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Found 270 results
  1. 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)
  2. News Article
    Changes to maternity services during the pandemic, including the mandatory redeployment of midwives and doctors to care for infected patients, may have affected the care given to women who had stillborn babies, a Healthcare Safety Investigation Branch (HSIB) investigation has found. The safety watchdog launched an investigation after the number of stillbirths after the onset of labour increased between April and June 2020. During the three months there were 45 stillbirths compared to 24 in the same period in 2019. The HSIB launched a probe examining the care of 37 cases. Among its fi
  3. Content Article
    Safety recommendations HSIB made eight safety recommendations as a result of this investigation, five to NHS England and NHS Improvement, one to the Royal College of Obstetricians and Gynaecologists, one to NHSX, and one to DHSC. HSIB recommends that future iterations of the Royal College of Obstetricians and Gynaecologists’ guidance clarify the management of a reported change in fetal movements during the third trimester of pregnancy with due regard to national policy. HSIB recommends that NHS England and NHS Improvement leads work to develop a process to ensure consistency
  4. Content Article
    The areas of concerns which the assessors have identified include: Concerns about in-patient bed capacity in the antenatal and postnatal period Lack of shared intrapartum care guidelines Lack of agreement about senior medical staff cover (there was no clarity as to how the rota system worked, cover for holidays or absence or what was expected from the consultants e.g. when they were expected to be present on labour ward or when they should attend out of hours) A robust escalation policy when the maternity unit is full (the policy was written and ratified in September
  5. News Article
    ‘Very heavy-handed, laborious and expensive’ inspections ‘have not been the right way’ of regulating hospitals, according to the Care Quality Commission’s (CQC) former chair. Speaking at a Royal Society of Medicine event on Wednesday, Lord David Prior, who is now the chair of NHS England, said “very few” physicians will have improved their work after reading a report from the regulator. He added that there is a role for the CQC to move in when “things are going wrong” although he is “sceptical” the regulator can actually drive improvement in hospitals. Lord Prior said: “I am hig
  6. 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.
  7. Content Article
    This review covers everything from operational performance to planned developments in the 2021/22. There are key sections on family and NHS staff engagement – focusing on their experiences of working with HSIB including how they gather their feedback and sharing direct quotes. The review also sets out how HSIB fits into the wider maternity picture, explaining the way they work with other organisations and the contributions they have made to high-profile initiatives, projects, inquiries and reports. Over 2020/21, HSIB maternity investigation reports have contained 1500 safety recommendatio
  8. 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
  9. Content Article
    A year on from the publication of First Do No Harm, the report by the Independent Medicines and Medical Devices Safety (IMMDS) Review, the Government released its full response to the Review's recommendations.[1] [2] Published alongside this was the report from the independent Patient Reference Group, established to provide advice, challenge and scrutiny to the work developing the Government’s response.[3] The IMMDS Review examined the response of the healthcare system in England to the harmful side effects of three medical interventions: Hormone pregnancy tests, Sodium valproate and Pelv
  10. Content Article
    The IMMDS Review examined how the healthcare system in England responded to reports about harmful side effects of medicines and medical devices, focusing on three specific interventions: Hormone pregnancy tests, Sodium valproate and Pelvic mesh implants. Its findings and recommendations were published in the First Do No Harm report on 8 July 2020. Summary of the government response to each of the recommendations Recommendation 1: The government should immediately issue a fulsome apology on behalf of the healthcare system to the families affected by Primodos, sodium valproate and
  11. Content Article
    The IMMDS Review examined how the healthcare system in England responded to reports about harmful side effects of medicines and medical devices, focusing on three specific interventions: Hormone pregnancy tests, Sodium valproate and Pelvic mesh implants. Its findings and recommendations were published in the First Do No Harm report on 8 July 2020. The Department of Health and Social Care established a Patient Reference Group to provide advice, challenge and scrutiny to work to develop the government response to the First Do No Harm report. Its independent end-of-project report sets out th
  12. Community Post
    About 1000 angry nurses and doctors have rallied outside Perth Children’s Hospital in Australia following the death of seven-year-old Aishwarya Aswath, demanding vital improvements to the state’s struggling health system. The Australian Nurses Federation was joined by the Australian Medical Association for the rally, with staff from hospitals across Perth attending. Many people held signs that read “We care about Aishwarya”, “Listen to frontline staff”, “Report the executive — not us” and “Please don’t throw me under the bus”. Aishwarya developed a fever on Good Friday and was taken
  13. News Article
    A new study has been published focusing on surgical innovation and how it could be made safer. The research set out to develop a 'core outcome set', an agreed minimum set of outcomes to measure and report for safe surgical techniques in all audits, research, and clinical practice. The study, co-led by Dr Kerry Avery, a Senior Lecturer at the University of Bristol and NIHR Bristol Biomedical Research Centre (BRC) has said "It may surprise many people to learn that surgical procedures haven’t traditionally been subject to the kind of regulation we see in other areas of medicine. But
  14. Content Article
    To download the infographic, produced by Katherine Barrio, Better Births Project Midwife, please see the attachment at the bottom of the page. Further reading: House of Commons Debate - Ockenden Review Reflections on the initial findings of the Ockenden Review Midwifery Continuity of Carer: What does good look like?
  15. Content Article
    The debate centred on a motion put forward by Emma Hardy, MP for Kingston upon Hull West and Hessle, which read as follows: That this House notes the publication of the Independent Medicines and Medical Devices Safety Review, First Do No Harm; further notes the Government’s failure to respond to the recommendations of that review in full; notes the significant discrepancy between the incidence of complication following mesh surgery in the Hospital Episode Statistics and the British Society of Urogynaecology databases, as highlighted in the Royal College of Obstetricians and Gynaecologists
  16. Content Article
    The World Health Assembly (WHA) in May 2019 adopted a resolution, ‘Global action on patient safety’, to give priority to patient safety as an essential foundational step in building, designing, operating and evaluating the performance of all healthcare systems. The resolution asked the Director General of WHO to formulate a Global Patient Safety Action Plan in consultation with Member States and a wide range of partners and other organisations. This Action Plan was formally adopted at WHA on the 28 May 2021 and provides a 10-year roadmap and actions to work towards its vision of a world
  17. News Article
    NICE will speed up patients’ access to the latest and most effective treatments, and dynamic guideline recommendations will be put in the hands of healthcare professionals more quickly under plans unveiled by NICE in its 5-year strategy launched on Monday (19 April 2021). NICE will transform key elements of its approach to ensure efficiency and speed while maintaining robust, trusted methods. The COVID-19 pandemic has reaffirmed the need to place science and evidence at the heart of health and care decision making and improve outcomes for all patients across the healthcare system.
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