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Mark Hughes

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  1. Content Article
    Radiation safety culture in health care encompasses every action taken to improve the protection and safety of patients and personnel involved in medical exposure. This report provides a framework to establish, maintain and enhance radiation safety culture in health care. It highlights patterns of organisational and individual thinking and behaviours which define a positive safety culture and provides a set of tools to assess the existing level and quality of radiation safety culture and good practice examples. The publication was developed by the World Health Organization (WHO) jointly with the International Atomic Energy Agency (IAEA), the International Organization for Medical Physics (IOMP) and the International Radiation Protection Association (IRPA).
  2. Content Article
    The National Guardian’s Office (NGO) leads, trains and supports a network of Freedom to Speak Up (FTSU) Guardians in England. It also conducts speaking up reviews to identify learning and support improvement of the speaking up culture of the healthcare sector. This is their updated strategy to support cultural change in healthcare to improve worker experience and patient safety.
  3. Content Article
    Listening to the voices of workers is essential for a safe and effective healthcare for workers, patients and the public. Freedom to Speak Up Guardians provide an opportunity for organisations to learn from these voices which may not otherwise be heard. Freedom to Speak Up Guardians are required to report non-identifiable information on the cases they receive both locally to their boards and senior leadership and to the National Guardian’s Office. This report summarises the data shared by Guardians about the speaking up cases they received between 1 April 2023 and 31 March 2024.
  4. Content Article
    Safety is a core dimension of health care quality, and measurement of patient safety culture in Organisation for Economic Co-operation and Development (OECD) countries is increasingly conducted as part of efforts to monitor patient safety and to contribute to health system performance assessment. This Health Working Paper looks at the findings of the second OECD pilot on patient safety culture. This occurred in 2022-2023 and in total took data from 648,209 health care providers from 14 countries.
  5. Content Article
    On the 30 May 2024, the World Health Organization published the its Global Patient Safety Report 2024. In this blog, Assistant Professor John Tingle from Birmingham Law School at the University of Birmingham, reflects on the findings of this report, in particular considering progress made in nurturing patient safety cultures in different healthcare systems.
  6. Content Article
    This is the recording of a webinar on hosted by the Safety for All Campaign to present findings from a survey on violence and aggression sustained by nursing and midwifery students in a UK university. The findings were presented by Dr Kevin Hambridge, Lecturer in Adult Nursing (Education), Francis Thompson, Associate Professor in Mental Health Nursing (Education) and Dr Matt Carey, Associate Professor in Child Health Nursing – Acute Care, all from the University of Plymouth. The results highlighted worrying trends of verbal violence or aggression, physical violence and sexual violence towards students. The responses also highlighted a culture of acceptance among students who have been programmed to see violence at work as part of the job. There was a detailed question and answer session following the presentation in which webinar attendees asked questions about prevention, protection and collaboration.  
  7. Event
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    Taking place on Tuesday 10th December 2024 at the Royal College of Physicians in London, the third annual Safety For All conference provides an opportunity to hear from the nation’s leading voices in healthcare worker safety and patient safety and to network with frontline healthcare workers, unions, key decision makers in public and private healthcare, and patients. This event is hosted by the Safer Healthcare and Biosafety Network and Patient Safety Learning as part of the Safety For All campaign. Launched in 2021, the Safety For All campaign is focused on driving improvements in and between healthcare worker safety and patient safety, highlighting how poor staff safety standards and practice impact adversely on patient safety and vice versa. It is championing the need for a systematic and integrated approach to improve safety practice for staff and patients across health and social care so that the sum is greater than the parts. The conference will be hosted by Dr Rob Galloway, A&E Consultant at Brighton and Sussex Hospital NHS Trust, and regular columnist in the Daily Mail, and with keynote speakers including the CEO of the Royal College of Nursing, and Professor Charlotte McArdle, Deputy Chief Nursing Officer for Patient Safety and Improvement, NHS England. Sessions include; Sustainability Mental health Violence at work Antimicrobial resistance Implementing the Patient Safety Incident Response Framework (PSIRF) Register here.
