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Content Article
Tackling bias in healthcare (29 April 2025)
Patient Safety Learning posted an article in Health inequalities
Bias in the way medical research is carried out means that new medicines for diseases such as cancer – as well as the tools used to diagnose patients with some conditions – are disproportionally tested on people of European heritage. This can lead to those not represented in the data being misdiagnosed as well as some treatments not working as well as they should. From the Ghanaian scientist helping to develop cancer treatments which work better for African people, to the team in England using AI to diagnose dementia in communities where English isn’t widely spoken, in this programme we will meet the solution-seekers trying to make healthcare more equal.- Posted
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News Article
Warning over ‘dangerous’ nasal tanning sprays with cancer risk sold online
Patient Safety Learning posted a news article in News
Unregulated nasal tanning sprays, touted across social media, are raising alarms with Trading Standards due to potential health risks, including a possible link to melanoma skin cancer. These sprays, which contain Melanotan 2, a chemical that darkens skin pigmentation, are being sold outside current UK regulations. The Chartered Trading Standards Institute (CTSI) has issued a warning about these products, highlighting potential dangers beyond skin cancer. Users have reported nausea, vomiting, high blood pressure, and even changes in mole size and shape. While marketed as cosmetics, bypassing regulations applied to medicinal products containing Melanotan 2, these sprays aren't subject to the same scrutiny as other beauty products. This regulatory gap raises concerns about long-term health consequences, with studies suggesting a potential link to melanoma. Read full story Source: The Independent, 16 May 2025- Posted
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News Article
Hancock ignored call to test all NHS staff, Covid inquiry hears
Patient Safety Learning posted a news article in News
The government ignored an early warning by two Nobel prize-winning scientists that all healthcare workers should be routinely tested for coronavirus in the pandemic, the Covid inquiry has heard. The advice came in a strongly-worded letter sent in April 2020 by the chief executive of the Francis Crick Institute, Sir Paul Nurse, and its research director, Sir Peter Ratcliffe, to the then health secretary Matt Hancock. NHS and care home staff were not offered Covid tests until November 2020 in England, unless they had symptoms of the disease. Matt Hancock is due to appear at the inquiry next week, along with other health ministers from the four nations of the UK. Giving evidence, Sir Paul, who won the Nobel prize for medicine in 2001, said it was "disturbing" that he did not receive a response to his concerns until July 2020. "For the secretary of state to ignore a letter from two Nobel laureates in physiology or medicine for three months is a little surprising, I would say," he told the inquiry. "Rather than acknowledge they couldn't do it, because that would have indicated a mistake in their overall strategy, they remained silent." It was likely that the decision not to routinely test NHS and care home staff led to an increase in infections and deaths in the early stages of the pandemic, he added. Read full story Source: BBC News, 15 May 2025 Further reading on the hub: "Forgotten heroes" – the sequel: a blog and resources from David Osborn The pandemic – questions around Government governance: a blog from David Osborn- Posted
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Event
untilAre you passionate about creating better practice learning environments in healthcare? This is a free, one-day event to explore the NHS England Safe Learning Environment Charter (SLEC) — a framework developed to support healthcare learners, initially in maternity and neonatal settings and now being adopted across a wide range of professions. This event offers a valuable opportunity to: Hear from the NHSE South West team who created the charter Hear success stories and examples of charter implementation across different professions and organisations including medical education and the University of Surrey Network with learners and peers from Higher Education Institutions, placement providers, Integrated Care Systems and NHS England Consider how you could implement SLEC in your services Attendance is especially encouraged for learners, practice supervisors, assessors, and educators. Lunch and refreshments will be provided. Date: Wednesday, 2nd July 2025 Time: 9:30 AM – 4:00 PM Location: University of Surrey, Stag Hill Campus, Guildford, GU2 7HX (Just a 10-minute walk from Guildford Railway Station. Free campus parking available.) Register here by Thursday 29th May: https://forms.office.com/e/VnRkaeGa1H Note: Places are limited, and you may be added to a waiting list if demand exceeds capacity. If you need to cancel, please email: [email protected] For information about the Safe Learning Environment Charter, visit: https://www.england.nhs.uk/long-read/safe-learning-environment-charter/ Invitation to SLEC Event 2nd July 2025.pdf -
Content Article
The Saudi Patient Safety Center works to reach the largest possible number of patients and their families while receiving healthcare by visiting them at the healthcare facility and talking to them and communicating the message of health empowerment and providing information that helps them to be an active patient in health care through the Patient Safety Caravan which is a virtual Caravan that includes group of people visiting patients and their families in hospitals (in inpatient wards, outpatient clinics, emergency departments , etc.) to increase patient safety awareness through empowering, educating, and supporting them. Objectives: To reach as many patients and families as possible to improve the safety of their healthcare encounters. To increase patient's safety level in the healthcare facilities and to ensure patients and families' participations in their treatment plan with healthcare providers. To raise volunteers' awareness about patient safety to share with patients and families. Collaborating with patients experience centers at hospitals to activate patient's empowerment concept through their daily duties.- Posted
