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We often hear from the Patient Safety Management Network that members are in interested in how others from different industries do things. In this hub top picks, we have pulled together useful websites on safety and investigations in other industries, including aviation, rail and nuclear. Aviation safety Air Accidents Investigation Branch (AAIB) AAIB Reports Collection National Transportation Safety Board (NTSB) NTSB Aviation Accident Database ASRS - Aviation Safety Reporting System European Union Aviation Safety Agency (EASA) EASA Safety Publications Safety - International Civil Aviation Organization BEA Safety Hub - France Confidential Human Factors Incident Reporting Programme (CHIRP) SKYbrary Aviation Safety THE NIMROD REVIEW An independent review into the broader issues surrounding the loss of the RAF Nimrod MR2 Aircraft XV230 in Afghanistan in 2006 HC 1025 Aircraft Accident Report AAR 2/2023 - Sikorsky S-92A, G-MCGY Marine safety Marine Accident Investigation Branch International Maritime Organization Marine Safety Investigation Reports Nuclear industry safety International Atomic Energy Agency (IAEA) IAEA Safety Reports Series World Association of Nuclear Operators (WANO) The Public Inquiry into the Piper Alpha Disaster: Volume 1 Oil and gas and major accidents Energy institute Deepwater Horizon Investigation Report Rail safety Rail Safety and Standards Board (RSSB) Rail Accident Investigation Branch Reporting railway incidents - Office of Rail and Road Related reading See our Good practice from other industries category on the hub for more resources and reading. Do you have any safety resources from other industries that you have adapted to use in your organisation? We'd love to share them on the hub. Comment below (you'll need to be a hub member—sign up is free and easy to do) or email [email protected].

Sebastian Gonzalez, hub topic lead and learning disability lead nurse at Barts Health NHS Trust, reflects on the lack of progress made in reducing health inequalities for people with a learning disability despite a number of reports and recommendations over the last few years. He highlights the new reasonable adjustment digital flag that is being implemented across the NHS, which allows the sharing of detailed information across the healthcare system about the reasonable adjustments individuals require. Sebastian asks you to explore what your organisation is doing to implement the reasonable adjustment digital flag to help identify and support patients with a learning disability. Since the publication of the Confidential Inquiry into Premature Deaths of People with Learning Disabilities (CIPOLD),[1] we have been aware of the profound health inequalities across the country. Currently, it is estimated that 1.5 million people with a learning disability live in the UK,[2] and more recent data show that, on average, adults with a learning disability die 19.5 years earlier than the general population and that 40.2% of their deaths are considered avoidable.[3] The National Confidential Enquiry into Patient Outcome and Death report The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) is a UK based charity that reviews the quality of healthcare in order to improve patient safety and outcomes. In 2026 they published a study report: Learning Together: A Review of the Quality of Care Provided to Adults with a Learning Disability When Admitted to Hospital Acutely Unwell (NCEPOD).[4] More than a decade after CIPOLD first exposed the health inequalities experienced by people with a learning disability, the findings of this report demonstrate that significant challenges remain and that further action is needed to improve patient safety and healthcare outcomes. The study focused on adults aged 18 years and over with a learning disability who were admitted to hospital as an emergency between 1 July and 30 September 2024. Data were gathered from a range of sources, including clinician questionnaires, primary care questionnaires, organisational questionnaires, surveys completed by healthcare professionals, patients and carers, and detailed reviews of patient case notes. Key findings: Incorrect use of the terms learning disability and learning difficulty. Underuse of flagging and alert systems. Failure to consistently implement reasonable adjustments. Poor adherence to the Mental Capacity Act. Limited involvement of people with a learning disability in their own care decisions. Unequal access to specialist learning disability services. A focus on flagging and alert systems The study found that hospital services often failed to accurately identify and flag people with a learning disability. One of the key expectations introduced in 2018 through the Learning Disability Improvement Standards for NHS Trusts was that organisations should have mechanisms in place to identify and flag patients with a learning disability, autism, or both, from the point of admission through to discharge. Yet, the report highlighted that while 89.7% of the organisations reported having flagging or alert systems in place, only 52.2% of patients had these alerts. The issues were compounded by the incorrect use of the term learning difficulty, an issue well known to people with a learning disability and those that support them.