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Mark Hughes

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  1. Content Article
    This study, published online by Cambridge University Press, looks at the impact of the Covid-19 pandemic on incidences of healthcare-associated infection in hospitals in the United States of America. The authors analyse events reported to the National Healthcare Safety Network for 2019 and 2020 by acute-care hospitals.
  2. Content Article
    In this blog, Mabel Prendergast reflects on key themes discussed at the Institute of Global Health Innovation's (IGHI) third World Patient Safety Day event on the 17 September 2021, with the theme of safer maternal and newborn care. This virtual event was chaired by Dr Mike Durkin, IGHI’s Senior Advisor on Patient Safety Policy and Leadership, and included a range of speakers and panellists.
  3. Content Article
    This is the transcript of a debate in the House of Commons ahead of Baby Loss Awareness Week (9 to 15 October 2021). In this debate, MPs reflected on personal experiences and those of their constituents, the role of Baby Loss Awareness Week as an essential focal point for bereaved families and the potential for the Government to mandate and fund the National Bereavement Care Pathway programme.
  4. Content Article
    This study, published in JAMA Network Open, looks at the effectiveness of using an evidence-based mobile app to reduce the occurrence of medication errors, compared with conventional preparation methods during simulated paediatric out-of-hospital cardiac arrest scenarios. Its results indicated a decreased rate of medication errors through use of a mobile app, suggesting this could have the potential to improve medication safety and change practices in paediatric emergency medicine.
  5. Content Article
    This is the transcript of a Westminster Hall debate in the House of Commons on Black Maternal Health Awareness Week, dedicated to raising awareness about the disparities in maternal outcomes for Black women.
  6. Content Article
    The Lampard Inquiry is a statutory inquiry investigating mental health inpatient deaths in Essex, focused on services provided by the Essex Partnership University Foundation NHS Trust (EPUT) and the North East London Foundation Trust (NELFT) and their predecessor organisations. This Inquiry continues the work of the Essex Mental Health Independent Inquiry. This website provides information about the inquiry team, terms of reference and publications relating to this.
  7. Content Article
    This article, published by the Institute for Healthcare Improvement, discusses some of the key patient safety issues in the Danish Prison and Probation Service. The author, Christian Vestergaard, a Medical Advisor with the Danish Society for Patient Safety, highlights differences in approaches to patient safety in prisons compared to other areas of healthcare provision in Denmark and stresses the need for action to improve the safety of care in these settings.
  8. Content Article
    In this blog Alice Fletcher, Programme Manager for Patient Safety (Mental Health) at the Innovation Agency, talks about the first phrase of the Mental Health Safety Improvement Programme being delivered by the 15 Academic Health and Science Networks in England. Its initial focus is on reducing restrictive practice in mental health wards, considering where this can be dealt with differently if staff have adequate training and knowledge of other methods.
  9. Content Article
    Pharmacovigilance is the science and activities relating to the detection, assessment, understanding and prevention of adverse effects or any other medicine/vaccine related problem. This article, published in the journal Drug Safety, outlines how the Egypt Chapter of the International Society of Pharmacovigilance (ISoP) approached raising awareness of the importance of pharmacovigilance and reporting adverse drug reactions during MedSafetyWeek 2020.
  10. Content Article
    Published at the halfway point of the Global action plan on the public health response to dementia 2017 – 2025, this report from the World Health Organization assesses the actions taken by Member States, WHO and civil society since the adoption of this plan and identifies barriers to its implementation. The report also includes estimates on dementia burden and costs globally based on WHO’s Global Health Estimates 2019 and the Global Burden of Disease study 2019.
  11. Content Article
    Research suggests that a key factor contributing to diagnostic errors is the breakdown of communication between patients and healthcare professionals. The Agency for Healthcare Research and Quality (AHRQ) in the United States has developed this toolkit to promote enhanced communication and information sharing between patients and healthcare professionals. It is designed to help patients, families, and health professionals work together as partners to improve diagnostic safety.
  12. Content Article
    This document sets out guidelines for recommended nurse/midwife to patient ratios in the Kingdom of Saudi Arabia. It describes the rationale for introducing national regulations for safe staffing ratios, considers concerns and challenges in this respect, and then outlines specific ratios in different areas of care. This has been produced by the Saudi Patient Safety Center, in collaboration with the Saudi Commission for Health Specialties and the Saudi Nurses Association.
  13. Content Article
    This guide, developed by the charity Action Against Medical Accidents (AvMA), aims to provide support for people seeking legal advice about a possible clinical negligence claim. It is intended to provide information about what to expect from a first meeting with a lawyer and how to prepare for this.
