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Content Article
This study examined the current fall prevention practices and implementation strategies used by the US hospitals. It found that there is substantial variation in US hospitals’ choice of fall prevention practices and a lack of implementation strategies to enhance staff adherence to the practices. The findings suggest a critical need for more standardised, evidence-based, and individualised approaches to effectively reduce falls. -
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Several hospitals in India face challenges in establishing a strong patient safety culture, which is crucial for quality health care. This study aimed to evaluate and benchmark the patient safety cultures across various Indian hospitals. An analysis of the data on patient safety culture obtained using a questionnaire showed that 62 (79%) hospitals used the Agency for Healthcare Research and Quality tool. Analysis of the composite positive response score of safety culture dimensions highlighted strengths in organisational learning and teamwork, but weaknesses in staffing and work conditions . This study highlights the current patient safety culture in Indian hospitals and identifies its strengths and gaps. These findings serve as a basis for benchmarking and targeted improvements, particularly in staffing and communication, to enhance the overall patient safety. -
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For too long, women’s experiences, symptoms and outcomes have not been adequately reflected in the evidence and systems that shape their care. Artificial Intelligence (AI) presents an enormous opportunity to do things differently. But if it is developed using data and approaches that reproduce existing inequalities, we risk carrying those same problems into the future. In this blog the Patient Safety Commissioner for England, Henrietta Hughes, explores why women’s health could be a defining test for AI in healthcare and why safety, transparency and patient voice need to be built in from the start. -
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National patient safety investigation bodies conduct system-level investigations and produce recommendations intended to improve patient safety. However, evidence that such recommendations translate into meaningful improvement is often weak. This study examined how recommendations produced by the Health Services Safety Investigations Body (HSSIB) are produced by investigators and received by the national organizations to whom they are directed. HSSIB investigates patient safety concerns across the NHS in England and in independent healthcare settings where safety learning could help to improve NHS care. Funded by the NIHR Patient Safety Research Collaboration: Greater Manchester, this study analysed 22 published investigation reports, ran two focus groups with 12 HSSIB investigators, and carried out interviews with 11 senior representatives from national bodies including NHS England, the Care Quality Commission, the General Medical Council, and several medical royal colleges. -
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State of Care is the annual assessment of health care and social care in England by the Care Quality Commission (CQC), the independent regulator of health and adult social care in England. The report looks at the trends, shares examples of good and outstanding care, and highlights where care needs to improve. -
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In this HSJ article, Dr Aaliya Goyal argues that the NHS’s new staff standards are hampered by their reliance on annual NHS Staff Survey results, which provide delayed and retrospective insights into workforce problems. Instead, she advocates using real-time, anonymised occupational health (OH) data as an early-warning system for issues such as bullying, discrimination, racism, sexual harassment, burnout and poor management, arguing that these problems often surface in OH consultations long before they appear in surveys, grievances or formal reports. Yesterday
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This is the second interim report in Health Services Safety Investigations Body (HSSIB)s investigation into electronic patient record systems and electronic referrals for ongoing care. It has been published to highlight a risk to patient safety associated with the electronic referral service (e-RS), where referrals may be removed from healthcare provider organisation worklists without warning or recognition. The e-RS system generates digital worklists, which are used by provider organisations to manage patient referral processes. Referrals are automatically removed from a provider’s worklist within e-RS when a user performs an action, like accepting a referral or booking a patient appointment, or when 180 days pass with no action since the unique booking reference number (the patient referral) entered a worklist. The 180-day function was designed into e-RS to reduce the risk of large worklists affecting the performance of the service. However, the investigation found that the function also creates a hazard to patients. -
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An integrated quality report (IQR or IQPR) connects clinical quality, experience, workforce, operations, risk and improvement. It is not every metric in one pack; it helps teams and boards judge whether services are safe, effective, caring, responsive and well-led, where assurance is limited and what must happen next. In this article, GGi senior consultant James Avery asks what constitutes a good integrated quality report. The article explores how: Good quality reports turn data into insight that drives change. Triangulated evidence explains not just what changed, but why. Insight must reach the frontline teams who can act. A seven-step test and maturity matrix shows where to improve. -