[5] Furthermore, the report identified a key link between the use of flags and the provision of reasonable adjustments, highlighting how adjustments were more likely to be made when patients had been accurately identified and flagged. Moving forward Throughout the years, several reports have provided evidence of the poorer outcomes experienced by people with a learning disability and have made recommendations on how to improve their care. Despite this, it remains clear that there is still a long way to go in reducing the health inequalities experienced by this patient group. While the process of identifying and flagging patients may seem administrative in nature, it represents an essential patient safety mechanism that helps ensure individuals receive healthcare that is reasonably adjusted to meet their needs. In addition, an effective flagging system enables organisations to monitor outcomes closely, including incidents involving this group of patients. This, in turn, can support more effective service planning and ultimately contribute to improved patient outcomes. The reasonable adjustment digital flag[6] being implemented across the NHS represents an opportunity to go beyond simply identifying and flagging patients. Not only does it allow for detailed information about the reasonable adjustments individuals require, but it also promotes the sharing of this information across the healthcare system. If your role involves improving patient safety, consider exploring what your organisation is doing to implement the reasonable adjustment digital flag, and how it identifies patients with a learning disability and ensures they receive the support they need. Small changes in these areas have the potential to make a significant difference to patient experience and outcomes. References Heslop P, et al. Confidential Inquiry into premature deaths of people with learning disabilities (CIPOLD) Final report. Norah Fry Research Centre, 2013. Mencap. Learning Disability Research and Statistics. Last accessed 5 July 2026. White SA, et al. LeDeR Annual Report Learning from Lives and Deaths: People with a Learning Disability and Autistic People. The Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London. Last update June 2026. Tavaré A. Learning Together A review of the quality of care provided to adults with a learning disability when admitted to hospital acutely unwell. NCEPOD, 2026. Mencap. Learning Difficulties: Types, Causes and Symptoms. Last accessed 5 July 2026). NHS England. The reasonable adjustment digital flag action checklist: what you need to do to achieve compliance. 25 March 2024.

NHS Resolution is an arm’s length body of the Department of Health and Social Care. It provides expertise to the NHS on resolving concerns and disputes fairly, sharing learning for improvement and preserving resources for patient care. It handles negligence claims on behalf of NHS organisations and independent sector providers of NHS care. Their annual report and accounts for 2025/26 reflects on the first year of their three-year strategy, Resolution Through Collaboration, providing an overview of the work of NHS Resolution over this period. Key points highlighted in this report include: There has been in increase in new clinical claims received, which totalled 15,236 in 2025/26 (up from 14,428 claims in 2024/25). 84% of clinical claims were kept out of formal court proceedings, providing earlier resolution for patients and healthcare staff, and saving costs. £3.2 billion was paid out in 2025/26 for compensation and associated costs on all of NHS Resolution’s clinical schemes (up from £3.1 billion in 2024/2025 and £2.8 billion in 2023/24). 40% (£1.3bn) of the total clinical negligence payments (£3.2bn) in 2025/26 related to maternity. This is a reduction from 42% in 2024/25. The estimated total cost of harm incurred in 2025/26 was £4.8 billion. The majority of this related to the main clinical scheme, the Clinical Negligence Scheme for Trusts, which was £4.5 billion. NHS Resolution’s provision for future liabilities as of 31 March 2026 was £60.3 billion.

I have spent almost three years as an NHS stop smoking advisor in Luton. A client called me five days after removing her nicotine patch due to a skin reaction. She had started smoking again. She was distressed and convinced she had failed. The answer to her question took me thirty seconds. She could have had it five days earlier if there had been anywhere to turn at the moment she needed it. That moment made me ask whether technology could do what the NHS structurally cannot. Provide trusted, clinically grounded support at any hour, in any language, in the moments when relapse is most likely to happen. So, I developed an AI-powered stop smoking support tool. This blog is about what building this innovative product taught me about patient safety. The gap that innovation has to fill Relapse in smoking cessation does not usually happen because someone stops wanting to quit. It happens in unguarded moments between appointments. At 11pm on a Saturday. After a stressful day at work. When something goes wrong with nicotine replacement therapy (NRT) and there is nobody to call. That structural gap is not a failure of the NHS. It is a limitation of what any appointment-based service can provide. Innovation exists to fill gaps that existing systems cannot reach. This was mine to fill. The innovation I built alongside my NHS role While continuing in my NHS role, I built an AI-powered stop smoking support platform delivered through WhatsApp. The choice of WhatsApp was deliberate. No app download is required. It works on any smartphone and is available in six languages. In Luton, where significant communities speak Urdu, Bengali, Arabic, Polish and Romanian as their first language, removing every possible barrier to access was a patient safety decision as much as a design one. The platform provides real-time nicotine craving support, NRT guidance, behavioural nudges, relapse prevention messaging and proactive check-ins. Every response is grounded in verified NHS clinical guidance using a technique called retrieval augmented generation, meaning the AI draws from a curated clinical knowledge base rather than generating health information from general training data. The innovation is not the technology itself. The technology exists. The innovation is applying it to a specific, underserved clinical gap with genuine patient safety discipline built in from the beginning. Why patient safety had to come before innovation