  Gone through its complaints process Received a final response to your complaint. Their website will give you more information on what Northern Ireland Public Services Ombudsman do, how to make a complaint, and their investigations.
  11. Content Article
    The Regulation and Quality Improvement Authority (RQIA) are an independent health and social care regulator in Northern Ireland. RQIA aim to assure public confidence in health and social care through their independent, proportionate and responsible regulation. Through inspections, reviews and audits, RQIA provides assurance about the quality of care, challenges poor practice, promotes improvement and safeguards the rights of service users. RQIA informs the public of their findings through the publication of reports. They are committed to working closely with service providers so that they can deliver improved care and are dedicated to hearing and acting on the experiences of patients, clients, families and carers. This leaflet provides more information about RQIA.
  12. News Article
    A group of doctors offered a controversial medical technique which allegedly put kidney patients' health at risk. At least 20 patients at Queen Alexandra Hospital (QA) in Portsmouth have been using the procedure, which is not recommended in UK guidelines. A consultant was wrongly sacked from the hospital in 2018 after objecting to the practice. The hospital trust said the safety and care of its patients was its priority. Jasna Macanovic, who worked at the QA for 17 years, had raised concerns about the way the trust was allowing some staff to deliver the dialysis technique - known as buttonholing. "I don't think they're fit to practise medicine," Dr Macanovic told the BBC. When Dr Macanovic examined the records of 15 patients using the buttonholing technique at the QA, she found infection rates four times higher than they experienced using the standard technique. Read full story Source: BBC News, 15 March 2024
  13. Content Article
    This episode of the Business of Healthcare podcast delves into the complex and sensitive topic of the mesh scandal which has impacted countless women's lives. Host Tara Humphrey welcomes Consultant Gynecologist and Urogynecology subspecialist Dr Wael Agur to share his expert insights on the rise and fall of mesh devices in surgical procedures. Wael offers a candid look at the multifaceted issues surrounding patient consent, the role of manufacturers, aggressive marketing strategies, and the ethical dilemmas faced by medical professionals.
  14. News Article
    The government is facing calls for a public inquiry into the scandal of sexual abuse in mental health hospitals, following an investigation by The Independent. Rape Crisis England and Wales has warned that the “alarming” scale of abuse within the UK’s psychiatric system requires “major intervention” from ministers. It comes after an expose by the Independent and Sky News revealed that almost 20,000 reports of sexual incidents – involving both patients and staff – had been made in more than half of NHS mental health trusts in the past five years. As well as a public inquiry, which would give survivors the chance to give evidence, Rape Crisis England and Wales wants the government to appoint a named minister with responsibility for addressing the problem. Chief executive Ciara Bergman said: “That anyone in the already vulnerable position of needing or being detained for in-patient care because of their mental health needs should experience sexual violence and abuse whilst in the care of the state, is deeply concerning. “We are concerned that without major intervention and leadership at the highest levels, this could lead to more incidents of sexual violence and abuse happening, and this behaviour being accepted as inevitable, when it is not, and is indeed absolutely preventable.” Read full story Source: The Independent, 15 March 2024
  15. Content Article
    This article provides an overview of recent legislative developments intended to create a new independent board within the Department of Health and Human Services to improve patient safety in the United States of America.
  16. Content Article
    Ambulances lined up outside hospital Emergency Departments (EDs) are a vivid, and politically embarrassing, indication of inadequate capacity in the NHS. Media reports of diktats demanding that hospital CEOs meet performance targets suggest a desire for action, but are the local solutions being implemented to ease the pressure in the best interest of patient safety? The use of ‘safety cases’ in healthcare has received some interest in recent years but the conclusion drawn by, for example, Leberati and her colleagues,[1] was that while they have some potential value they are "fraught with challenge, highlighting the limitations of efforts to transfer safety management practices to healthcare from other sectors". A survey of the literature suggests that there is a danger of conflating ‘safety cases’ with ‘safety management’ or ‘quality’ systems. Part of the problem might be that safety cases are more a concept rather than a methodology: there is no script to follow. In this blog, Norman MacLeod discusses whether the the current crisis in hospital capacity can be explored through the safety case lens.