  14. Content Article
    A new national NHS Learn from patient safety events service (previously called the patient safety incident management system – PSIMS – during development) is in the final stages of development as a central service for the recording and analysis of patient safety events that occur in healthcare. NHS England has now commenced the public beta stage, where some organisations can begin using the system, instead of the NRLS. LFPSE is replacing the current National Reporting and Learning System (NRLS) and Strategic Executive Information System (StEIS), to offer better support for staff from all health and care sectors.
  15. Content Article
    The Healthcare Safety Investigation Branch (HSIB) identified a patient safety risk involving the timely detection and treatment of non-malignant spinal compression (cauda equina syndrome). Cauda equina syndrome (CES) is a rare and severe type of spinal stenosis, causing all the nerves in the lower back to become suddenly and severely compressed. If CES is not diagnosed and treated in a timely way it can lead to permanent incontinence, sexual dysfunction and even paralysis. The investigation was launched after HSIB identified an event where a patient had several GP and hospital presentations before CES was diagnosed.
  16. Content Article
    In this study, published in the Journal of Patient Safety and Risk Management, the authors explore and compare types and longitudinal trends of hospital adverse events in Norway and Sweden in the years 2013-2018 with special reference to the adverse events that contributed to death. They found that 13.2% of hospital admissions in Norway and 13.1% in Sweden were associated with an adverse event, with 0.23% of admissions in Norway and 0.26% in Sweden associated with an adverse event that contributed to death. In addition to the similar rates in adverse events between the two countries, the authors also found that there was no significant change in the level adverse events or fatal adverse events in either country over the six-year time period.
  17. Content Article
    This episode of HSJ’s Health Check podcast considers concerns raised in Coroners Prevention of Future Deaths reports about the impact of pandemic hospital visiting restrictions on patient care and patient safety.
  18. Content Article
    This report provides a review of the Healthcare Safety Investigation Branch (HSIB) maternity investigation programme during 2020/21, including an overview of activity during this period, themes arising from investigations and plans for the future. It is intended for healthcare organisations, policymakers and the public to understand the work HSIB have undertaken.
  19. Content Article
    This is the response submitted by the Patients Association to the Department of Health and Social Care as part of its consultation seeking views on the proposed legislative details on the appointment and operation of the Patient Safety Commissioner for England. In this they argue for arrangements for the Commissioner's appointment and operation to guarantee their independence as securely as possible, and express disappointment that the role will not cover all aspects of patient safety.
  20. Content Article
    In this article Sharon Hartles looks at the tragic case of the death of Robbie Powell and the work of his parents, Will and Diane, in their relentless pursuit for truth, justice and accountability. It looks in detail at the events around and after Robbie's death and their campaign for a individual legal Duty of Candour for healthcare professionals (the current statutory Duty of Candour in the UK covers all care providers registered with the Care Quality Commission, but not individuals).
  21. Content Article
    Azra Hussain died by suicide while a patient at Mary Seacole House, operated and staffed by Birmingham and Solihull Mental Health Foundation Trust. In their report, the Coroner raised patient safety concerns relating to her family being unable to participate in a multidisciplinary team meeting prior to her death due to Covid-19 visiting restrictions.
  22. Content Article
    Do all your staff receive training for the management of anaphylaxis as part of their mandatory training? Do you have a specific maternal cardiac arrest emergency call to include obstetricians and neonatologists? Do all resuscitation trolleys in your trust have a scalpel and umbilical cord clamps as an essential kit requirement? Are you aware of the obstetric cardiac arrest quick reference guide from the Resus Council, OAA and MBRRACE? Obstetric cardiac arrest is rare but devastating. This quick reference guidance, produced by Resuscitation Council UK and Obstetric Anaesthetists’ Association (and endorsed by MBRRACE), has been developed to aid Advanced Life Support providers response to this. It aims to help structure the team response, with reminders of modifications required for the pregnant patient and causes of cardiac arrest to consider.
  23. Content Article
    This article reviews the Missouri Quality Initiative, which aims to reduce hospital admissions among nursing home residents. It involves placing an advanced practice registered nurse within the nursing home, supported by an interdisciplinary team of long-term care specialists, to identify when a resident may be experiencing a functional decline. Results from this initiative showed statistically significant decreases in hospitalisations.
  24. Content Article
    Kishorkumar Patel and Kofi Aning were both treated at the Nightingale Hospital in London in April 2021. In both cases there was a serious incident in which the wrong filter was found to have been used within the breathing systems of their intensive care ventilator.
  25. Content Article
    This study, published in the Journal of Advanced Nursing, investigates the processes through which personnel understaffing and expertise understaffing jointly shape near misses among nurses during the Covid-19 pandemic. It looks at survey data collected from 120 nurses in the United States of America working in hospitals during the pandemic. The authors conclude that the challenges created by understaffing of nurses have been amplified by the pandemic. They suggest that understanding the mechanisms through which safety outcomes are affected by understaffing can help healthcare organisations be better prepare for safety challenges that may arise when staffing shortages are experienced.
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