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Found 238 results
  1. News Article
    Endometriosis care across the UK needs urgent improvement and diagnosis times need to be cut in half, a report by MPs says. It found an average wait for a diagnosis was eight years and that has not improved in more than a decade. Endometriosis affects one in 10 women in the UK and causes debilitating pain, very heavy periods and infertility. Nadine Dorries, minister for women's health, said awareness was increasing but there was still a long way to go. More than 10,000 people took part in the All-Party Political Group inquiry which found that 58% of people visited the GP more th
  2. News Article
    The Royal College of GPs has called for an independent review of the link between poor Care Quality Commission (CQC) inspection ratings and the ethnicity of GP partners. The college called for the regulator to commission the work in particular for those rated “requires improvement” and “inadequate” over the past five years, including practices which have since closed down. This will assess “if there is an association between the outcomes of inspections and ethnicity or country of qualification of the GP partners”, according to the RCGP. In addition, the RCGP wants to work with the re
  3. News Article
    Pregabalin may be associated with serious breathing problems in patients with compromised respiratory systems, according to a drug safety alert from the medicines regulator. Elderly patients, patients with neurological disease, renal impairment and those who are taking antidepressant medication are also at increased risk of breathing problems from the drug, the Medicines Healthcare Regulatory Agency (MHRA) said (18 February). Pregabalin is a medication that has increasingly been prescribed to treat chronic pain, however, it is also used to treat epilepsy, fibromyalgia, restless leg s
  4. Content Article
    The report sets out seven themes identified by the review and charts the safety risks for pregnant women that emerged as the NHS adapted to respond to COVID-19. It describes the circumstances and pathways of care for the 19 women where some of the risks identified in the theme areas may have contributed to the outcome for those women. The review also highlighted that the ‘system factors’ identified in the maternal reviews were seen across the NHS and have been or are being addressed in other HSIB investigations. The seven themes are: Unprecedented demand for telephone health advice
  5. Content Article
    In 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
  6. News Article
    Failures to follow national guidelines to prevent group B Strep infections in newborn babies is leading to a postcode lottery of care and opportunities to stop deadly infections being missed, a new report has found. Nearly 90% of hospitals in the UK are not using the recommended test for GBS carriage – which costs around £11- despite clear guidance issued by the Royal College of Obstetricians and Gynaecologists (RCOG) and Public Health England (PHE) that the test can significantly decrease false-negative results. Group B Strep is the UK’s most common cause of severe infection in newborn b
  7. Content Article
    Group B Strep Support recommends that: All NHS Trusts/Boards adopt and implement the Royal College of Obstetricians & Gynaecologists’ Green-top guideline on group B Strep promptly. All pregnant women are provided with a high-quality information leaflet on group B Strep as a routine part of their antenatal care. Pregnant women who had a positive test result for group B Strep in a previous pregnancy are offered the option of testing for group B Strep in the current pregnancy, or of being treated as a carrier this pregnancy. Where pregnant women are offered testing for
  8. Content Article
    In 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
  9. Event
    Veracuity was conceived out of a recognition that the practice of pharmacovigilance is performed suboptimally. That is because it relies entirely on a voluntary reporting system – one in which consumers and healthcare professionals must devote considerable energy if they were so inclined to notify somebody about a side effect they attribute to a bio-pharmaceutical product. Adverse event reporting is infrequent and cumbersome because stakeholders are only vaguely aware of their responsibility and the current system is neither easy nor fast to use. Nor does it provide reporters with any immediat
  10. News Article
    At least seven so-called NHS “never events” should be reclassified because the health service has failed to put in place effective measures to stop them from repeatedly happening, safety experts have said. The independent Healthcare Safety Investigation Branch (HSIB) said NHS England should remove the never event incidents from the list of 15 it requires hospitals to report, because they are not “wholly preventable” and the NHS has not adequately recognised the systemic risks that mean they keep happening. The errors include examples such as a 62-year-old man having the wrong hip rep
  11. Content Article
    HSIB has made three safety recommendations as a result of this report - two to NHS England and NHS Improvement, and one to the Centre for Perioperative Care. NHS England and NHS Improvement It is recommended that NHS England and NHS Improvement revises the Never Events list to remove events, such as those presented in this national learning report, that do not have strong and systemic safety barriers. It is recommended that NHS England and NHS Improvement develops and commissions programmes of work to find strong and systemic safety barriers for specific incidents where barrie
  12. News Article
    In 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
  13. News Article
    In 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
  14. News Article
    All NHS trusts in England have been given a deadline of Monday to enact safety improvements in maternity care amid Shropshire's baby deaths scandal. Heath chiefs have told hospitals they must have the 12 "urgent clinical priorities" in place by 17:00 GMT. The move is to address "too much variation" in outcomes for families. It comes during a probe into the maternity care of more than 1,800 families in Shropshire. The inquiry, launched amid concerns of repeated failings at Shrewsbury and Telford Hospital NHS Trust (SaTH), focuses on the experience of 1,862 in total, and includes
  15. News Article
    NHS guidance ‘too long to read,’ say hospital staff as safety watchdog exposes systemic risks to patients. The Healthcare Safety Investigation Branch (HSIB) revealed some NHS staff had admitted not reading official guidance on how to avoid the ‘never event’ error as part of a new report identifying deeper systemic problems that it said left patients at an increased risk. The independent body warned patients across the NHS remained vulnerable to being injured or even killed by the error that keeps happening in hospitals despite warnings and safety alerts over the last 15 years. H
  16. Content Article
    Nasogastric (NG) tubes placed incorrectly, going undetected and delivering food, liquid or medication into the lungs is a well-recognised never event in the NHS. Despite safety alerts and various safety initiatives, the investigation identified that this type of never event continues to happen and that there are not strong ‘systemic’ barriers to prevent NG tubes being accidentally placed into the lungs. Data from national reporting systems shows that there were 14 incidents of misplaced NG tubes from April to September this year. The report acknowledges that measures carried out to tackle
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