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Keep up to date with the latest news, research and activity in patient safety.

Voices of blind women help reshape screening care

The distressing testimonies of women with sight loss have influenced new guidelines designed to make cervical screening more accessible.
The Royal National Institute of Blind People (RNIB) Scotland says the more than 100,000 blind and partially sighted women in Scotland face a range of barriers in accessing cervical screening.
Some women have described their experience as “rough” and “painful”, telling the charity that they feel uninformed and unsupported throughout.
Kirin from Edinburgh is registered blind. Reflecting on her experience attending a cervical screening appointment, she said:
“I only went once, and it went disastrously wrong. It was very painful. I didn’t know what was going to happen, or when it was going to happen. 
“I have not and will not go back. 
“The nurse took no time to explain what was going to happen; or what the procedure entailed. Having to position myself on the table with no sight was incredibly difficult.”
Another woman described how distressing the process can be when communication and care are lacking: 
“I had my tests conducted by a nurse who was rude and rough.”
“I was told not to be stupid, and that I was behaving like a child.
“The nurse did not explain to me what they were doing, and this was unpleasant enough that I haven’t gone back to have another screening.”
Read full story
Source: Health and Care Scotland, 16 April 2025
Patient Safety Learning

WHO Member States conclude negotiations and make significant progress on draft pandemic agreement

After more than three years of intensive negotiations, WHO Member States took a major step forward in efforts to make the world safer from pandemics, by forging a draft agreement for consideration at the upcoming World Health Assembly in May. The proposal aims to strengthen global collaboration on prevention, preparedness and response to future pandemic threats.
In December 2021, at the height of the COVID-19 pandemic, WHO Member States established the Intergovernmental Negotiating Body (INB) to draft and negotiate a convention, agreement or other international instrument, under the WHO Constitution, to strengthen pandemic prevention, preparedness and response.
Following 13 formal rounds of meetings, nine of which were extended, and many informal and intersessional negotiations on various aspects of the draft agreement, the INB today finalized a proposal for the WHO Pandemic Agreement. The outcome of the INB’s work will now be presented to the Seventy-eighth World Health Assembly for its consideration.
"The nations of the world made history in Geneva today," said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. "In reaching consensus on the Pandemic Agreement, not only did they put in place a generational accord to make the world safer, they have also demonstrated that multilateralism is alive and well, and that in our divided world, nations can still work together to find common ground, and a shared response to shared threats. I thank WHO's Member States, and their negotiating teams, for their foresight, commitment and tireless work. We look forward to the World Health Assembly's consideration of the agreement and – we hope – its adoption."
Proposals within the text developed by the INB include establishing a pathogen access and benefit sharing system; taking concrete measures on pandemic prevention, including through a One Health approach; building geographically diverse research and development capacities; facilitating the transfer of technology and related knowledge, skills and expertise for the production of pandemic-related health products; mobilizing  a skilled, trained and multidisciplinary national and global health emergency workforce; setting up a coordinating financial mechanism; taking concrete measures to strengthen preparedness, readiness and health system functions and resilience; and establishing a global supply chain and logistics network.
Read full story
Source: WHO, 16 April 2025
Patient Safety Learning

How Japan could shape the future of the NHS

The health secretary is taking inspiration from Japan in his bid to change how Britons are treated by the NHS.
Wes Streeting has said he's interested in the idea of "health MOTs" for Britain's older citizens, evoking how the Asian island nation relies on personalised medical plans for its ageing population.
Japan combines genomics and AI machine learning to offer hyper-bespoke programmes for individuals, helping to predict and prevent illnesses before they really take hold.
Mr Streeting said such an approach could be a "game-changer" in the UK, as he prepares to publish his 10-year plan for the health service later in 2025.
He has repeatedly spoken about his desire to move more of the NHS's work out of hospitals and into local communities, focusing more on preventative care than more expensive and invasive emergency treatment.
Read full story
Source: Sky News, 19 April 2025
Patient Safety Learning

Centers for Medicare & Medicaid Services considers dropping some quality measures

The Centers for Medicare & Medicaid Services (CMS) is proposing to modify several hospital quality measures and remove four others, including those focused on health equity and social drivers of health.
The agency outlined the changes on 11 April as part of its 2026 proposed rule for the Medicare payment systems that cover inpatient and long-term care hospitals. 
The agency has proposed modifying these current quality measures:
Total hip arthroplasty/Total knee arthroplasty complication rate and 30-day stroke mortality rate. Hybrid, hospital-wide readmission and mortality measures. CMS is also proposing to remove four measures from the IQR programme:
Hospital commitment to health equity  COVID-19 vaccination coverage among healthcare personnel Screening for social drivers of health Screen positive rate for social drivers of health Read full story
Source: Becker's Clinical Leadership, 14 April 2025
Patient Safety Learning

Prime Minister told to take 'swift action' on 'death threats' against women since gender ruling

