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The work of the Department of Health and Social Care (DHSC) and its organisations touches the lives of an average of 1.7 million patients per day and costs the UK taxpayer around £187.3 billion per year. This report presents the Public Accounts Committee’s analysis of the DHSC Accounts for 2023/24. The Public Accounts Committee is a Select Committee in the House of Commons that examines value for money of Government projects, programmes and service delivery. This report highlights a number of issues of concern, including the two areas highlighted below. Abolition of NHS England The Committee points to several issues where it believes further clarity is required from the Government in this respect: The lack of a clear plan for how DHSC and NHS England will achieve significant headcount reductions, and the costs involved. How the reductions fit in with the wider 10 Year Health Plan for the NHS. How savings made from reducing NHSE staff costs help frontline services. How the institutional knowledge of NHSE would be preserved following its abolition. The scale of headcount reductions in the DHSC, and the geographical spread of the planned 50% headcount reductions in NHSE and across local Integrated Care Boards. Clinical negligence The Committee has expressed disappointment in this area and stressed the need for significant improvements, stating that: “Both patients and public money need to be better protected by the Department. Far too many patients still suffer clinical negligence which can cause devasting harm to those affected. It also results in large sums of public money being spent on legal fees and compensation, drawing resources from the wider health service.” Concerns it highlights include: £58.2bn has been set aside to cover the potential cost of clinical negligence events in the latest accounts – the second largest liability across government after nuclear decommissioning. 19% of money awarded to claimants in 2023-24 goes to their lawyers (£536m of the total £2.8bn paid that year), on top of the fees payable for the Government Legal Team. It recommends that within six months, DHSC should set out a plan with clear actions to: Reduce tragic incidences of patient harm to as low a level as possible Manage the costs of clinical negligence more effectively, including introducing a mechanism to reduce legal fees. Improve patient safety across the NHS and in particular in maternity services- Posted
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At the beginning of 2025 we launched our video interview series Speaking up for patient safety. The series is hosted by Peter Duffy, NHS whistleblower and Chair of the Healthcare Working Group at WhistleblowersUK, and Helen Hughes, Patient Safety Learning’s Chief Executive. In each interview we hear from someone who has raised concerns about patient safety in healthcare, often at great cost to their own career and personal life. They share their story and their reflections on what needs to be done to improve organisational cultures so that when staff raise patient safety issues, their concerns are responded to appropriately and not dismissed because they are inconvenient to address. Alongside the thread of bravery and tenacity that runs through each contributor, a number of common themes come up time and again as people share their experiences. In this blog, Helen and Peter look at some of these themes and outline their implications for people who speak up or whistleblow. We are now three months into the series, which seems like a good time to stop and reflect on what we have learned so far. Our introductory blog about ‘Speaking up for patient safety’ explains why we launched the series and what we hope it will achieve. It also explains in more detail what we mean when we talk about speaking up and whistleblowing. Briefly, speaking up in healthcare is when a member of staff raises concerns about something that is worrying them to a manager or someone else within, or outside of, their organisation. In some cases—but not all—when someone speaks up, it is also defined as ‘whistleblowing’. Whistleblowing always involves a concern that is in the public interest and might relate to a criminal offence, health and safety risks, failures to carry out legal obligations, a miscarriage of justice, or an attempt to conceal and cover up any of these things. Three key themes from the interviews so far These are the top three recurring themes we have noticed coming up in the interviews so far. Other issues we have noticed include the lack of clarity about who should take responsibility for whistleblowing and the reality of threats and bullying, and we will continue to explore these issues going forward. 1. “I didn’t realise I was speaking up, I was just doing my job!” Perhaps the comment we have heard most frequently is that people didn’t realise they were formally speaking up or whistleblowing—they just thought they were doing their job. Every healthcare profession has a set of professional standards which all practitioners are expected to keep to. For example, the General Medical Council (GMC) states that all doctors have a duty to take action by raising concerns if they believe patient care or safety are at risk.[1] In addition, each healthcare organisation has a code of conduct, which will include requirements for staff to be honest, open and accountable for their work. For the interviewees we spoke to, to not raise their concerns would be a failure to fulfil their duty to both their patients and their organisation. When people speak up, they often find themselves in the middle of a process that they had no idea they were entering. This can be very disorientating and leave them unprepared for the path ahead of them. At the end of this blog, we share some advice from our interviewees about what to do if you find yourself in this position. 