  17. Event
    Featuring leading legal experts and experienced clinicians this event will provide an update on current claims processes and how to respond to claims. The conference will look at the patient perspective and explore why patients decide to litigate. There will be an extended session on mediation and ADR. The conference will also update delegates on the new Patient Safety Incident Response Framework (PSIRF) and implications for Clinical Negligence Litigation. The conference will also consider current issues topical in clinical negligence including Maternity Safety and clinical negligence reform. Throughout the day, there will be interactive sessions, small breakout groups, and collaborative exercises, fostering a dynamic learning experience. This conference will enable you to: Network with colleagues with an interest in clinical negligence. Learn from outstanding practice in responding to claims. Reflect on national developments and learning. Understand the patient perspective and why patients decide to litigate. Explore the impact of the new Patient Safety Incident Response Framework on Clinical Negligence claims and litigation. Improve the way claims are responded to and improve practice in mediation and ADR. Develop your skills in learning from claims to reduce avoidable harm. Understand how you can bring together Complaints, Claims and Patients Safety Investigation. Identify key strategies for supporting staff who are the subject of a claim. Reflect on the progress towards clinical negligence reform and how the system may change. Understand the standards to which services will be judged during the Pandemic. Ensure you are up to date with the latest data with regard to learning from obstetric and maternity claims. Self assess and reflect on your own practice. Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register Follow on Twitter @HCUK_Clare #ClinicalNegligence hub members receive a 20% discount. Email info@pslhub.org for discount code.
  18. Content Article
    This report examined whether the NHS has been successful in improving the patient safety culture, encouraging reporting and learning from patient safety incidents. 
  19. News Article
    Patient Safety Awareness Week, an annual recognition event in the USA that occurs in March, is intended to encourage everyone to learn more about health care safety. During this week, the Institute for Healthcare Improvement (IHI) seeks to advance important discussions locally and globally, and inspire action to improve the safety of the health care system — for patients and the workforce. Patient Safety Awareness Week serves as a dedicated time and platform for growing awareness about patient safety and recognising the work already being done. IHI works with partners around the world to improve the safety of health care for patients, caregivers, and the health care workforce. Learn more about IHI's work to advance patient and workforce safety.
  20. Content Article
    The Northern Care Alliance NHS Foundation Trust (NCA) has published an independent report by Barrister Mr Carlo Breen into the Trust’s historic management of concerns in relation to a Consultant Spinal Surgeon. The investigation found that certain patients, relatives and colleagues had been significantly let down. The Trust fully accepts the findings and apologises for any distress or harm caused by the issues identified within the report. In response to a significant Freedom to Speak Up concern, NCA Chief Executive Dr Owen Williams commissioned Mr Breen in March 2022 to investigate how historic concerns and complaints dating back to 2007 relating to this consultant’s conduct, probity and capability had been previously handled and what lessons could be learned. Mr Breen’s review is the second review commissioned by the Trust relating to these important matters. The first report detailed the findings of the “Spinal Patient Safety Look Back Review” and was published last year. Dr Williams said: “I am deeply sorry and apologise to the patients and their families for the care which is described in both Mr Breen’s report released today and the patient look back review from last year. “I also apologise to my NCA colleagues who have had to work too hard to get their concerns heard and thoroughly investigated. I am thankful that they persisted. We will do right by them and our patients by continuing to put into practice what we have learned”.
  21. News Article
    England’s NHS Ombudsman has warned that cancer patients could be put at risk because of over-stretched and exhausted health staff working in a system at breaking point and delays in diagnosis and treatment. The Parliamentary and Health Service Ombudsman (PHSO) revealed that between April 2020 and December 2023, his Office carried out 1,019 investigations related to cancer. Of those 185 were upheld or partly upheld. Issues with diagnosis and treatment were the most common cancer-related issues investigated by PHSO. These issues included treatment delays, misdiagnosis, failure to identify cancer, the mismanagement of conditions, and pain management. Complaints about cancer care also included concerns about poor communication, complaint handling, referrals, and end-of-life care. Most investigations were about lung cancer, followed by breast cancer and colorectal cancer. The Ombudsman recently closed an investigation around the death of Sandra Eastwood whose cancer was not diagnosed for almost a year after scans were not read correctly. The delay meant she missed out on the chance of treatment which has a 95% survival rate. In 2021, PHSO published a report about recurrent failings in the way X-rays and scans are reported on and followed up across the NHS service. Mr Behrens said, “What happened to Mrs Eastwood was unacceptable and her family’s grief will no doubt have been compounded by knowing that mistakes were made in her care. “Her case also shows, in the most tragic of ways, that while some progress has been made on my recommendations to improve imaging services, it is not enough and more must be done. “Government must act now to prioritise this issue and protect more patients from harm.” Read full story Source: Parliamentary Health and Health Service Ombudsman, 9 March 2024
