Review finds safety recommendations system ‘untenable’
The current situation on recommendations for safety and quality in healthcare is untenable according to a new review.
The DHSC-commissioned review was published by HSSIB on behalf of a group of ALBs. It concludes that the substantial number of recommendations made to the healthcare system means providers struggle to prioritise and implement recommendations.
It found that the lack of structure around the creation and implementation of recommendations as well as the lack of monitoring of actions means many are not improving patient care while continuing to burden providers.
Some recommendations duplicate or contradict others and most are not costed, which may affect providers’ ability to implement them and means there is a lack of information to support prioritisation decisions. Some may be of limited relevance to certain providers and could promote inequalities by negatively impacting certain patient groups if implemented. There is a lack of monitoring of the actions planned or taken to address recommendations.
Welcoming the report, the PSC said: ‘It is becoming increasingly clear to the public that vital recommendations for urgent changes to be made to keep the public safe are simply not being acted upon, leaving persistent risks unaddressed and patients and staff vulnerable.
‘It is essential that the public can have the confidence that recommendations commissioned from independent safety bodies, reviews and Inquiries are properly co-ordinated and followed up with tangible actions. Patients deserve a healthcare system where safety is a top priority, where lessons are learned, and avoidable harms are removed. It is unacceptable that findings which could prevent harm or injury can be neglected for decades.’
The review recommends further work to look at setting up a repository for recommendations, a monitoring system and a route of escalation for recommendations that are not implemented.
PSC welcomes new guidance on valproate usage by men
Men taking valproate and their partners are being advised to use effective contraception according to new guidance from the MHRA. It recommends that male patients and their partners use effective contraception during valproate treatment and for at least three months after stopping the medication.
It follows a study which reports a possible association between valproate use by men and a small increased risk of a range of neurodevelopmental disorders in their children when compared to men prescribed other medicines for the same conditions (lamotrigine or levetiracetam).
Though the risk is much lower than the risk of neurodevelopmental disorders in children born to mothers who take valproate during pregnancy, and the MHRA has long advised against the use of valproate by women able to have children unless there is a Pregnancy Prevention Programme (PPP) in place, this new advice acknowledges that valproate use in fathers is also associated with risk to children as well.
The full guidance can be found here
Patients must be part of the review into NHS performance
The PSC is calling for patient voice to be included in the independent investigation into NHS performance, to be led by Lord Darzi, announced by the new Health Secretary Wes Streeting.
Dr Henrietta Hughes said: ‘The unique views of patients and families are key to making improvements. Their views as part of this investigation are key as patients have crucial insights which otherwise may be missed.’
Martha’s Rule oversight group begins work
The new Martha’s Rule oversight group, chaired by the Patient Safety Commissioner with a secretariat provided by the Department of Health and Social Care, has begun its work to support the implementation of the new initiative.
The overarching aim of the oversight group is to bring together the whole healthcare system so that everyone with an interest in patient safety can support the implementation of Martha’s Rule, including patient and family views, healthcare staff, providers, regulators, professional regulators and national bodies.
As chair of the group, the PSC Henrietta Hughes is engaging widely with staff groups and patients from England and internationally to understand their views of the new initiative and to learn from existing patient and family activation systems. She recently attended the Intensive Care Society conference in Liverpool and heard a range of questions from staff at the frontline delivering Martha’s Rule. This valuable feedback will help to improve the design and communication to patients, the public and staff.
The group will also ensure the approach to gathering evidence in support of the initiative is as broad and consistent as possible, to inform the evaluation by NIHR and the potential wider roll-out of Martha’s Rule beyond 2024/25.
Government to lay regulations on post market surveillance of medical devices
Minister for Patient Safety Baroness Merron last week announced the government’s commitment to lay draft regulations for the post market surveillance of medical devices before Parliament later this year. The aim is for these draft regulations to make medical devices safer for patients by setting out clearer and more stringent requirements for manufacturers when reporting incidents.
The PSC responded: ‘I welcome the SI updating the post-market surveillance requirement for medical devices as these are key to diagnostic safety and this SI marks an important step in keeping patients safe.’
New summary of key patient safety surveys
The 2024 edition of Patient Experience in England is now available from Care Opinion.
As well as summarising the key findings from last year’s large scale patient surveys, the report looks at wider research covering issues such as equity and accessibility as well as studies on patient voice and safety. It is available at Patient Experience Library
NHS England launches new primary care patient safety strategy
NHS England has released a new primary care patient safety strategy. Although the National Patient Strategy pertains to all sectors, this new strategy provides specific focus on primary care and sets out national and local commitments. View it at NHS England » The NHS Patient Safety Strategy
The latest blog from the PSC:
'It is up to us to seize the opportunities from Darzi'
To celebrate World Patient Safety Day, I have spoken with and learned from global patient safety leaders at the Patient Safety Movement Foundation, the World Health Organisation, the Women in Medicine International Network, and...
The latest guest blog:
Learning for Martha’s Rule in Wales
Eirian Edwards and Chris Subbe explain how they have implemented the new initiative in Wales. In April 2023 we officially launched the Call 4Concern service for all adult patients admitted to our hospital in Bangor, as the first site in Wales to...
The latest blog from the PSC:
'It is up to us to seize the opportunities from Darzi'
To celebrate World Patient Safety Day, I have spoken with and learned from global patient safety leaders at the Patient Safety Movement Foundation, the World Health Organisation, the Women in Medicine International Network, and...
New: Implementing Martha’s Rule
As Martha’s Rule is introduced into the health system, colleagues who have pioneered the initiative in the UK and globally outline their experience in a series of blogs.
Below Eirian Edwards and Chris Subbe explain how they have implemented the new initiative in Wales.
Learning for Martha’s Rule in Wales
Eirian Edwards and Chris Subbe explain how they have implemented the new initiative in Wales. In April 2023 we officially launched the Call 4Concern service for all adult patients admitted to our hospital in Bangor, as the first site in Wales to...
Click here to report any side effects from a medicine or medical device