2. There is a whistleblowing ‘playbook’ Most organisations have policies and support in place to listen to staff members who raise concerns, including access to a Freedom to Speak Up Guardian. We have interviewed Jayne Chidgey-Clark, the National Guardian, who described the good practice that many are developing. However, we are hearing about several common tactics that some organisations use when dealing with people who speak up or blow the whistle. The experiences of our interviewees suggest that these approaches may be deliberately designed to disadvantage the individual throughout the process—from investigation through to employment tribunals. Some of the key activities we have heard about include: Organisations not responding—or responding at the very last minute—to communications from the staff member. Interviewees said they received emails with key information at 5pm on a Friday, which left them with no opportunity to ask questions or respond until the next working week. They expressed their belief that this may be a deliberate tactic to exert pressure on the individual speaking up, which amounts to emotional bullying. The use of occupational health as a way to cast doubt on the mental state of the person. Occupational health providers are often very supportive, but we are concerned that organisations are fishing for reasons to question the believability and motives of staff who speak up. Over-focus on HR issues, rather than focusing on the patient safety issues someone has raised. Mandated isolation from colleagues while investigations take place. This can have a very damaging effect on the person’s mental health as well as restricting their ability to source evidence from other staff in support of the concerns they have raised. We have heard examples of colleagues agreeing to provide supportive testimony, but then feeling pressurised to withdraw this support. Retaliatory referrals against the person speaking up to professional regulators, such as the General Medical Council and Nursing and Midwifery Council, which can have a detrimental effect on a healthcare professional’s reputation and career. Regulators are aware of how such referrals can be used to intimidate whistleblowers and discourage them from raising concerns. Some have approaches to ensure that fitness to practice concerns are appropriately addressed without unfairly impacting doctors who have raised whistleblowing concerns. We believe it is important to identify and call out these tactics so that people raising concerns are aware of them and can seek support and advice. Organisational leaders need to look at their own practice and recognise the ethics of their approaches and whether their actions match their stated organisational values. They need to be aware of the significant damage these tactics cause to people who raise concerns and the chilling impact it might have on their organisational culture, effectively preventing others’ raising concerns. 3. Employment tribunals are unfit, unfair and imbalanced Every person we spoke to who had attempted to pursue justice at an employment tribunal commented that the process was unfit for purpose and not the right place for whistleblowing cases to be heard. Employment tribunals take no interest in the safety issues being raised. The main issue we keep hearing is that the tribunal system is weighted in favour of whichever side has the most financial resources—which will almost always be the employer. A single individual who has lost their employment can rarely succeed against the millions of pounds that organisations are willing to spend on highly specialised lawyers who have tried and tested ways of winning. The playbook we identified above also runs into employment tribunals, with whistleblowers reporting: The employer and their legal advisers withholding key documents, and emails, minutes, notes and other vital information going missing. Key witnesses, often in senior leadership positions, being unable to recall events. Receiving last minute threats from their former employer to come after them for costs and often being given a limited time to consider signing a non-disclosure (NDA) to settle a case. If rejected, often the NHS organisation will seek the full costs from the whistleblower, including expensive external legal costs and internal staff costs, which can amount to thousands of pounds—few whistleblowers can afford to take this financial risk, even if they and their advisers think they have a strong case. Advice from our interviewees if you find yourself speaking up Reflecting on their experiences, our contributors have made some observations about how you can protect yourself when speaking up, should the issue escalate. Try to resolve issues locally first. This is not always possible, but if a concern can be raised and dealt with within a team or with a manager, in some cases this will prevent the situation from escalating to a formal process. Keep a record of concerns and events as they happen. This means you will have some facts and clear observations to refer back to, if the situation does escalate. Don’t go to meetings alone. Take a trusted colleague with you so that every conversation is witnessed. Get your union involved if you are called to meetings about your concerns or receive counter-complaints or accusations. Regulation of NHS managers Some of the interviewees highlighted that regulating NHS managers may be a potential means of tackling some of these issues. The Department of Health and Social Care recently held a public consultation on proposals that could see managers who use misconduct to silence whistleblowers barred from working in the NHS. Patient Safety Learning has formally responded to the consultation, stating that there is a clear case for the regulation of NHS managers, for the protection and benefit of both staff and patients. Everyone in healthcare should be honest and transparent when something goes wrong. Patient Safety Learning’s response expressed support for a professional register of NHS managers and the requirement for individuals in NHS leadership to have a professional duty of candour. These measures would be a positive step in increasing accountability for healthcare organisations in how they respond to staff raising patient safety concerns. But this is only one part of a much wider set of changes needed—significant cultural change also needs to take place in tandem with these reforms. Staff across many organisations are still afraid to speak up, as indicated by the most recent NHS staff survey results. Thank you to our contributors, and an invitation to get involved We’d like to take this opportunity to express our gratitude again to each person who has been willing to share their experiences and insights with us—it can be very difficult to retell traumatic events that have changed the course of your life. We are also aware that there are many other individuals who have experienced unjust treatment because they have spoken up for safety. If that’s you, thank you for your commitment to standing up for safe, ethical care. We invite everyone with experience in this area to contribute to this vital conversation. We would particularly like to hear from: Allied health professionals. Staff from Black and minority ethnic backgrounds Staff in non-clinical roles such as administration. If you would like to share your story, you can: Contribute to our community conversation (you’ll need to sign up first). Comment on any hub post (you’ll need to sign up first). You can find information about organisations that offer support and guidance for staff about speaking up and whistleblowing on the hub. Watch the interviews Helené Donnelly Martyn Pitman Jayne Chidgey-Clark Gordon Caldwell Bernie Rochford Beatrice Fraenkel References General Medical Council. Professional Standards: Raising and acting on concerns about patient safety, 13 December 2024- Posted