  22. News Article
    Nearly 70 healthcare workers with Long Covid will take their fight to the High Court later to sue the NHS and other employers for compensation. The staff, from England and Wales, believe they first caught Covid at work during the pandemic and say they were not properly protected from the virus. Many of them say they are left with life-changing disabilities and are likely to lose income as a result. The Department of Health said "there are lessons to be learnt" from Covid. The group believe they were not provided with adequate personal protective equipment (PPE) at work, which includes eye protection, gloves, gowns and aprons. In particular, they say they should have had access to high-grade masks, which help block droplets in the air from patient's coughs and sneezes which can contain the Covid virus. But the masks they were given tended to be in line with national guidance. Rachel Hext, who is 36, has always insisted that she caught Covid in her job as a nurse in a small community hospital in Devon. "It's devastating. I live an existence rather than a life. It prevents me doing so much of what I want to do. And it's been four years." Her list of long Covid symptoms includes everything from brain fog and extreme fatigue to nerve damage, and deafness in one ear. Solicitor Kevin Digby, who represents more than 60 members of the group, describes their case as "very important". He says: "It's quite harrowing. These people really have been abandoned, and they are really struggling to fight to get anything. "Now, they can take it to court and hope that they can get some compensation for the injuries that they've suffered." Read full story Source: BBC News, 6 March 2024 Related reading on the hub: Healthcare workers with Long Covid: Group litigation – a blog from David Osborn The pandemic – questions around Government governance: a blog from David Osborn
  23. Content Article
    Antibiotic underdosing is a widespread issue in the healthcare system. The use of modern infusion pumps to deliver intravenous (IV) medications has resulted in the practice of flushing IV lines being lost in some specialties. Failure to give full doses of IV antibiotics poses significant risks to individual patients as well as adding to the problem of antimicrobial resistance (AMR). In this interview, Ruth Dando, Head of Nursing, Theatres, Critical Care and Anaesthetics at Barking, Havering and Redbridge University Hospitals Trust (BHRUHT) explains why antibiotic underdosing is a risk to patient safety and describes how she has implemented a change in practice to tackle the issue across BHRUHT. A transcript is available below the video.
  24. News Article
    MPs are calling for a new review into the dangers of the drug Primodos, claiming that families who suffered avoidable harm from it have been "sidelined and stonewalled". MPs said the suggestion there is no proven link between the hormone pregnancy test and babies being born with malformations is "factually and morally wrong". A report by the All-Party Parliamentary Group (APPG) on hormone pregnancy tests claims evidence was "covered up" and it is possible to "piece together a case that could reveal one of the biggest medical frauds of the 20th century". Around 1.5 million women in Britain were given hormone pregnancy tests between the 1950s and 1970s. They were instructed to take the drug by their GPs as a way of finding out if they were pregnant. But Primodos was withdrawn from the market in the UK in the late 1970s after regulators warned "an association was confirmed" between the drug and birth defects. However, in 2017 an expert working group found there was insufficient evidence of a causal association. But MPs now claim this report is flawed. It's hugely significant because the study was relied upon by the government and manufacturers last year to strike out a claim for compensation by the alleged victims. Read full story Source: Sky News, 1 March 2024
  25. News Article
    A surgeon sacked by a hospital after raising safety concerns has accused the trust of a cover-up after a patient was partially blinded during an operation. Juanita Graham, 41, lost the sight in her left eye during an operation at Bath's Royal United Hospital (RUH) in 2019. She is now suing the trust. Serryth Colbert said he was put down as the lead author on an investigation into the incident, but said he "did not write a word" of it. Mr Colbert has described the hospital investigation into Mrs Graham's operation as "deeply flawed". The surgeon, who specialises in the head, neck, face and jaw, has made several serious allegations about patient safety at the RUH, and believes these claims led to him being regarded as a troublemaker and dismissed in October 2023. Mrs Graham, from Trowbridge, said she was still traumatised by the operation on her eye. "I remember coming round, seeing the time and felt like a gush and I couldn't see," she said. "The next time I remember waking up again, I thought it was my partner but it was a surgeon and he was crying. I said 'what's gone wrong?'". After the operation, a Root Cause Analyses (RCA) report produced by the trust said the hospital was not to blame, although it did say the risks could have been explained more clearly to Mrs Graham. Mr Colbert, whose name was added as the lead investigator, said his only involvement in the report was when he was called on the phone by a nurse, who he said did the RCA, to explain what the operation involved. The 48-year-old surgeon said: "I have been put down here to my amazement as the lead author on this. "That is not correct. I did not write a word of this. "The conclusion is the root cause of the complication was down to a bit of paperwork which could have been performed a bit better. "The root cause was not down to paperwork. It was all covered up... that was indefensible." Read full story Source: BBC News, 29 February 2024
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