Before I wrote a single line of code, I had to answer an uncomfortable question. What could go wrong if this AI got something wrong? In a stop smoking context the risks are real and specific. A pregnant client might ask about NRT safety. Someone in mental health crisis might reach out through the tool. A user might receive confident sounding information that is clinically incorrect. These were not hypothetical concerns. They were situations I had encountered as a human advisor. I completed a full clinical hazard log covering fifteen clinical and technical risks before the platform went live. I built human escalation logic as the first feature not the last. When the AI detects language suggesting crisis, risk or a clinical situation beyond its scope, it immediately directs the user to their advisor, a crisis line or emergency services. The innovation only works if the safety net is stronger than the gap it is trying to fill. The innovation lesson I learned from getting it wrong My first multilingual responses were translations of English text rather than naturally generated responses in each language. They were grammatically correct but culturally flat and in some cases confusing. For communities in Luton where English is not the first language this was a patient safety issue not just a usability one. A client who misunderstands health information because the language feels unnatural may make the wrong decision at a critical moment. I rebuilt the language handling so the AI generates responses directly in each language as a native speaker would write them rather than translating from English. Sometimes the most important innovations are not the ones you planned. They are the ones you discover by getting something wrong. What this innovation does not yet know I am currently preparing the AI-powered stop smoking support tool for a pilot with NHS stop smoking services in Luton in partnership with University of Bedfordshire and Luton Borough Council Public Health. The evaluation will compare quit rates against NICE benchmarks and traditional support methods. But I want to be honest about what this innovation does not yet know. Whether AI can fully replicate the human connection that makes stop smoking support effective. How clients with complex needs will interact with the tool in real-world conditions. What risks will emerge in practice that did not appear in design. Innovation in health is not finished when the technology works. It is finished when the evidence says it is safe, effective and reaching the people it was built for. We are not there yet. The pilot is where that work begins. Opinions expressed in blogs and other content are those of the author. Patient Safety Learning welcomes sharing content and opinions that promotes safer patient care and for the reduction of avoidable harm. The views expressed on the hub however do not necessarily represent Patient Safety Learning's views or values. References to a specific product or service does not imply a recommendation or endorsement.

Earlier this year, Clare Collins from Northumbria Healthcare NHS Foundation Trust gave a presentation at the Patient Safety Management Network (PSMN) meeting on how their Trust has aimed to improve patient safety though a project to remove caffeinated drinks. In this blog, Clare shares their journey and what they have learned about implementation, engagement, organisational readiness and sustainability.  From a practical idea to a patient safety movement What started as a simple question: “Could changing the type of tea and coffee routinely served on our wards improve patient safety?”, has evolved into a growing quality improvement programme with local, regional and international interest. As a team, we wanted to explore whether a small and practical change to everyday care could contribute to safer, calmer and more restorative ward environments. At Northumbria Healthcare NHS Foundation Trust, we developed the Decaf by Default initiative to explore whether routinely offering decaffeinated tea and coffee to patients could help reduce toileting related falls, improve sleep and hydration, and support calmer, safer ward environments. The project has since expanded across multiple inpatient settings, generated strong staff engagement, and prompted wider conversations around organisational readiness for cultural change in patient safety. Why consider going decaf? For many years, staff across our wards routinely offered caffeinated hot drinks to patients as the default option. While this was often seen as a normal part of care and comfort, emerging conversations within our Care for the Older Person community raised questions about whether this practice unintentionally contributed to avoidable harm. Several factors prompted further exploration: NICE guidance recommends reducing caffeine intake in relation to urinary incontinence and pelvic organ prolapse in women. Caffeine can increase urinary urgency and frequency, potentially increasing the risk of toileting-related falls. Caffeine may negatively impact sleep and contribute to agitation. Non-caffeinated drinks can support hydration, rest, recovery and overall wellbeing. A review of Datix reports also identified that approximately 25% of inpatient falls over a one-month period were related to toileting activities, particularly within older people’s services. This led us to consider whether a relatively small environmental and behavioural change could contribute to safer care. Building the foundations: organisational readiness and engagement One of the strongest themes highlighted through discussions at the PSMN meeting was that success depended less on the decaf itself, and more on organisational readiness, staff engagement and shared ownership. From the outset, we did not approach this as a top-down instruction. Instead, the project focused on creating curiosity, shared ownership and practical collaboration. With