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In this podcast, Ricky Tenchavez shares his journey of implementing Scan4Safety at Doncaster and Bassetlaw NHS Trust. Discover how his clinical background and focus on staff engagement proved crucial to success, transforming initial resistance into enthusiastic adoption. Learn practical strategies for change management, from comprehensive staff training to building a champions network, and hear how the trust achieved rapid rollout across 28 theatres through effective communication and continuous support for staff. You can view some of the resources Ricky developed here scan4safety.nhs.uk/how-clinical-en…undation-trust/ Visit the Scan4Safety website scan4safety.nhs.uk/ A transcript of this episode is available. -
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WHO: State of the world's nursing report 2025
Patient Safety Learning posted an article in WHO
The global nursing workforce has grown from 27.9 million in 2018 to 29.8 million in 2023, but wide disparities in the availability of nurses remain across regions and countries, according to the State of the World’s Nursing 2025 report, published by the World Health Organization (WHO), International Council of Nurses (ICN) and partners. Inequities in the global nursing workforce leave many of the world’s population without access to essential health services, which could threaten progress towards universal health coverage (UHC), global health security and the health-related development goals. The new report released on International Nurses Day provides a comprehensive and up-to-date analysis of the nursing workforce at global, regional and country levels. Consolidating information from WHO’s 194 Member States, the evidence indicates global progress in reducing the nursing workforce shortage from 6.2 million in 2020 to 5.8 million in 2023, with a projection to decline to 4.1 million by 2030. But, the overall progress still masks deep regional disparities: approximately 78% of the world’s nurses are concentrated in countries representing just 49% of the global population. Low- and middle-income countries are facing challenges in graduating, employing and retaining nurses in the health system and will need to raise domestic investments to create and sustain jobs. In parallel, high-income countries need to be prepared to manage high levels of retiring nurses and review their reliance on foreign-trained nurses, strengthening bilateral agreements with the countries they recruit from.- Posted
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Corridor care and patient safety
Patient_Safety_Learning posted an article in Equipment and facilities
Corridor care is increasingly being used in the NHS as demand for emergency care grows and hospital departments struggle with patient numbers. In a series of blogs for the hub, we shine a light on some of the key patient safety issues surrounding corridor care. Corridor care can broadly be defined as care being provided to patients in corridors, non-clinical areas or unsuitable clinical areas because of a lack of hospital bed capacity. Documenting the experiences of more than 5,000 nursing staff, a recent report from the Royal College of Nursing has set out in stark terms how corridor care has become normalised in the NHS. Almost 7 in 10 (66.8%) of those surveyed said they were delivering care in over-crowded or unsuitable places. More than 9 in 10 (90.8%) of those surveyed said patient safety is being compromised. Corridor care has now become so normalised that in September 2024 NHS England published new guidance setting out principles for providing safe and good quality care in what it describes as ‘temporary escalation spaces’ (TES). Key patient safety concerns At Patient Safety Learning we will continue to raise awareness of the significant patient safety concerns relating to corridor care, including: Delayed treatment. Inadequate monitoring. Compromised infection control. Patient dignity not being supported. Relatives not being able to support patients who may not otherwise be closely monitored. Moral injury and impact on staff delivering poor standards of care. Manual handling safely. Trip hazards and obstructions. Blocked evacuation routes in the case of fires of other major incidents. Corridor care blogs In a series of blogs for the hub, we shine a light on some of the safety concerns surrounding corridor care. The crisis of corridor care in the NHS: patient safety concerns and incident reporting On the 16 January 2025, the Royal College of Nursing (RCN) published a new report presenting the findings of a survey of nursing staff outlining the extent of corridor care across the UK. This blog sets out Patient Safety Learning’s response to this report. The crisis of corridor care in the NHS: patient safety concerns and incident reporting In this blog, Patient Safety Learning’s Director Clare Wade reflects on the challenges that growing prevalence of corridor care poses to reporting and acting on patient safety concerns in the NHS. How corridor care in the NHS is affecting safety culture: A blog by Claire Cox Patient Safety Learning’s Associate Director Claire Cox looked at how corridor care within the NHS is affecting safety culture and examined its implications for both healthcare professionals and patients. Corridor care: are the health and safety risks being addressed? Patient Safety Learning’s Associate Director Claire Cox writes about the associated health and safety risks, questioning whether these are being properly addressed. Claire draws out key areas for consideration and suggests practical measures that can help protect patient safety in such challenging working environments. A nurse's response to the NHSE guidance on their principles for providing safe and good quality care in temporary escalation spaces In this blog, an anonymous nurse reflects on the recent NHS England (NHSE) guidance on the use of "temporary escalation spaces" and why this is so far removed from 'work as done' on the frontline. A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift In this anonymous account, a nurse shares their experience of corridor nursing, highlighting that corridor settings lack essential infrastructure and pose many safety risks for patients. They also outline the practical difficulties providing corridor care causes for staff, as well as the potential for moral injury. Using the System Engineering Initiative for Patient Safety (SEIPS) framework, they describe the work system, the processes and how that influences the outcomes. Share your insights Do you have experience of corridor care either as a patient or a healthcare professional? What impact have you seen on patient safety? You can comment below (sign up here for free first) or email the editorial team at [email protected]- Posted