  8. Event
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    Clinical communications and data sharing should focus both on the needs of patients and staff and safety to turn insights into better patient care. With the demands of patients greater than ever before, the demands placed on clinical staff have only increased in all areas of healthcare. Care teams need to work smarter with a quick and coordinated response to patient incidents by communicating critical notifications and other clinical and operational systems to the right care team members, enhance communication and simplify workflow throughout the process. This Safety For All webinar will delve into the transformative journey undertaken by South Eastern Health & Social Care Trust and the Royal National Orthopaedic Hospital to enhance clinical communications. Attendees will learn about the strategies and innovations implemented by these institutions to improve the clinical workflows, efficiency, effectiveness, and improving clinical quality using their clinical communication system. The session will cover key lessons learned, best practices, and the tangible benefits achieved through their efforts. Join us to gain valuable insights into how these leading healthcare organisations have successfully navigated their path to excellence in clinical communications. Register here.
  9. Content Article
    In its manifesto ahead of the 2024 UK general election, the NHS Race & Health Observatory calls for a unification of efforts towards eradicating racial and ethnic health disparities in the nation’s healthcare system.
  10. News Article
    One in five recent inspections of maternity services have raised concerns over “essential” breathing equipment for newborn babies, HSJ has found. Care Quality Commission (CQC) inspectors have flagged fears over shortages and overdue maintenance of resuscitaire, a device commonly used by midwives if babies require additional support with breathing. Experts say the equipment should be immediately available to ensure safe resuscitation. The CQC itself said the lack of such equipment was impacting patient safety at some hospitals. Read the full story (paywalled) Source: HSJ, 31 May 2024
  11. Content Article
    The first ever World Health Organization (WHO) global report on patient safety aims to provide a foundational understanding of the current state of patient safety across the world, aligned with the Global Patient Safety Action Plan 2021-2030. It contains insights and information beneficial to health care professionals, policy-makers, patients and patient safety advocates, researchers – essentially anyone involved or interested in the improvement of health care and patient safety globally.
  12. Content Article
    In this joint statement, National Voices, The Richmond Group of Charities and 68 other health and social care organisations are calling on the Department of Health and Social Care to pause or extend the consultation process for the 10-year review of the NHS Constitution, ensuring that everyone is able to respond. Patient Safety Learning is one of the signatories of this statement.
  13. Content Article
    An investigation published by BBC News has revealed that Electronic patient record (EPR) system failures have been linked to the death of three patients and more than 100 instances of serious harm at NHS hospitals trusts in England. In this short blog, Patient Safety Learning reflects of these issues and the importance of patient safety being at the heart of the development and implementation of EPRs.
  14. News Article
    IT system failures have been linked to the deaths of three patients and more than 100 instances of serious harm at NHS hospital trusts in England, BBC News has found. A Freedom of Information request also found 200,000 medical letters had gone unsent due to widespread problems with NHS computer systems. Nearly half of hospital trusts with electronic patient systems reported issues that could affect patients. NHS England says it has invested £900m over the past two years to help introduce new and improved systems. Some hospital trusts have spent hundreds of millions of pounds on new electronic patient record (EPR) systems, but BBC News has discovered many are experiencing major problems with how they work. Quoted in this article, Clive Flashman, Chief Digital Officer of Patient Safety Learning, said, “If you look at the sorts of serious issues that are coming out around the country where patients are being harmed, in some cases dying, as a result of these systems not working properly, I would imagine there are tens of thousands of these that are happening that probably never get discussed”. Read the full story. Source: BBC News, 30 May 2024 Read more about Patient Safety Learning's reflections on these issues and the importance of patient safety being at the heart of the development and implementation of EPRs here.
  15. Content Article
    This systematic literature review looks at the international evidence on how interventions to improve safety culture may benefit hospital staff and how they can be designed and implemented. In its conclusion, the authors note that the impact of safety culture interventions on staff outcomes, evidence on staff experiences is scarce. They suggested that a greater focus on staff outcomes would provide more meaningful insight into staff experience within safety culture and results from the safety culture.