Last week, judges at the UK's highest court unanimously ruled that the definition of a "woman" and "sex" in the Equality Act 2010 refers to "a biological woman and biological sex".
Baroness Kishwer Falkner, chair of the UK's Equality and Human Rights Commission (EHRC), said the ruling was "enormously consequential" and ensured clarity.
She vowed to pursue organisations that do not update their policies, saying they should be "taking care" to look at the "very readable judgment".
On single-sex hospital wards, Baroness Falkner told BBC Radio 4's Today programme the NHS will "have to change" their 2019 policy, which says transgender patients are entitled to be accommodated on single-sex wards matching how they identify.
She said the court ruling means there is now "no confusion" and the NHS "can start to implement the new legal reasoning and produce their exceptions forthwith".
Keir Starmer says last week's Supreme Court decision - which prompted impassioned protests by trans rights activists at the weekend - has given "much needed clarity" to women and service providers.
Read full story
Source: Sky News, 22 April 2025
Patient Safety Learning

Patients urged to check packs of blood pressure medicine lercanidipine after labelling error

Patients who take the common blood pressure medicine Lercanidipine HCI 20mg tablets (lercanidipine hydrochloride) from the manufacturer Recordati Pharmaceuticals Limited, should, as a precautionary measure, urgently check if they have the batch number MD4L07 with an expiry date of 01/2028 on any packs they have at home. The batch number is printed on the foil of the blister strips.
This follows an error in the strength of the product printed on some of the sides of the pack. The error is limited to one batch of the medicine only.
The packs are incorrectly labelled as 10mg on some sides of the pack when they are 20mg tablets. The correct strength (20mg) is printed on the top of the carton and on the blister strips.
An alert has been issued by the Medicines and Healthcare products Regulatory Agency (MHRA).
Patients prescribed 10mg tablets and have received tablets with this batch number should contact their pharmacist or GP immediately.
If the GP or pharmacist cannot be reached, patients should call NHS 111 for advice on continuing their medication.
Read full story
Source: MHRA, 17 April 2025
Patient Safety Learning

Hospital patient had to wait more than 10 days for a bed - as 'unacceptable' crisis laid bare

Around 49,000 A&E patients had to wait 24 hours or more for a hospital bed in England last year, according to NHS figures.
Data compiled by the Liberal Democrats from freedom of information requests shows the longest wait was 10 days and 13 hours.
The party said there were 48,830 "trolley waits" of 24 hours or longer in 2024. That is 19.8% higher than 2023 (40,735) and 57.9% higher than 2022 (30,921).
A "trolley wait" is the time taken for a patient to be transferred to a ward after a decision has been taken to admit them to hospital.
The Lib Dems said the real numbers were likely to be far higher because only 54 out of 141 NHS trusts had provided full data.
The Royal College of Nursing said the figures "only begin to scratch the surface" of a "crisis in corridor care" - and that declining recruitment in nursing was adding to the problem.
General secretary Professor Nicola Ranger said corridor care is "undignified and unsafe" and "must be eradicated".
Read full story
Source: Sky News, 21 April 2025
Further reading on the hub:
How corridor care in the NHS is affecting safety culture: A blog by Claire Cox The crisis of corridor care in the NHS: patient safety concerns and incident reporting Response to RCN report: On the frontline of the UK’s corridor care crisis
Patient Safety Learning

NHS cancer patients denied life-saving drugs due to Brexit costs, report finds

British cancer patients are being denied life-saving drugs and trials of revolutionary treatments are being derailed by the red tape and extra costs brought on by Brexit, a leaked report warns.
Soaring numbers are being diagnosed with the disease amid a growing and ageing population, improved diagnosis initiatives and wider public awareness – making global collaborations to find new medicines essential.
But five years after the UK’s exit from the EU, the most comprehensive analysis of its kind concludes that while patients across Europe are benefiting from a golden age of pioneering research and novel treatments, Britons with cancer have “lost out” thanks to rising prices and red tape.
Brexit has “damaged the practical ability” of doctors to offer NHS patients life-saving new drugs via international clinical trials, according to the 54-page report obtained by the Guardian.
In some cases, the cost of importing new cancer drugs for Britons has nearly quadrupled as a result of post-Brexit red tape. Some trials have had shipping costs alone increase to 10 times since Brexit.
The extra rules and costs have had a “significant negative impact” on UK cancer research, creating “new barriers” that are “holding back life-saving research” for Britons, the report says.
In some cases, the impact has been devastating. Children are among the NHS cancer patients whose tumours have returned or treatment has stopped working, leaving them in limbo and denied drugs that could extend or save their lives, senior doctors told the Guardian.
Read full story
Source: The Guardian, 20 April 2025
Patient Safety Learning