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The Parkinson’s Excellence Network have released a series of resources to support UK healthcare professionals in hospitals to improve the delivery of time critical medication for people with Parkinson’s. Parkinson's UK time critical medication dashboard. The new dashboard estimates the benefits of improving time critical medication management for people with Parkinson's in hospitals in England, Scotland and Wales. The dashboard estimates the direct cost for hospitals and impact on patient outcomes of delayed or missed medication doses. Audit and awareness: how staff at Hexham General Hospital improved the delivery of time critical medication. This case study details how a staff nurse's dissertation led to an increase in Parkinson's medication delivered on time on a ward at Hexham General Hospital. Webinar: Driving improvement on time critical Parkinson's medication. In February our fully subscribed webinar included a session on practical benchmarking against the 10 recommendations. Watch the webinar recording and read the Q&A document now. Time critical medication patients' stories: in their own words. In these new short films, people with Parkinson’s share their experiences of receiving their Parkinson's medication in hospital and how this impacted on their health and well being. These films have been developed to raise awareness and support education and training of health professionals. Read more in the latest time critical medication blog by former nurse Patsy Cotton. Access all of the time critical medication resources. -
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In June 2023 the Secretary of State for Health and Social Care announced that HSSIB would undertake a series of investigations focused on mental health inpatient settings. This overarching report brings together and explores cross-cutting patient safety risks across five individual investigations. The aim of this report is to examine patient safety risks identified across the following HSSIB investigations: Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of suicide risk and safety planning (12 September 2024) Creating conditions for the delivery of safe and therapeutic care to adults in mental health inpatient settings (24 October 2024) Mental health inpatient settings: out of area placements (21 November 2024) Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s mental health services to adult mental health services (12 December 2024) Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge (30 January 2025) Findings Safety, investigation, and learning culture There remains a fear of blame in mental health settings when safety events happen. This contributes to a more defensive culture despite staff actively wanting to learn. Many recommendations to support learning for improvements in mental health care do not lead to implemented actions. Reasons for this include a lack of impact assessment resulting in unintended consequences, no clear recipient involved in the development of recommendations, and duplicated recommendations across organisations. System integration and accountability The integration of health and social care within an integrated care system currently relies on relationships, with an expectation and hope that they will work well. However, where this is not the case, a lack of clear accountability can result in poor outcomes for people with mental illness and severe mental illness. The delivery of care for people with mental illness and severe mental illness is challenging because health and social care services are not always integrated and their goals are not always aligned. Physical health of patients in mental health inpatient settings There are gaps in the provision of physical health care for people with severe mental illness, including inconsistent health checks, poor emergency responses, and misattribution of physical symptoms to mental illness. The misattribution of physical symptoms to patients’ mental health was observed and had the potential to contribute to worsened patient outcomes. National reports, strategies and research have made recommendations to improve the physical health of people with severe mental illness. However, there is evidence that recommendations are delayed in implementation and people continue to die prematurely. Integrated care boards lack the required data and the necessary analytical capability to assess disparities in access, experience and outcomes related to the physical health needs of people with severe mental illness. There is variation in how the physical health checks are carried out on mental health inpatient wards, with limitations in processes for following up on patients’ physical health needs. There is variation in the knowledge, skills and experience of staff who undertake physical health checks and in the environments in which these checks take place. Patients may not always be supported in terms of health education about their physical health risks and modifiable risk factors, for example smoking, dietary advice and physical activity. Caring for people in the community Integrated care boards cannot consistently draw reliable insights from data at national, system or local level, to optimise and improve services, patient care, and outcomes across mental health pathways of care. This results in variability in service provision which does not always meet the needs of individual patients or local populations. Inpatient ‘bed days’ are taken up by people who no longer need them, because people who are clinically fit for discharge are delayed in being transferred to their home or a suitable residence (appropriate placement). Reasons for delayed discharges include issues with housing support and establishing suitable accommodation. This means patients are not always in the right place of care. Barriers to discharge affect patient flow and may result in delays in admission for people with severe mental illness. This means they have to be cared for in a community setting while waiting for an inpatient bed. There is variation across the country in how drug and alcohol services are provided. The variation does not allow for fair and equitable treatment for all patients. Community services are vital to support