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Found 1,311 results
  1. 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.
  2. 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
  3. 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.
  4. 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.
  5. 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.
  6. 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. 
  7. 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.
  8. 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.
  9. 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”.
  10. 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
  11. 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
  12. 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.
  13. 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
  14. 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
  15. Content Article
    This systematic review of qualitative evidence aimed to improve understanding of the processes and outcomes of redress and reconciliation following a life-changing event, from the perspectives of individuals experiencing the event and their families. The authors searched six bibliographic databases for primary qualitative evidence exploring the views of individuals who have experienced a life-changing event, and/or their family or carers, of redress or reconciliation processes. This was supplemented with targeted database searches, forward and backward citation chasing and searches of Google Scholar and relevant websites. The review identified three themes identified by patients and families that represent procedural elements required to support a fair and objective process: transparency, person-centred and trustworthy. A further theme identified—restorative justice—is about how a fair process feels to those who have experienced a life-changing event. It highlights the importance of an empathic relationship between the different parties involved in the process and the significance of being able to engage in meaningful action. Theses findings provide insights on how to conduct a fair review into instances of medical harm.
  16. Content Article
    Strategies to reduce medication dosing errors are crucial for improving outcomes. The Medication Education for Dosing Safety (MEDS) intervention, consisting of a simplified handout, dosing syringe, dose demonstration and teach-back, was shown to be effective in the emergency department (ED), but optimal intervention strategies to move it into clinical practice remain to be described. This study aimed tov describe implementation of MEDS in routine clinical practice and associated outcomes. The study was conducted in five stages (baseline, intervention 1, washout, intervention 2, and sustainability phases). The 2 intervention phases taught clinical staff the MEDS intervention using different implementation strategies. The study found that both MEDS intervention phases were associated with decreased risk of error and that some improvement was sustained without active intervention. These findings suggest that attempts to develop simplified, brief interventions may be associated with improved medication safety for children after discharge from the ED
  17. News Article
    Scrapping the new Therapeutic Products Act (TPA) will leave thousands of New Zealanders exposed to ongoing harm from dodgy medical devices, warn patient safety advocates and legal experts. The act, which was due to come into force in 2026, would have modernised the regulation of medicines and natural health products, and made medical devices, as well as cell, gene and tissue therapies, subject to a similar regulatory regime as drugs. The industry has backed the move, saying the new law was heavy-handed and would stop people getting access to the latest lifesaving technological advances. However, Auckland woman Carmel Berry — who was left in constant knife-like pain from plastic mesh implanted during surgery — said she was “living proof” of the old system’s failures. It took more than 10 years of lobbying by her and the other founders of Mesh Down Under to get authorities to take action — a decade in which hundreds of other people were injured. She is horrified that the TPA, signed into law in only July, is on the chopping block. Beginning work to repeal it was No 47 out of 49 points on the Government’s to-do list for its first 100 days. “I’m horrified. After so many years of developing and rewriting the act and getting it through ... shame on them.” Read full story Source: New Zealand Herald, 18 February 2024
  18. News Article
    Staff have assaulted patients and falsified medical records following deaths, according to a shocking new report into a scandal-hit mental health hospital where Nottingham killer Valdo Calocane was a patient. Multiple incidents of staff physically assaulting patients and workers feeling too scared to report problems at Highbury Hospital have been uncovered by the Care Quality Commission (CQC). The watchdog revealed police have investigating the deaths of at least two patients in which staff involved were later found by the hospital to have falsified their medical records in a new report, published on Friday. The news comes after The Independent revealed Nottinghamshire Healthcare Foundation Trust, which runs Highbury Hospital, had suspended more than 30 staff members following allegations of mistreating patients and falsifying records of medical observations. The trust also faces a further CQC review, commissioned by health secretary Victoria Atkins, following the conviction of killer Valdo Calocane who was a patient of Highbury Hospital’s community service teams. This review is due to be published later this year. Read full story Source: The Independent, 1 March 2023
  19. News Article
    It is still unclear how unauthorised metal parts came to be implanted in a number of the 19 children with spina bifida who suffered significant complications after spinal surgery. But it has emerged that one child died and 18 others suffered a range of complications after surgery at Temple Street Children’s Hospital – with several needing further surgery, including the removal of metal parts which were not authorised for use. Parents of the children undergoing complex surgery were left distraught by the disclosures that emerged yesterday, after campaigning for years while the young patients in need of operations deteriorated on waiting lists. Gerry Maguire, of Spina Bifida Hydrocephalus Ireland, said “absolute horror is being visited on parents and their advocates”. He condemned as disturbing the information which is “being drip-fed to his group and “more alarmingly the families concerned”. One mother expressed concern about further delays in surgery and said children are too complex to be taken for care abroad. Read full story Source: Irish Independent, 19 September 2023
  20. Event
    At this webinar, WHO will launch two WHO publications on Medication Safety, “Global burden of preventable medication-related harm” and “Policy brief on Medication Without Harm”, to create awareness and to support implementation of the WHO Global Patient Safety Challenge: Medication Without Harm. Register
  21. Content Article
    Wellcome Collection long read on two women who battled through decades of medical paternalism: Marie Lyon, who took Primodos, and Dr Isabel Gal, the scientist who first raised the alarm.
