doctor holding clipboard.

The Inherent Value of Patient Safety Reports as Key Educational Tools

By John Tingle

Many patient safety adverse events across the National Health Service (NHS) in England have common causes, which exist regardless of clinical specialty, such as failures in communication, poor record keeping, and poor staffing levels.

This commonality of cause means that patient reports emanating from various clinical areas can have general, health system-wide value, relevance, and application. From these reports, it is possible to extrapolate generally applicable patient safety themes that can apply in a wide range of health care settings.

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Empty hospital bed.

The Inevitability of Error in Health Care

By John Tingle

A recent publication by the World Health Organization (WHO), a first draft of a global patient safety action plan 2021-2030, seems to have rekindled conversations about the “inevitability of error” in the field of patient safety.

The “inevitability of error” argument indicates that mistakes in health care do inevitably happen; that they are the consequences of the complex nature of health care treatment. Nursing and medicine depend on people, and nobody is infallible — we all make mistakes.

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NHS building

COVID-19 and the State of Health and Social Care in England

By John Tingle

The COVID-19 pandemic has exacerbated challenges facing the provision of health and social care in England, a recent report from the Care Quality Commission (CQC) finds.

The CQC is the independent regulator of health and social care in England. Every year they produce an assessment of the state of the country’s health and social care. The yearly lookbacks include information on trends, challenges, successes, failures and opportunities.

The most recent report analyzes service provision both pre- and post COVID-19, and draws key conclusions from this information. From a patient safety perspective, the report contains important lessons about issues the COVID-19 pandemic has brought into sharp focus. The report also highlights trailing patient safety problems that existed before the pandemic, and are still present as England grapples with the pandemic’s second wave.

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NHS building

Update on Developing a Culture of Patient Safety in the NHS

By John Tingle

There are no quick fixes to developing an ingrained patient safety culture in health systems — change will not happen overnight. Nevertheless, the National Health Service (NHS) and the government in the U.K. are committed to continuing to improve patient safety.

In 2019, NHS England and NHS Improvement laid down an NHS Patient Safety Strategy roadmap, which continues to hold potential one year later.

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WHO flag.

A Dose of Perspective on World Patient Safety Day

By John Tingle

The second World Health Organization (WHO) World Patient Safety Day was held on September 17th, 2020.

WHO made a call for global support, commitment, and collective action by all countries and international partners to improve patient safety. The theme for the year is “health worker safety: a priority for patient safety.”

The annual WHO World Patient Safety Day campaign is a welcome one, especially in the context of the COVID-19 pandemic.

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NHS building

The Enormity of the Patient Safety Challenges Facing the NHS in England

By John Tingle

Adding to the enormity of the challenges facing the NHS in developing a patient safety-focused culture, NHS Resolution and the Care Quality Commission (CQC) have recently produced important reports on NHS litigation and poor care. The analysis of these reports will help to reveal the full nature and extent of the NHS’s patient safety problems.

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NHS building

The Long and Winding Road of NHS Complaints System Reform

By John Tingle

Sadly, the NHS (National Health Service) has not been able to get its complaint system right, even after decades of trying.

Despite several reports published over two and half decades detailing the challenges the complaint system faces, as well as potential solutions, it still is not fit for purpose. Most recently, the Parliamentary Health Service Ombudsman (PHSO) has produced a report on complaint handling with a focus on the NHS. It is a good, hard-hitting report, which spells out clearly the problems, difficulties, and opportunities to put things right with NHS complaints.

It is, however, another good NHS complaint system reform report in a long line of others. The other reports failed to change adequately the NHS complaints culture and there is little evidence to suggest that this one will succeed where the others have failed.

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NHS building

First Do No Harm: The Independent Medicines and Medical Devices Safety Review

By John Tingle

A new hard-hitting report on medicines and medical device safety published in the U.K. presents controversial proposals that have the potential to improve National Health Service (NHS) patient safety.

The report, The Independent Medicines and Medical Devices Safety Review, was published on July 8th, 2020 after a two year investigation chaired by Baroness Julia Cumberlege. The review investigated two medications — Primodos and sodium valproate — and one medical device — pelvic mesh.

The reviews remit was to examine how the healthcare system in England responded to reports about harmful side effects from medicines and medical devices and how best to respond in the future.

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