people to stay as well as possible and to prevent hospital admissions. However, there is variation in community service provision across the country. Staffing and resourcing Staffing and resource constraints in inpatient and community mental health settings impact their ability to provide safe and therapeutic care. In inpatient settings, constraints contribute to mental health wards aiming to staff for ‘safety’ but not always for ‘therapy’. Challenges for staff include the emotionally demanding nature of their work; this can lead to staff burnout and sickness, and further strain on services. There are gaps in mental health workforce planning, particularly in community services where there is no evidence based workforce planning tool to support a standardised staffing establishment setting model. Digital support for safe and therapeutic care A lack of interoperability or integration between digital systems affects the provision of care across mental health, acute and community providers. Challenges in securing appropriate funding impacts on the ability of hospitals to integrate and update their digital services and infrastructure. Electronic patient record functionality is often not available or does not meet staff needs, and so it is not used. Examples include absent functions for food and fluid balance monitoring and risk assessment of venous thromboembolism (blood clots). Challenges in providing and maintaining patient-facing technology, for example televisions and payphones, impacts on the therapeutic environment and the ability of patients to maintain contact with families and loved ones. Where technology for monitoring patients had been introduced, implementation has required considerations to ensure it is used appropriately, is patient-centred, maintains therapeutic engagement, and supports patients to feel safe. Suicide risk and safety assessment ‘Doing’ tasks, like ‘ticking’ checklists, overshadow meaningful, empathetic ‘being’ interactions with patients. Open, compassionate conversations that build trust and therapeutic relationships, enabling patients to own their risk while feeling supported, can help mitigate this. Investigation processes can contribute to a fear of blame, and subsequently contribute to defensive practices such as checklists and a ‘tick box’ culture. This inhibits open and honest conversations and the ability to put the patient, as their authentic self, at the heart of them. Safety recommendations HSSIB recommends that the Department of Health and Social Care continues to work with the ‘recommendations but no action working group’ and other relevant organisations, to ensure that recommendations made by national organisations specific to mental health inpatient settings are reviewed. This work should consider the mechanisms that supported or hindered the implementation of actions from these recommendations. This may help the Department of Health and Social Care understand what has worked when implementing actions from recommendations and enable learning about why some recommendations have not achieved their intention. HSSIB recommends that the Secretary of State for Health and Social Care directs and oversees the identification and development of a patient safety responsibilities and accountabilities strategy related to health and social care integration. This is to support the management of patient safety risks and issues that span integrated care systems. Safety observation National bodies can improve patient safety in mental health inpatient settings in England by supporting provider investment in equipment, digital systems and physical environments to enable conditions within which staff are able to provide, and patients can receive, safe and therapeutic care.- Posted
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WHO champions patient-centred health care, where patients and their families shape health care decisions. Watch this video to learn about how engaging patients may help to ensure patient safety.- Posted
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An estimated one in every 10 patients experience harm in health care facilities, and each year, there are more than three million deaths globally due to unsafe health care. Most of the patient harm is preventable, with patient and family engagement being one of the most important strategies for reducing harm. This video shows how listening to the voices of patients, families and caregivers can lead to safer health care for all.- Posted
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Expectations of patient and family involvement in investigations of healthcare harm are becoming conventional. Nonetheless, how people should be involved, is less clear. Therefore, the “Learn Together” guidance was co-designed, aiming to provide practical and emotional support to investigators, patients and families. This study evaluated the use of the Learn Together guidance in practice—designed to support patient and family involvement in investigations of healthcare harm. Findings The guidance supported the systematic involvement of patients and families in investigations of healthcare harm and informed them how, why, and when to be involved across settings. However, within hospital Trusts, investigators often had to conduct “pre-investigations” to source appropriate details of people to contact, juggle ethical dilemmas of involving vs. re-traumatising, and work within contexts of unclear organisational processes and responsibilities. These issues were largely circumvented when investigations were conducted by an independent body, due to better established processes, infrastructure and resources, however independence did introduce challenge to the rebuilding of relationships between families and the hospital Trust. Across settings, the involvement of patients and families fluctuated over time and sharing a draft investigation report marked an important part of the process—perhaps symbolic of organizational ethos surrounding involvement. This was made particularly difficult within hospital Trusts, as investigators often had to navigate systemic barriers alone. Organisational learning was also a challenge across settings. Conclusions Investigations of healthcare harm are complex, relational processes that have the potential to either repair, or compound harm. The Learn Together guidance helped to support patient and family involvement and the evaluation led to further revisions, to better inform and support patients, families and investigators in ways that meet their needs (https://learn-together.org.uk). In particular, the five-stage process is designed to centre the needs of patients and families to be heard, and their experiences dignified, before moving to address organisational needs for learning and improvement. However, as a healthcare system, we call for more formal recognition, support and training for the complex challenges investigators face—beyond clinical skills, as well as the appropriate and flexible infrastructure to enable a receptive organisational culture and context for meaningful patient and family involvement. Related reading on the hub: The Learn Together programme (part A): co-designing an approach to support patient and family involvement and engagement in patient safety incident investigations- Posted