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Content Article
Many errors in surgical patient care are caused by poor non-technical skills (NTS). This includes skills like decision-making and communication. How often these errors cause harm and death is not known. This goal of this study was to report how many surgical deaths are associated with NTS errors in Australia by assessing all surgical deaths from 2012 to 2019. Some 64% of cases had an NTS error linked to death. Decision-Making and Situational Awareness errors were the most common. The results of this study can be used to guide improvement and reduce future errors and patient death.- Posted
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Content Article
The NHS workforce is under considerable operational pressure at every level from the combined effects of record demand and shortages of capital and resource. In addition, seismic shifts are on the horizon, including the abolition of NHS England (NHSE), the expected recommendations from the second Penny Dash report on patient safety, and the upcoming 10 year health plan. The level of change the NHS is facing, as a safety critical sector, makes culture a strategic priority. To achieve the ambition behind these changes, we need an engaged, motivated workforce and a supportive, enabling environment, writes Isabelle Brown and Laura Turner. Getting the “how” right of any reform that might be introduced by the 10 year health plan is just as important as the “what” and the ”why.”- Posted
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Karina Johnson joined the community
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Content Article
Patient safety culture (PSC) is crucial for reducing medical errors and improving patient outcomes globally. This study aims to identify key improvement targets in China’s PSC to promote a safer healthcare environment. It found that while teamwork is a notable strength, there is room to enhance the nonpunitive response to errors. Improving feedback and communication practices can further bolster openness and collaboration within teams, leading to an overall healthier work environment.- Posted
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Content Article
The fundamental importance of having enough registered nurses present to deliver care is well supported by evidence. Lower registered nurse staffing levels are associated with higher risks to patients and poorer quality care. Here is the Royal College of Nursing's position statement on registered nurse staffing levels for patient safety.- Posted
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News Article
NHS gave private firms record £216m to examine X-rays in 2024
Patient Safety Learning posted a news article in News
The NHS handed private firms a record £216m last year to examine X-rays and scans because hospitals have too few radiologists. The amount of money NHS organisations across the UK are paying companies to interpret scans has doubled in five years as demand rises for diagnostic tests. Despite the growth in privatisation, the NHS in England failed to read 976,000 X-rays and CT and MRI scan results within its one-month target – the highest number ever. Scans play a crucial role in telling doctors if a patient has cancer or a broken bone, for example. The Royal College of Radiologists (RCR), which collated the figures from doctors across the UK, said the £216m given to private firms in 2024 was “a false economy” which it blamed on the NHS’s failure to recruit enough specialists to read all the scans patients have in its hospitals. The college said the growing outsourcing of scan analysis risked creating “a vicious cycle” in which NHS radiology services were increasingly weakened and its doctors drawn to private work. Dr Katharine Halliday, the RCR’s president, said: “The current sticking plaster approach to managing excess demand in radiology is unsustainable and certainly isn’t working for patients, who face agonising waits for answers about their health. “It is a false economy to be spending over £200m of NHS funds outsourcing radiology work to private companies, and evidence of our failure to train and retain the amount of NHS radiologists we need.” Read full story Source: The Guardian, 15 May 2025- Posted
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Content Article
If you have up to an hour to spare, these 'micro credentials' are great for topping up your learning. The Chartered Institute of Ergonomics & Human Factors (CIEHF) online bitesize modules will offer you short, focused and easily digestible content. Delivered through CIEHF's online learning platform, they'll provide the flexibility to learn at your own pace, to your schedule and from wherever you choose. Whether you're a professional seeking to improve workplace ergonomics or a curious learner eager to understand how humans interact with their surroundings, these modules are designed to inspire you by providing real-world examples, case studies and best practice that can be applied across many sectors. You'll get insights into identifying and addressing human factors challenges, ultimately contributing to improved safety, efficiency and overall wellbeing.- Posted
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News Article
Trust in row with BMA over senior doctor
Patient Safety Learning posted a news article in News