  22. News Article
    Health secretary Victoria Atkins has said mental health patients and staff must report the “horrific” sexual abuse allegations uncovered by The Independent to the police. Ms Atkins said victims would have her full support if they reported their claims to the police. Her intervention comes following a joint investigation by The Independent and Sky News, which revealed almost 20,000 reports of sexual harassment and abuse on NHS mental health wards in England. The allegations uncovered include patients claiming to have been raped by staff and other patients while being treated on mental health wards. In response to the initial investigation, Ms Atkins said a review launched last year into mental health services would now also look into sexual assault within the sector. Speaking on Sky News, she said: “These are horrific allegations that should not and must not happen in our care. Very, very vulnerable people have to stay in mental health inpatient facilities, and they do so because they need care, support, and treatment. “Some of the behaviours that have come to light are criminal offences, and so I would encourage anyone who feels able to – and I appreciate it is a difficult step – to go to the police and please report them, because they are crimes and we must drive them out.” Read full story Source: The Independent, 21 February 2024
  23. News Article
    In 2009, Emma Murphy took a phone call from her sister that changed her life. “At first, I couldn’t make out what she was saying; she was crying so much,” Murphy says. “All I could hear was ‘Epilim’.” This was a brand name for sodium valproate, the medication Murphy had been taking since she was 12 to manage her epilepsy. Her sister explained that a woman, Janet Williams, on the local news had claimed that taking the drug during her pregnancies had harmed her children. She was appealing for other women who might have experienced this to come forward. Murphy found the news segment that evening and watched it. “I was just stunned,” she says. “Watching that, I knew. I knew there and then that my children had been affected.” At that point, Murphy was a mother to five children, all under six, and married to Joe, a taxi driver in Manchester. “My kids are fabulous, all of them, but I’d known for years that something was wrong,” she says. “They weren’t meeting milestones. There was delayed speech, slowness to crawl, not walking. There was a lot of drooling – that was really apparent. They were poorly, with constant infections. I was always at the doctors with one of them." A call between Murphy and Janet Williams was the start of an incredible partnership. It led to the report published this month by England’s patient safety commissioner, Dr Henrietta Hughes, which recommended a compensation scheme for families of children harmed by valproate taken in pregnancy. Hughes has suggested initial payments of £100,000 and described the damage caused by the drug as “a bigger scandal than thalidomide”. It is estimated that 20,000 British children have been exposed to the drug while in the womb. Williams and Murphy have campaigned relentlessly to reach this point. It is by no means the endpoint – even now, an estimated three babies are born each month having been exposed to the drug. Together, the women formed In-Fact (the Independent Fetal Anti Convulsant Trust) to find and support families like theirs. They were instrumental in the creation of an all-party parliamentary group to raise awareness in government. Read full story Source: The Guardian, 22 February 2024
  24. Content Article
    North Central London Integrated Care System has piloted new guidelines and a local dashboard to ensure there is a safety net in place for females taking sodium valproate.This is a paywalled article published by the Pharmaceutical Journal.
  25. Content Article
    On the 7 February 2024, the Patient Safety Commissioner for England published a report considering options for redress for those who have been harmed by two of the interventions covered by the Independent Medicines and Medical Devices Safety Review: sodium valproate and pelvic mesh. In this blog, Patient Safety Learning sets out the background to this report, outlines responses from patient groups and campaigners, and reflects on how this work will be taken forward.
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