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Safety in surgery series
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A wonderful read, thank you. Please see our resources for enabling a culture shift: https://restorativethinking.co.uk/resources/- Posted
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The Royal College of Surgeons of Edinburgh (RCSEd) have drawn up their top 10 tips for surgical safety using the SEIPS (Safety Engineering Initiative for Patient Safety) model. Click on image to enlarge or download from the attachment below: See also: Top 10 priorities for patient safety in surgery Top 10 patient safety tips for surgical trainees- Posted
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We asked the Patient Safety Group (PSG) of The Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top 10 patient safety tips for surgical trainees. See also: Top 10 tips for surgical safety: ‘Think Safety, think SEIPS’ Top 10 priorities for patient safety in surgery Listen to the patient and what matters to them; share decisions with them. Encourage the patient to be in control of their care; they only have to consider their own care and will not be lost to follow up. Trust your instincts; always speak up if you think something is not right. Never be afraid to ask for help if you need it. Look after yourself and your team; there can be no patient safety without team safety. Foster good team working; recognise and respect the value of all team members; take account of everyone’s strengths and weaknesses. Take responsibility for the safety of your patients; patient safety is everyone’s responsibility, not just that of the quality improvement team. Help design systems that make it easier for you to do the right thing. Do not make assumptions. Work as imagined is not the same as work done; make sure you always test any process in practice and confirm that what you think is the case is actually happening. Regularly audit your practice. Celebrate good practice and share your experiences. Take on board feedback and learn from it; be willing to change practice. When outcomes are not as expected, openly discuss and learn, to enable you and your team to reduce the risk of the same thing happening again.- Posted
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We asked the Patient Safety Group (PSG) of The Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top 10 priorities for patient safety in surgery. This resource is for surgeons, anaesthetists and other healthcare professionals who work in surgery and contains links to useful tools and further reading. See also: Top 10 tips for surgical safety: ‘Think Safety, think SEIPS’ Top 10 patient safety tips for surgical trainees 1. Foster a culture of safety through design Establish a psychologically safe environment, through design, where staff feel empowered to speak up without fear of blame. Promote a Just Culture, balancing personal accountability with systems-based learning from adverse events and near misses. Actively encourage multidisciplinary teamwork and peer support, with support from senior leadership, to enhance safety and well-being. Other useful RCSEd resources: Anti bullying and undermining campaign Sexual misconduct in surgery - Lets remove it campaign Addressing conflict in surgical teams workshop 2. Implement team-based quality and safety reviews Use team-based quality reviews (TBQRs) and structured case analysis to learn from everyday work, incidents and near misses. Translate findings into sustainable improvement initiatives that enhance both patient outcomes and staff experience. Foster a culture of collective learning, ensuring safety insights lead to actionable change. Other useful RCSEd resources: Making sense of mistakes workshop 3. Apply Human Factors principles and systems thinking principles in surgical and clinical practice Design resilient systems that mitigate work and cognitive overload and enhance performance reliability. Use TBQR principles to support this. Standardise workflows, optimise usability of IT systems and medical devices, and integrate cognitive aids (e.g. WHO Safe Surgery Checklists, prompts). Ensure governance processes support safe, efficient and user-friendly surgical environments. Other useful RCSEd resources: Systems safety on surgical ward rounds Improving the working environment for safe surgical care Improving safety out of hours 4. Enhance communication & handover processes Implement structured communication tools such as SBAR (Situation, Background, Assessment, Recommendation) to improve clarity and effective decision-making. Optimise handover processes with digital tools, checklists and standardised documentation. Reinforce closed-loop communication, ensuring critical information is confirmed and acted upon. Other useful RCSEd resources: Consultation Skills that matter for Surgeon (COSMOS) 5. Strengthen leadership & accountability in patient safety Senior leaders must visibly support safety initiatives and proactively engage frontline staff in decision-making. Embed structured mechanisms for raising concerns, including TBQR, safety huddles and escalation pathways. Ensure staff have access to training, resources and protected time for safety and quality improvement work. 6. Minimise medication errors in surgery Implement electronic prescribing and technology assisted medication administration to mitigate errors. Enforce double-check procedures for high-risk medications and standardised drug labelling. Improve intra and peri-operative medication safety with clear labelling, colour-coded syringes and real-time verification. 