  16. Content Article
    In this article, Sharon Hartles looks at the ongoing fight for justice by families affected by the hormone pregnancy test (HPT) Primodos. She discusses the impact of new evidence and advocacy efforts, highlighting the resilience of those involved in the quest for accountability. She also considers the absence of consideration of patients and family members affected by HPTs from the recent Hughes Report, which looked at redress options for the other two medical interventions covered by the Independent Medicines and Medical Devices Safety Review. Sharon Hartles is a member of the Harm and Evidence Research Collaborative at the Open University. Additionally, she is affiliated with the Risky Hormones research project, an international collaboration in partnership with patient groups. You can read the blog here. Related reading First Do No Harm. The report of the Independent Medicines and Medical Devices Safety Review (8 July 2020) The Hughes Report: Options for redress for those harmed by valproate and pelvic mesh (Patient Safety Commissioner for England, 7 February 2024) Reflections on The Hughes Report: Pelvic mesh, sodium valproate, hormone pregnancy tests and options for redress (a blog from Patient Safety Learning) A Bitter Pill: Primodos, The Forgotten Thalidomide (APPG on Hormone Pregnancy Tests, 27 February 2024) Patient Safety Spotlight interview with Marie Lyon, chair of the Association for Children Damaged by Hormone Pregnancy Tests
  17. Event
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    The first ever World Health Organization (WHO) Global Report on Patient Safety will provide a comprehensive overview of patient safety measures globally, aligned with the Global Patient Safety Action Plan 2021–2030. It will include detailed analyses and summaries that highlight the burden of unsafe care and the strategies different countries are using to improve safety in health care. This WHO webinar will mark the launch of this report. Register here. agenda_global-patient-safety-report-2024-launch-webinar.pdf flyer_launch-event-global-patient-safety-report-2024.pdf
  18. Content Article
    In January 2024, the Institute for Healthcare Improvement (IHI) Lucian Leape Institute convened an expert panel to explore the promise and potential risks for patient safety from generative artificial intelligence (genAI). This report is based on the expert panel’s review and discussion.
  19. Content Article
    This investigation by the Health Services Safety Investigations Body (HSSIB) considers how patient safety can be improved in relation to children and young people with mental health needs while they stay on an acute paediatric ward—a ward for children and young people in a hospital that typically treats physical health conditions. It focuses on the risk factors associated with the design of these wards in acute hospitals.
  20. Content Article
    This qualitative study looked at healthcare professionals perceptions of patient safety culture in Ghana. It was conducted with 42 healthcare professionals in two regional government hospitals in Ghana from March to June 2022. The authors note that despite positive attitudes and knowledge of patient safety, healthcare professionals expressed concerns about the implementation of patient safety policies outlined by hospitals. They also highlighted that there was a perception that curriculum training on patient safety during school education and the availability of dedicated officers for patient safety at their facilities may help improve patient safety.
  21. Content Article
    This is the transcript of a statement in the House of Commons by the Minister for the Cabinet Office and Paymaster General, John Glen MP, in response to the publication of the final report of the Infected Blood Inquiry. He sets out plans for a proposed scheme to provide compensation to those infected and affected by this scandal. This was followed by comments from other members of the House of Commons.
  22. Content Article
    This is the transcript of a statement in the House of Commons by the Prime Minister, Rishi Sunak MP, in response to the publication of the final report of the Infected Blood Inquiry. He apologises for the failure in blood policy and blood products, the repeated failure of the state and medical professionals to recognise the harm caused by this and for the institutional refusal to face up to these failings. He also says that the Government will pay comprehensive compensation to those infected and affected by this scandal. This statement is followed by a response from the Leader of the Opposition, Sir Keir Starmer MP, and comments from other members of the House of Commons.
  23. Content Article
    In 2021, the Independent Medicines and Medical Devices Safety review, led by Baroness Cumberlege, conducted a comprehensive review of historic documents and found that Hormone Pregnancy Tests had caused avoidable harm, that they should have been withdrawn by the regulator after the first warnings in 1967 and that this failure to act meant that women were exposed unnecessarily to a potential risk. This report by the All-Party Parliamentary Group on Hormone Pregnancy Tests sets out the background to this and considers the findings in 2017 of an expert working group that was relied upon by the Government and manufacturers to strike out a claim for compensation in 2023. The report recommends that the Government sets up an independent review to examine the findings of this working group.
  24. Content Article
    This cross-sectional study, published in Cureus, was conducted among 423 nurses working at tertiary care hospitals in the Al-Jouf region in Saudi Arabia. The authors note that participants valued the aspects of teamwork within units, organisational learning-continuous improvement, and overall perceptions of patient safety as areas of strength and important elements of patient safety culture. However, they also highlighted areas of concern that need improvement, such as nonpunitive response to errors, handoffs and transitions, communication openness, staffing, and frequency of events reported.
  25. Content Article
    In vitro diagnostic (IVD) devices are used to examine samples taken from the human body and to diagnose and monitor health conditions. The Medicines and Healthcare products Regulatory Agency (MHRA) are seeking views on a new policy would require manufacturers to comply with additional measures for certain high risk IVDs, such as blood tests used to identify blood type before transfusions or tests which identify life-threatening diseases, introducing harmonised requirements for these products. The consultation closes at 11.59pm on 14 June 2024.
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