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The Witness to Harm project has published a range of resources to support patients, families, colleagues and members of the public involved in fitness to practise proceedings. Developed from mixed-methods research into people’s experiences of taking part in hearings, the resources aim to improve understanding of the process and help people feel better prepared. They include a short film on what to expect before, during and after a hearing, alongside animations, information about the research and links to further support. Last week
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Patient and Public Involvement and Engagement (PPIE) can bring valuable lived experience into decision-making, service improvement, research, and patient safety work. However, even well-intentioned organisations can make mistakes that reduce the impact of involvement and leave participants feeling undervalued. hub Topic leader, Aurora Todisco shares seven of the most common pitfalls and how to avoid them. -
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This study assesses the effects of an ambient artificial intelligence (AI) scribe on documentation time, note quality, clinician and patient experience in clinician–patient encounters. Using an ambient AI scribe for clinician-patient encounters reduces documentation burden, enhances clinician fulfilment and satisfaction and improves quality of interactions for patients. Effects of longer-term scribe use on professional efficiency and well-being, and patient care and outcomes warrant investigation. -
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The sixth module of the UK Covid-19 Inquiry examines the impact of the pandemic on the adult social care sector in England, Scotland, Wales and Northern Ireland. The module includes care provided in adult care and residential homes, in people’s own homes by professional carers and unpaid care provided by family members or friends. It looks at the decisions made by each nation’s government and considers: what happened to people living and working in the care sector during the pandemic how limiting visits to care homes affected residents and their loved ones how decisions to discharge patients to free up hospital beds affected those living and working in care homes. The module also examines the steps taken in care homes to stop the virus spreading and the care sector’s capacity to respond to the pandemic. Related reading on the hub: UK Covid-19 Inquiry Module 1: The resilience and preparedness of the United Kingdom Covid-19 Inquiry: Module 2, 2A, 2B, 2C Report – Core decision-making and political governance Covid-19 Inquiry: Module 3 Report – The impact of the Covid-19 pandemic on the healthcare systems of the United Kingdom UK Covid-19 Inquiry: Module 4 -Vaccines and therapeutics (16 April 2026) UK Covid-19 Inquiry: Module 5 – Procurement (14 July 2026) Questions around Government governance Covid Inquiry Recommendations Tracker (Covid-19 Bereaved Families for Justice) -
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Patient Safety Partners (PSPs) can be patients, relatives, carers or other members of the public who want to support and contribute to a healthcare organisation’s governance and management processes for patient safety. In this blog, Lea Tiernan, Patient safety engagement & involvement lead at Imperial College Healthcare NHS Trust, shares their approach to evaluating the impact of PSPs alongside a suite of related resources for others to adapt and use. -
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The Health Bill will shape how patients’ voices are heard in health and social care for years to come. On 8 October 2026, the Patients Association brought together patients, carers and representatives from national, local and community organisations to explore what independent patient voice needs to look like in practice. Participants were clear that being listened to is not enough. Patients need an independent voice that reaches decision-makers, leads to action and holds the system to account. This report sets out what independent patient voice means, seven principles that future arrangements must meet, and the messages decision-makers need to hear to ensure patients can influence decisions and see meaningful change. -
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New research commissioned by the Professional Standards Authority for Health and Social Care (PSA) reveals consumers spend almost as long researching a hotel stay as they do a private baby scan clinic, with 1 in 4 not considering safety checks when booking appointments. 'Look Before You Book’ is a PSA public awareness campaign, encouraging people to look for the Quality Mark to check that their practitioner is on an Accredited Register. It focuses on counselling and psychotherapy, private baby scans (sonography) and non-surgical cosmetic procedures, helping consumers recognise the PSA Quality Mark and make safer choices when booking private health and wellbeing services. Their dedicated Look Before You Book campaign landing pages provide tailored information for people considering counselling and psychotherapy, private baby scans or non-surgical cosmetic procedures. Each page explains why it is important to check who you are booking and how the PSA Quality Mark can help you make a safer, more informed choice. -
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New safety measures are now being implemented for all patients taking antidepressant medications. This follows completion of a detailed review, involving patients and their families, into how the risks of suicidal thoughts and behaviours, and persistent sexual dysfunction are communicated in the patient information leaflets (PILs) that accompany antidepressant medications. These changes involve a new boxed warning in the PIL, a new patient card and a supporting safety (ancillary) leaflet. The term post SSRI sexual dysfunction ('PSSD') is also being added to the PIL for some antidepressant medications. -