7. Improve early recognition & response to deterioration Appropriate regular training of teams on processes and pathways supported by good design of staff rota ensuring adequate staffing levels. Implement early warning scores and establish rapid response pathways for deteriorating patients. Standardise post-operative surveillance strategies, ensuring timely escalation and intervention. Other useful RCSEd resources: Recognition and prevention of deterioration and injury (RAPID) course for training in recognising critically ill patients 8. Engage patients & families as safety partners Encourage shared decision-making to align treatment plans with patient expectations and values. Provide clear communication on risks, benefits and post-operative care, using tools like patient safety checklists and focus on informed consent processes. Actively involve patients and families in safety and quality initiatives and hospital discharge planning. Other useful RCSEd resources: Patient/carer/families resources and information Informed consent courses (ICoNS) 9. Standardise, simplify & optimise surgical processes Reduce unnecessary complexity in clinical workflows, making processes intuitive, efficient and reliable. Co-design standard operating procedures, policies and pathways with frontline teams to minimise variation. Implement automation and digital solutions where feasible to streamline repetitive tasks. Other useful RCSEd resources: NOTSS (Non Operative Technical Skills for Surgery) courses for surgeons DenTS courses for dentists 10. Promote continuous learning & simulation-based training Conduct regular simulation training for critical scenarios (e.g. sepsis, airway emergencies, human factors). Use insights from TBQR and incident reviews to target training needs and refine clinical practice. Ensure ongoing professional development by providing staff with time, resources, incentives and institutional support for learning. Other useful RCSEd resources: Education pages Edinburgh Surgery OnLine MSc in Patient Safety and Clinical Human Factors- Posted
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The being fair tool will support decision-making for patient safety incidents referred to workforce, and to ensure that staff are not treated unfairly after a patient safety incident. In rare circumstances a learning response may raise concerns about an individual’s conduct or fitness to practise. It is in these specific circumstances that the being fair decision-making tool can help decide what next steps to take.- Posted
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AHRQ's MRSA prevention toolkit: Targeting SSI
Patient Safety Learning posted an article in Surgical site infections
The Agency for Healthcare Research and Quality (AHRQ) toolkit for MRSA Prevention: Targeting SSI highlights four key evidence-based strategies to prevent MRSA and SSI: nasal decolonisation, preoperative skin antisepsis, antimicrobial prophylaxis and evidence-based prevention strategies. Surgical teams can incorporate concepts from the AHRQ Comprehensive Unit-based Safety Programme framework into their current care team to promote patient safety culture and enhance teamwork and communication. Access the toolkit’s extensive resources, including presentations and facilitator guides, plus staff and patient training materials to help your facility get started or supplement your existing MRSA and SSI prevention efforts.- Posted
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The US Department of Health and Human Services (HHS)’s vision is to be a global leader in innovating and adopting responsible AI to achieve unparalleled advances in the health and well-being of all Americans. This HHS AI Strategic Plan provides a framework and roadmap to ensure that HHS fulfils its obligation to the Nation and pioneers the responsible use of AI to improve people’s lives -
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This study looked at the factors influencing nurses' recognition and response to patient deterioration. Seventeen studies were reviewed and appraised. Recognising patient deterioration was encapsulated in four themes: (1) assessing the patient; (2) knowing the patient; (3) education and (4) environmental factors. Responding to patient deterioration was encapsulated in three themes; (1) non-technical skills; (2) access to support and (3) negative emotional responses. The study concluded that issues involved in timely recognition of and response to clinical deterioration remain complex, yet patient safety relies on nurses’ timely assessments and actions.- Posted
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Health Literacy in Medicines Use and Pharmacy: A Definitive Guide highlights issues related to medication literacy from the context of the pharmacist and other healthcare professionals. The book provides a clear explanation of medication literacy, presents different tools to assess health and medication literacy, readability, and comprehensibility of written medicine information (WMI), and elaborates on different approaches to develop customized and patient-friendly WMI. The book also covers health and medication literacy in special populations, including geriatrics, paediatrics, and pregnant/lactating patients. Written by experts in health communication, this book will help pharmacists, other health professionals, educators, students, and regulators, who need to develop customised educational materials that can be understood by a broad range of patients, especially those with low health literacy.- Posted
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Diagnostic uncertainty was relatively common in critically ill children admitted to the paediatric intensive care unit (PICU), an AHRQ-funded study in Critical Care Medicine concluded. Diagnostic uncertainty is the subjective perception of clinicians of their inability to provide an accurate explanation of a patient’s health problem. Researchers aimed to identify the frequency and factors associated with diagnostic uncertainty among critically ill children admitted to PICU. They reviewed the medical records of 882 patients admitted to one of four PICUs. Diagnostic uncertainty at admission was observed in 228 out of 882 patients. They also found a significant association between diagnostic uncertainty and diagnostic error. Researchers highlighted the need for more research and better strategies to address diagnostic uncertainty.- Posted
