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Found 397 results
  1. News Article
    Babies and mothers are at risk of injury and death because too many maternity units have not improved care despite a string of childbirth scandals, a Care Quality Commission (CQC) report has warned. In a highly critical report published on Tuesday, the CQC voiced serious concern that lessons are not being learned and that many incidents involving patients’ safety are still not being recorded. Some hospitals have been “too slow” to take the steps needed to make labour and birth safer, despite multiple inquiries, reports and recommendations to do so, it said. The CQC also found ot
  2. Content Article
    The report highlights the next steps that maternity services and the CQC need to take: For maternity services and local maternity systems Leadership: In line with essential action 2 of the first Ockenden review, Boards must take effective ownership of the safety of maternity services. This includes ensuring that they have high quality, multidisciplinary leadership and positive learning cultures. They must seek assurance that staff feel free to raise concerns, that their concerns and adverse events lead to learning and improvement and that individual maternity staff competencies ar
  3. News Article
    A mental health hospital in Suffolk has been closed after inspectors found it was failing to protect patients from harm and abuse. St John's House in Palgrave, near Diss, was previously rated inadequate by the Care Quality Commission (CQC). A further inspection of the 49-bed hospital found the care was "unacceptable" and "insufficient progress had been made regarding patient safety". The company that runs the hospital, Partnerships in Care, part of the Priory Group, has now decided to close the site. Stuart Dunn, CQC head of inspection for mental health and community services, s
  4. News Article
    At least three people died and more came to ‘severe harm’ after treatment delays across three specialties at one hospital trust, new reports have revealed. King’s College Hospital Foundation Trust commissioned harm reviews due to problems with a lack of capacity and poor management of waiting lists in endoscopy, dermatology and ophthalmology pre-pandemic. Most of the problems relate to the trust’s southern site, Princess Royal University Hospital, and took place before the current executive team took over. The most recent board papers revealed a review of 614 cases at the PRUH’s endo
  5. News Article
    76 people were unintentionally exposed to ionising radiation in Irish hospitals in 2020, according to the Health and Information Quality Authority (HIQA). This figure represents an 11% increase on the total reported in 2019. HIQA today published an overview report on the 'increase in accidental and unintended exposure to ionising radiation events notified to HIQA in 2020. Under the European Union (Basic Safety Standards for Protection against dangers arising from Medical Exposure to Ionising Radiation) Regulations 2018 and 2019, HIQA is the competent authority for patient protection
  6. Content Article
    Further reading HIQA: Annual report of accidental or unintended exposures to ionising radiation in 2019 CQC reports on safe use of radiation in healthcare settings (19 December 2019)
  7. Content Article
    'To support all prescribers in prescribing safely and effectively, a single prescribing competency framework was originally published by the National Prescribing Centre/National Institute for Health and Care Excellence (NICE) in 2012. NICE and Health Education England approached the Royal Pharmaceutical Society (RPS) to manage the update of the framework on behalf of all the prescribing professions in the UK. A Competency Framework for all Prescribers was first published by the RPS in July 2016. Going forward, the RPS will continue to maintain and publish this framework in collabora
  8. Content Article
    The WHO's Global Patient Safety Action Plan framework includes seven strategic objectives, which can be achieved through 35 specific strategies represented in this infographic.
  9. Community Post
    What 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.