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Significant event analysis can help general practices understand why something went wrong, identify risks and improve patient safety. However, recording an event or discussing it at a meeting does not automatically produce meaningful learning. Practices need an open reporting culture, a proportionate method of review, and a reliable process for implementing and monitoring improvements. In this blog, Liam Stratton, a former Care Quality Commission (CQC) inspector, outlines six ways practices can improve their approach. These include making reporting accessible to every member of staff, examining reporting systems, involving patients where appropriate, turning findings into measurable actions and sharing learning across the organisation. Earlier
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Discover how one Pennsylvania facility strengthened breast milk-handling safety in its NICU after identifying preventable errors. This article reviews recent breast milk–related events reported statewide; outlines risks across collection, storage, and administration; and shares practical strategies hospitals can use to reduce harm. You’ll also learn how this facility sought guidance from the Patient Safety Authority as it implemented targeted improvements to close process gaps and enhance reliability. Explore these insights, lessons learned, and supportive resources designed to help facilities promote safer, more consistent care for infants and their families. -
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The NHS’s productivity problem is much bigger than top-down analysis suggests, with real patient journeys revealing how poorly designed processes can waste vast amounts of staff time and resources, writes Steve Black in this HSJ opinion piece. He says that analysing the patient journeys to identify the waste and chaos could drive far more improvement than the top-down analysis might suggest. And it could make the needed improvements far more concrete and convincing for the staff who need to implement them and far more convincing for the patients who need to support them. -
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Victoria Wilkins, Associate Safety and Learning Lead (North) at NHS Resolution, shares insights from a recent Northern Safety and Learning network meeting where four pilot trusts discussed their progress in implementing Martha’s Rule and shared their learning with other members. -
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Following this year's Picker Experience Network (PEN) Awards, their 'Learning from the best' report maps the 2026 winners against the priorities of the 10-Year Plan for Health. This report highlights where best practice is already happening and provides further details on the projects that won this year. For the full details of all shortlisted entries in 2026, PEN's Book of Best Practice is also available. Congratulations to the overall winner, University College London Hospitals NHS Foundation Trust (UCLH) and The Lighthouse Centre, who were recognised for their outstanding work to improve care for children who have experienced sexual abuse or exploitation. Its child-centred, trauma-informed model provides an alternative to fragmented care pathways. You can find out more about their winning entry here. -
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The prevailing strategy for combating surgically related adverse events (AEs) is to anticipate and prevent them by learning from adverse events (Safety-I). However, not all AEs can be anticipated or prevented in complex systems. This requires more focus on how daily work succeeds, that is, resilient and adaptive behaviour (Safety-II). Learning from success and promoting a positive patient safety culture (PSC) are key global strategies for eliminating preventable AEs. As a patient safety initiative, Learning from Excellence (LfE) captures episodes of successful everyday work and is thus, a system for applying a Safety-II perspective. However, its effect on PSC has not been evaluated. This study aimed to explore whether the implementation of LfE in a postanaesthesia care unit over a 16-month period changed the nurses’ perceptions of the measurable PSC dimensions ‘work engagement’, ‘teamwork climate’, ‘working conditions’ and ‘safety climate’. The authors concluded that LfE did not have a significant effect on PSC after 16 months implementation. Further longitudinal experimental studies are needed to measure the effect of LfE on PSC. Future research should focus on the role of psychological safety in LfE and assess whether reflexive spaces add value to LfE. -
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The Royal College of Physicians (RCP) has published a new report setting out a blueprint for reforming postgraduate medical training across the UK. Training physicians for the future: a blueprint for reforming postgraduate medical training calls for medical education to become a visible, protected and accountable part of NHS delivery. -
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World Menopause Awareness Day is celebrated every year on 18 October and is dedicated to raising global awareness about menopause and the health-related issues women face during this phase of life. At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples. In this Top picks, we’ve pulled together (1) resources and blogs shared on the hub for people who are going through menopause, and (2) resources and guidance for healthcare staff to support their patients and improve services. -