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The NHS is on the cusp of achieving 100% electronic patient record coverage in England, a significant milestone. However, research from the Health Foundation shows more needs to be done to reap the benefits. Key points Although England is on the verge of every NHS trust having an electronic patient record (EPR) system, a small number of organisations are still struggling to reach this milestone, and many more aren’t yet using these systems to their full potential. Used well, EPRs can deliver important improvements to care quality and productivity, ensuring staff have access to health information and supporting them to deliver safe and effective care. To explore the challenges in realising the benefits of EPRs, we conducted interviews with leaders in five acute NHS trusts in England, and also looked at an example from a leading US medical centre. This piece presents insights from these interviews and recommends next steps for unlocking the potential of EPRs. Simply ‘digitising paper’ doesn’t change the way we deliver care. NHS organisations need to be able to deploy EPR systems effectively to reap their benefits. Procuring and installing EPRs is merely the starting point for this journey. The experience of the US, where many providers are several years ahead of the UK in EPR use, reveals the hill to climb: reaching meaningful use of EPRs requires time, investment and cultural change. NHS providers can learn from those organisations in the UK and abroad who are further ahead with their EPR journeys. The government urgently needs to set out an EPR strategy for the NHS to facilitate effective benefits realisation – both to ensure trusts are getting the basics right, and to help develop and deploy higher order functionalities including AI. This will be as important as any digitisation plan of the last 20 years. Trusts will ultimately bear some of the responsibility for good implementation and usage of EPRs, and should be asked to develop their own plans to sit alongside the national roadmap. There’s no avoiding the fact that capitalising on EPRs is going to require more funding. But the prize further down the line will be advances in care quality and productivity. Having already made significant investment in acquiring EPRs, it is essential that NHS organisations are now supported to realise these benefits. There’s no time to lose. While the few trusts still to put EPRs in place need support to do so, the next stage of this strategy cannot wait for that. -
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Martha’s Rule is a key patient safety initiative to ensure patients, families, carers and hospital staff’s concerns about a worsening health condition are listened to. This can help detect deterioration early, so action can be taken to prevent more serious health problems. Effective communication is crucial to the success of Martha’s Rule. NHS England has launched a Martha’s Rule communications toolkit providing trusts with a range of resources to support them to: raise awareness of Martha’s Rule among hospital staff, patients, families, and carers support staff to understand their role in implementing Martha’s Rule, ensuring they feel confident to escalate concerns and ask for additional support when necessary empower patients and families to voice concerns about deteriorating health and to seek rapid reviews when needed.- Posted
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Community mental health care support the largest number of patients within England’s mental health services. Yet, when it comes to research on patient safety in these settings, there’s still a lot we don’t know. To address this gap, (Averill, Sevdalis and Henderson, 2025) undertook a first-of-its kind study looking at the free-text information that is routinely reported by staff in incident reports. This approach is crucial in mental health settings, where most staff-reported observational data lack numeric scales for comparison and is instead entered as free-text. While the National Reporting and Learning System (NRLS), does compile quantitative information from the National Health Service (NHS) and make this freely available, most of these data are counts of incident types, rather than detailed notes written by staff. These notes contain a rich source of information – and yet, they have not previously been studied for patterns or themes, and therefore the information is not widely available to disseminate outside of the NHS. It is important that dedicated researchers are involved in this process. They have skills and experience in mitigating potential biases that could arise when looking at the data – and help discern real or truthful relationships that ultimately improve the quality of care. -
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The Patient Safety Authority (PSA) 2024 Annual Report highlights PSA's commitment to safer care for Pennsylvanians. With over 5 million patient safety event reports, the Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest repository of its kind in the United States and one of the largest in the world. PSA's accomplishments last year include: Analysed serious event reports identifying neonatal injuries or death related to labour and delivery, published our findings in a report, and shared evidence-based strategies for mitigating the risks associated with shoulder dystocia. Worked with ambulatory surgical facilities to improve surgical site infection surveillance and reporting, including regional, in-person symposia throughout Pennsylvania on the identification of infection through the application of criteria and using hospital-acquired infection data to evaluate infection prevention programs. Published monthly newsletter articles featuring Patient Safety Reporting System (PA-PSRS) reports, such as "What to Know About Glacial Acetic Acid: Stop Using It" and "Pica Behavior in Acute Care Hospitals: Strategies for Screening and Mitigating Risk of Harm." These were also disseminated in PSA's peer-reviewed journal, Patient Safety, which reaches more than 150,000 readers worldwide. Embarked on an ambitious five-year strategic plan, Reimagine Patient Safety 2029, built on three main pillars: push the boundaries of information science to identify and understand patient safety issues, leverage relationships to implement changes that improve patient safety, and maintain a strong organizational culture that focuses on people and continuous organisational improvement.- Posted
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This Model ICB Blueprint has been developed by a group of Integrated Care Board (ICB) leaders from across the country, representing all regions and from systems of varying size, demographics, maturity and performance. It is a joint leadership product, developed and written by ICBs in partnership with NHS England. The group has worked together to develop a shared vision of the future with a view to providing clarity on the direction of travel and a consistent understanding of the future role and functions of ICBs. Future of ICB functions (click on image to enlarge): Source: HSJ The document sets out a blueprint for how ICBs can operate within a changing NHS landscape. It covers the following areas: purpose – why ICBs exist core functions – what they do enablers and capabilities – what needs to be in place to ensure success managing transition – supporting ICBs to manage this transition locally and the support and guidance that will be available.