  10. Event
    This webinar will focus on how to harness the vast experience of the voluntary sector and advocate locally appropriate strategies to improve patient safety, through a network of Ambassadors. Who should attend? Patient safety can only be achieved by collaboration between the professionals, patients, families, community members and stake holders. So, whatever your background you are most welcome. Objectives To raise awareness about the burden of unsafe health care. To bring together the voluntary sector with a stake in health improvement programmes, to adopt a c
  11. Content Article
    “I was not able to walk for weeks until it had healed up. The impact was quite dramatic.” (Patient account) About the project This project, sponsored by Mölnlycke*, invites patients who have experienced an infection following surgery to share their experiences by being interviewed. These patient insights will be used to create a ‘Digital Storybook’, alongside interviews with healthcare workers. Key aims: To raise awareness of how infections following surgery can affect a patient and/or their families and carers. This might include physical, emotional or professional imp
  12. Content Article
    Following incidents where bottles of liquefied phenol 80% were either confused with other medication or caused burns when spilt, this alert asks providers to eliminate its use and to follow professional guidance to use safer alternatives. Phenol, a caustic compound used for its antimicrobial, anaesthetic, and antipruritic properties, is highly toxic and corrosive. Liquefied phenol 80% can cause burns, severe tissue injury and is rapidly and well absorbed causing systemic toxicity. It is most commonly used in podiatry and orthopaedic foot surgery for destroying the nail matrix. Action
  13. Content Article
    The article concludes with the following key findings: There were 278,548 acute care events reported in PA-PSRS during 2020, representing a 5.3% decrease from 2019. Prior to 2020, reports of Incidents and Serious Events had increased each year since 2016. The number of reported high harm events has decreased from 726 in 2005 to 417 in 2020. The top four event types, accounting for more than three quarters of the acute event reports in 2020, are: Error Related to Procedure/Treatment/Test Medication Error Complication of Procedure/Treatment/Test
  14. News Article
    Ashford and St Peter’s Hospitals Foundation Trust, has apologised after nearly 1,000 patients faced delays due to a breakdown of referral systems. It was found 175 of these patients were considered urgent cases by their GPs and are now being reviewed for clinical harm. When the error was discovered, the patients were added to the referral tacker by 9 July, however until that point, they had not been on any patient waiting list, nor were they visible to either operational management or clinical teams. Trust chief executive Suzanne Rankin said in a statement: “We are very sorry for an
  15. News Article
    The Care Quality Commission has closed mental health hospital, Eldertree Lodge, in Staffordshire after inspectors saw evidence of patients being abused. The hospital, which looked after 40 adults with learning disabilities and autism, was found to have unprofessional and abusive staff members, with incidents being recorded on CCTV where staff slammed doors on patients. Staff were also found to pull or drag a patient in an attempt to move them to a ward seclusion room. Commenting on the latest report, Debbie Ivanova, CQC deputy chief inspector for people with a learning disability and
  16. News Article
    A report has concluded that significant failings by hospital staff led to the avoidable suffering of Ann Jones, 69, who had bowl cancer, before she died. During their investigation, the Public Services Ombudsman found complications after surgery were not properly identified and weight loss was blamed on psychological factors rather than the pain of a bowel obstruction. Betsi Cadwaladr University Health Board has apologised to Mrs Jones' family. Denbighshire council have also said they were "sincerely sorry" for the distress caused to the family and have issued a written apology to he
  17. 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
  18. News Article
    New research examining severe harm incidents and deaths in NHS hospitals has been published today in the Journal of the Royal Society of Medicine. The research, looking at more than 370 incidents has highlighted the risks to patients from fragmented care on busy wards and shortages of staff. According to the findings, “errors occurred due to a lack of clarity regarding responsibilities for patient care coordination, especially during emergency situations or out of hours. Poor documentation of long-term management plans and no reliable review system to ensure follow-up by the most appropri
  19. News Article
    A new report has revealed patients have died as a result of cancelled appointments to remove objects from their bodies that had been left inside them. Research looking at 23 coroners reports in England and Wales has found the deaths were largely preventable. Read full story (paywalled). Source: The Telegraph, 27 July 2021
  20. News Article
    A public inquiry into the infected blood scandal has heard that the government was right to say there was "no conclusive proof" that Aids could be transmitted by blood products in 1983. According to Lord Clarke, the phrase was entirely accurate at the time it was said. However, evidence in documents reveal senior health officials believed HIV could be carried through blood. "Somebody, somewhere, decided that that was the best most accurate line to take. It was repeatedly used by every minister. We kept repeating that because that was the scientific advice we had until it was perfectl
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