A hospital trust is involved in a row with the British Medical Association amid concerns over a ’bullying culture’, it has emerged. HSJ has learned of tensions at Doncaster and Bassetlaw Teaching Hospitals Foundation Trust, including an ongoing dispute over a senior medic who has been off work for an extended period. Meanwhile, in recent weeks, the union Unison has launched a survey of the trust’s staff about behaviour, and begun offering staff “don’t bully me” badges, according to flyers claiming there is a “bullying culture”. The union’s organiser Sarah Brummitt said its survey had been launched in response to local reports of bullying concerns. She said: “The survey is open to all staff, and will hopefully give us a better understanding of what issues they are facing, if any.” It follows several concerns raised over the past year about leadership and culture at the trust. The trust says it is “committed to fostering a respectful and inclusive working environment.” Read full story (paywalled) Source: HSJ, 15 May 2025 -
News Article
NHS Tayside has been formally ordered to improve maternity services at Ninewells Hospital following an unannounced inspection by a health watchdog. Healthcare Improvement Scotland (HIS) expanded its safe delivery of care inspections following a neonatal mortality review last year to “provide women, birthing people and families with an assessment of the quality of care” in maternity services. It carried out its first safe delivery of care inspection in an unannounced visit to maternity services at Ninewells in Dundee between 27 and 29 January this year. This was followed up with another unannounced visit on February 12 due to concerns, including that breastfeeding equipment was being cleaned in a sink with kitchen utensils, which had not been addressed at the time of the return visit. In an inspection report published on Thursday, HIS said after the revisit, “we were not assured that sufficient progress or improvement had been made with some of our concerns”, and it formally wrote to NHS Tayside to urge it to meet national standards for maternity services. Concerns included “variations in oversight and governance observed in both the hospital inspection and maternity services, and a lack of oversight by senior managers within maternity services”. Other areas of improvement included “safe staffing, fire safety issues and the maintenance of the hospital environment”, according to HIS. Read full story Source: The Scotsman, 15 May 2025 -
News Article
Cosmetic surgery patients are returning to the UK with superbugs
Patient Safety Learning posted a news article in News
British patients who travel abroad for cheap cosmetic surgery are bringing back dangerous superbugs, nurses have warned. Some NHS hospitals had a 30 per cent rise in infections caused by potentially fatal antibiotic-resistant bacteria, triggered by patients returning from operations overseas. NHS nurses spoke of “horrific wounds”, infections, sepsis and deaths in patients over the past two years from complications after having surgery overseas — and suggested that foreign clinics should pay the NHS compensation when things go wrong. Thousands of British patients faced with long NHS waiting lists and high costs for private surgery in are going abroad instead, most often to Turkey and eastern Europe. Popular procedures include weight-loss surgery, breast procedures and “Brazilian butt lifts” (BBLs). Clinics often offer “package deals” of several procedures, which adds to the risk. Wes Streeting, the health secretary, has urged people to “think very carefully” before going overseas for surgery — warning that the NHS is left to “pick up the pieces”. Read full story (paywalled) Source: The Times, 14 May 2025 -
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Content Article Comment
Reflections on the ICB Blueprint on Linkedn: 1. Liam Cahill wrote a particularly good summary. Link here: https://lnkd.in/eZXBVRBP 2. Jennifer Milner provides a pragmatic context. Link here: https://lnkd.in/eZV4KzkN 3. Sam Alsop-Hall stresses the importance of provider networks. Link here: https://lnkd.in/ePvjNE4N- Posted
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Patient Safety Learning started following Trust admits it ‘cannot safely run’ maternity service
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News Article
Trust admits it ‘cannot safely run’ maternity service
Patient Safety Learning posted a news article in News
A trust is set to close one of its birthing units for at least six months after admitting it “cannot safely run” the service. Somerset Foundation Trust will temporarily close the maternity unit at Yeovil District Hospital “for an initial period of six months” from next week, amid significant gaps in medical staffing. The trust has said it “cannot safely run” the special care baby unit, which provides dedicated support for premature newborns, nor “safely provide care during labour and birth”. The closure follows concerns being raised by the Care Quality Commission. The regulator rated maternity services at Yeovil “inadequate” last year and also issued a warning notice in January after finding its paediatric care “requires significant improvement”. The CQC said the service did not have enough medical staff or emergency equipment to keep babies safe, and found not all staff followed infection control procedures. Dr Iles added that senior paediatricians from Somerset FT’s Musgrove Park Hospital are helping to ensure paediatric inpatient and outpatient services at Yeovil remain open, including obstetric and midwifery antenatal clinics, scanning, antenatal screening services, and home births. But she added: “We cannot care for any newborns who require care in a special care baby unit or safely provide care during labour and birth at the Yeovil maternity unit. “We are committed to providing safe, high quality, and sustainable services for those who need them, but we must address these concerns and need the time and space to do this. I apologise again to anyone who is affected by these changes.” Read full story (paywalled) Source: HSJ, 15 May 2025 -