senior nursing support, we established a quality improvement multidisciplinary community to explore the issue collectively. Staff from a range of professions and settings contributed ideas, concerns and learning throughout the process. Importantly, we also connected with University Hospitals Leicester, who had previously undertaken similar work. This external collaboration provided valuable insight, reassurance and practical learning. Several factors helped support implementation: Clinical ownership Ward teams were encouraged to shape how the initiative worked within their own environments rather than applying a rigid model. This helped improve engagement and sustainability. Preserving patient choice The initiative was never about removing patient choice. Patients could still request caffeinated drinks if preferred. A Taste the Difference challenge helped staff and patients explore perceptions around decaffeinated drinks. While around 55% of participants noticed a taste difference, approximately 85% said they would be willing to switch once they understood the potential benefits. Consistent messaging Simple, practical education materials were developed for staff, patients and carers, including posters, conversations at ward level and patient information leaflets. For example, digital teams looked at incorporating brief health promotion messaging into discharge documentation: “While in hospital, you were given decaffeinated tea and coffee. It may help to continue this at home.” This will reinforce the intervention beyond admission and encourage patients and carers to consider whether continuing reduced caffeine intake at home might support sleep, continence, anxiety management or falls prevention. Communities of interest One of the most important learning points was the value of building communities of staff who were genuinely interested in improving patient safety. Enthusiasm and local leadership often became stronger drivers than formal instruction. As discussed during the PSMN presentation, staff ownership proved critical to successful implementation. Challenges and learning The project generated important discussions and learning. Questions raised during the PSMN presentation included whether rapid caffeine withdrawal effects had been observed. While no specific reports had been identified, the team acknowledged that individual caffeine intake prior to admission is often unknown. Alternative approaches, such as limiting caffeinated drinks to mornings only, were explored and trialled in one location by a member of the PSMN but were not found to be sustainable in practice. Another PSMN member reported that in their care home, although they had adopted the change successfully, they had not seen a reduction in toileting-related falls. This highlighted the importance of local context, fall data and ongoing evaluation over a longer time period. From local project to wider movement Following pilot work in 2024-2025, Decaf by Default was adopted Trust-wide in December 2025. Since then, interest has continued to grow across the region and beyond. The project is now being explored more widely through collaboration with: the regional NHS Alliance the North East and North Cumbria Integrated Care Board patient safety networks and quality improvement communities. There has also been increasing international interest in the concept as organisations look for low-cost, scalable interventions that may contribute to safer care environments. Alongside the Trust-wide rollout, work has also begun to extend the learning into care homes across Northumberland and North Tyneside. This has created opportunities to explore how similar approaches may support resident wellbeing and reduce risks associated with continence, sleep disturbance, anxiety and falls within community-based settings. A small community pilot project has been developed involving community nurses and Allied Health Professionals (AHPs). Participating staff carry supplies of decaffeinated tea and coffee within their clinical bags and are able to offer this as part of broader lifestyle conversations and personalised care interventions. The aim is not simply to replace drinks, but to encourage wider discussion around hydration, sleep, continence, falls prevention and anxiety management in a practical and accessible way during routine community contacts. What has perhaps resonated most strongly is that the project demonstrates how a relatively small cultural and environmental changes can stimulate wider conversations about patient safety, prevention and personalised care. Key reflections Looking back on the journey so far, several lessons stand out: Small changes can create meaningful conversations about patient safety. Organisational readiness matters as much as the intervention itself. Staff ownership and engagement are essential for sustainability. Preserving patient choice supports acceptability. Quality improvement requires curiosity, testing and adaptation. Simple interventions may have wider wellbeing benefits beyond their original aim. Most importantly, the initiative has highlighted the value of frontline teams identifying opportunities to improve care through practical, evidence-informed innovation. Related resources Go decaf! How a simple change on our wards could reduce falls, slips and trips What happened when we went decaf – the story so far How going decaf could boost patient safety by reducing falls in hospitals Patient flyer - go decaf How to join the Patient Safety Management Network You can join by signing up to the hub today. When putting in your details, please tick Patient Safety Management Network in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected]. Do you have a patient safety initiative you would like to share more widely. We'd love to hear from you and share it on the hub. Share here (you will need to be a member of the hub and signed in) or email [email protected].