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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.

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.

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.

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.”

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.

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.

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.

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.

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

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.

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.