Content Article
The way in which healthcare organisations are expected to respond after patient safety events in England changed significantly in August 2022 when the new Patient Safety Incident Response Framework (PSIRF) was introduced. What has actually happened is that the new processes built around the use of the Learning Response Tools in general and for After Action Review (AAR) in particular, are very varied. In this article, Judy Walker looks at the the variation in executing AARs and why this risks jeopardising the very essence of the AAR. *This article was first published in The After Action Review Newsletter May 2025 written by Judy Walker Associates Ltd. The way in which healthcare organisations are expected to respond after patient safety events in England changed significantly in August 2022 when the new Patient Safety Incident Response Framework (PSIRF) was introduced. What has actually happened is that the new processes built around the use of the Learning Response Tools in general and for After Action Review in particular, are very varied This is not surprising and is not concerning, as the PSIRF is purposefully designed to empower healthcare providers to implement in the framework in the way that suits their context best. However, I am concerned that the variation is also being manifested in the approach taken within the execution of the AAR itself, which risks jeopardising the very essence of the AAR. One of the risks is to the quality of the engagement and accountability with those who are attending the AARs. It was an excellent article published by Psychological Safety, on the Spectra of Participation which explores these concepts that gave me the idea for a framework for describing what I have observed that is a concern. Participation doesn’t guarantee engagement Looking at the IAP2 and other frameworks, the article explores the idea that participation doesn’t always guarantee engagement. The quality of engagement is a direct result of the goal of the process and the amount of psychological safety present. This analysis got me thinking about creating a scale of participation to bring to life the variety seen in AARs and is designed to help those leading AARs to be clear on the what their goals are. This table below sets out the five levels of participation that I’ve developed. Involve, Facilitate and Empower are all possible and healthy uses of the After Action Review approach. Organisational requirements will impact on how the AAR approach is deployed in each context and the full “Empower” approach where AAR participants are given full scope to act on the learning and their own recommendations, may not be appropriate for AARs taking place within a PSIRF governed process. However, it is a legitimate and valuable approach in project teams and other contexts. The continuum When you look at the continuum, you can see there is a shift from left to right of the AAR Conductor having knowledge of the event to needing to have very little. The Inform position is one where the AAR Conductor already has knowledge and is inviting participants to contribute to enrich the knowledge already held. This is not genuine engagement and along with the Consult approach, can be experienced as a tokenistic application of the AAR. The Facilitate and Empower positions, are those where the AAR Conductor needs have little knowledge prior to the AAR since the work is centred around the participants’ contributions and responses the AAR questions alone. This ensures meaningful engagement with the participants and requires skill in creating the psychological safety for honest conversations and asking the searching questions. The Empower position is different in that the aim is not to hand back the responsibility for action and reporting to the AAR Conductor, but to enable the participants to be ready to take the learning forward. Examples of the types of questions asked along the continuum Inform – “Did you have enough staff on duty?”, “ Was the NatSSIPS process followed?” Consult – “How did the patient respond?”, “Why weren’t the police called?” Involve – “What else was happening on the ward at the time?”, “What might prevent this happening again?” Facilitate – “Communication between agencies has been mentioned a few times: what might improve communication between agencies in future?” “Which of these ideas would make most impact?” Empower – “What do you want to do with this learning?” What support do you need to put this into action?” In summary As an AAR Conductor, you have to operate within your organisations’ context but it is vital to build trust in the AAR process. You will do this by ensuring your actions match your stated intentions and you are transparent about the level of participation you’re aiming for. Getting this right isn’t just about the integrity and standardisation of the AAR approach, it is also about maximising the potential for improvements in patient safety. Those AARs where Involving, Facilitating and Empowering are the goal, increase the level of accountability for change owned by the participants. We know from the research that when staff are fully engaged in the AARs they attend, their behaviour changes and patients are safer as a result.- Posted
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Patient safety articles by Professor Braithwaite
Patient Safety Learning posted an article in Research papers
Professor Jeffrey Braithwaite is Founding Director of the Australian Institute of Health Innovation, Director of the Centre for Healthcare Resilience and Implementation Science and Professor of Health Systems Research at Macquarie University. Professor Jeffrey Braithwaite is a leading health services and systems researcher with an international reputation for his work investigating and contributing to systems improvement. He has particular expertise in the culture and structure of acute settings, leadership, management and change in health sector organisations, quality and safety in healthcare, accreditation and surveying processes in the international context and the restructuring of health services. Professor Braithwaite is well known for bringing management and leadership concepts and evidence into the clinical arena and he has published extensively, with over 788 refereed contributions (including 15 edited books, 95 book chapters, 506 articles and 65 refereed conference papers; and 320 peer-reviewed abstracts and posters; and 231 other publications, e.g., international research reports). Links to some of Professor Brainthwaite's work can be found below. Patient safety articles by Professor Braithwaite Implementation Science and Translational Health Research Articles by Professor Braithwaite Resilient healthcare series Professor Jeffrey Braithwaite on patient safety and health systems improvement- Posted
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Content Article
Ensuring Patient Safety in healthcare is essential and requires efficient methods to reduce risks and improve the quality of care. Although incident reporting tools are commonly used to identify possible and actual care failures, their efficacy differs among various environments. The aim of this study was to evaluate the effectiveness of incident reporting tools in enhancing patient safety.- Posted
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News Article
No pay rise for managers of worst-performing trusts
Patient Safety Learning posted a news article in News
Very senior managers at the worst-performing trusts and ICBs will not receive annual pay rises from this year, under new national rules. The new very senior managers pay framework for trusts, foundation trusts and integrated care boards, published today, says some will for the first time be excluded for the annual pay uplift in 2025-26. They are: VSMs at organisations in segment five of NHS England’s new national oversight framework, except where they are “exempt” because they are less than two years into the job. Segment five is being introduced for the worst-performing organisations which are also deemed in a “diagnostic” to need the most intervention. Organisations currently in RSP – of which there are 25 – are due to “automatically” enter segment five (see list below); and Individuals who are “failing to meet their own objectives or targets” or are subject to investigation for “conduct and capability”. VSMs at segment three and four trusts will get the 2025-26 pay award, but warns “new provisions are expected to apply” from 2026-27. Read full story (paywalled) Source: HSJ, 15 May 2025 -
News Article
An ‘explosion’ in nurse lecturer cuts risks nursing jobs and patient safety
Patient Safety Learning posted a news article in News
The Royal College of Nursing (RCN) is warning that a rapid rise in the number of nurse lecturer redundancies and severances shows the higher education financial crisis is spreading through nursing courses in England and posing a risk to domestic workforce plans. This comes just days after the UK government announced immigration plans which could lead to an exodus of international nursing staff, and poses a serious risk to patient safety. The RCN believes the UK government must take action to protect all nursing courses. The capacity and state of the educator workforce must be a key consideration in nursing workforce planning. The RCN say the crisis in higher education is a real threat to the supply of nurses into the workforce and poses a serious risk to patient safety, potentially derailing the government’s new NHS 10-Year Health Plan due to be published this summer. A nurse educator workforce strategy and funded action plan which addresses recruitment and retention issues is needed, alongside those planned for the NHS and NHS workforce. Freedom of Information requests, sent by the RCN to universities in England offering nursing courses, have revealed nurse educator jobs decreased in 65% of institutions between August 2024 and February 2025. Nurse educators have a critical role to play in ensuring we have a nursing workforce that's sufficiently able and equipped to deliver high quality, innovative, safe and effective care to meet current and future population needs. They're essential to growing the nursing profession and keeping patients safe. Read full story Source: RCN, 15 May 2025- Posted
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Safety in surgery series
NZEMD commented on Patient Safety Learning's article in Surgery
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Thanks for sharing, worth reading 💯- Posted
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News Article
Sweeping changes to immigration rules could cut the “lifeline” of international recruitment for the UK care sector and negatively impact the NHS, leaders have warned. The government unveiled its Restoring Control over the Immigration System white paper on 12 May in which it said it would close social care visas to new applications from abroad because of “significant concerns over abuse and exploitation of individual workers.” “The agreements will move the UK away from dependence on overseas workers to fulfil our care needs,” said the paper, which aimed to tackle longstanding levels of low pay and poor working conditions in the sector in other ways, such as through establishing fair pay agreements. Read full story (paywalled) Source: BMJ, 13 May 2025- Posted
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Content Article
High-reliability organizations (HROs) operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures. Interventions are designed to change thinking about patient safety and system performance through distinct HRO principles. The purpose of this review was to determine the effectiveness of implementing HRO principles on patient safety outcomes.- Posted
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