Patient satisfaction with GP services in England has collapsed, research finds

Patients’ satisfaction with GP services has collapsed in recent years as family doctors have switched to providing far fewer face-to-face appointments, new research has revealed.
The proportion of patients seeing a GP in person has plummeted from more than four-fifths (80.7%) in 2019 to just under two-thirds (66.2%) last year.
Telephone appointments have almost doubled over the same period from 13.4% to 25.4%. Those undertaken by video or online, including some in which patients fill in an online form but have no direct interaction with a GP, have risen almost eightfold from 0.6% to 4.6%.
The Institute for Government (IFG) thinktank also found patients valued face-to-face appointments so highly that they regarded them as more important than their GP surgery offering more appointments overall by maximising the number provided remotely.
They are more satisfied with practices that offer more in-person sessions, and less satisfied with those relying more on telephone and remote consultations, even though those free GPs up to see more patients.
The dramatic shift in how family doctors interact with patients has coincided with a huge fall in public satisfaction with GP services.
“Patient satisfaction is higher in practices that deliver more of their appointments face to face,” according to an IFG report tracking the performance of England’s 6,200 GP surgeries since 2019. Surgeries that offer the most remote appointments have experienced the biggest falls in satisfaction, the IFG analysis shows.
Read full story
Source: The Guardian, 22 April 2025
Patient Safety Learning

Systems still reliant on agency staff

Six systems are still using more than 30% of their temporary staffing spend to employ agency workers, HSJ research has revealed. 
The investigation also highlights that the NHS will need to reduce spending on bank staff by almost as much as that on agency workers for the first time. 
Internal NHS England figures seen by HSJ reveal providers were on course to spend £8.3bn on temporary staffing in 2024-25, down from just under £10bn the previous year.
Three quarters of the overall spend in 2024-25 (£6bn) went on employing bank workers, with the remainder used for agency staff. Providers have been encouraged to shift agency workers to their staff banks for a number of years. However, HSJ research has revealed some systems are still struggling to move away from a reliance on agency staff. 
Read full story (paywalled)
Source: HSJ, 22 April 2025
Related reading on the hub:
Speaking up as an agency nurse cost me my career My experience as an agency nurse
Patient Safety Learning

CDC says measles cases are most likely underreported as outbreak swells in Texas

Measles cases are most likely being underreported in the United States as public health officials scramble to find resources to address a ballooning outbreak in the Southwest, according to a senior scientist at the Centers for Disease Control and Prevention.
So far this year, 747 cases have been recorded in the United States, according to NBC News’ tally. Two unvaccinated children in Texas and an unvaccinated adult in New Mexico have died. The adult tested positive for measles, but the official cause of death is still under investigation. 
Dr. David Sugerman, a senior scientist leading the CDC’s measles response, said Tuesday at a meeting of the CDC’s vaccine advisory committee that more than 90% of the cases are “related to the Southwest outbreak, driven by transmission in close-knit, undervaccinated communities.” The other cases have largely been imported from other countries, he said.
“We do believe that there’s quite a large amount of cases that are not reported and underreported,” Sugerman said Tuesday as he updated the committee on measles. “In working very closely with our colleagues in Texas; in talking with families, they may mention prior cases that have recovered and never received testing, other families that may have cases and never sought treatment.”
Read full story
Source: NBC News, 16 April 2025
Patient Safety Learning

USA: Efforts to address workplace violence gain renewed attention

Violence against healthcare workers made national headlines in March after the American Hospital Association warned of an alleged coordinated, multicity terrorist attack on hospitals in the coming weeks. The FBI found that the threat was not credible, but the incident brought violence prevention back to the forefront.
Healthcare workers are five times more likely to suffer a workplace violence injury than workers overall. A 2024 study found emergency nurses experienced verbal or physical violence daily, but often chose not to report it. When asked, nurses said they did not report workplace violence incidents for the following reasons: “nothing will change” (24%), “event was not severe enough” (21%), “part of the job” (15%), “electronic reporting system is time-consuming/complicated” (9%), “lack of time” (6%), “don’t know how” (3%) and “lack of leadership support” (3%).
Yet just 61.4% of hospitals reported having a workplace violence prevention initiative, according to 2021 data from the AHA, the most recent available.
More systems are reacting to the need for better security, with many installing metal detectors, hiring more security personnel and installing cameras, among other measures. In the last year, governments, governing bodies and associations have also started taking more steps to help address workplace violence.
Read full story
Source: Becker's Clinical Leadership, 14 April 2025
Patient Safety Learning

Young professionals go private for MRI scans and cancer checks

Young professionals are giving up on the NHS and going private for cancer checks and diagnostic scans, new data shows.
A record one million people received health tests and scans privately last year, as the public grew increasingly disillusioned with long and stressful waits for GP appointments and checks.
The report by the Independent Healthcare Provider Network (IHPN) found that demand for private health tests has soared among working-age professionals in their twenties, thirties and forties.
Experts said this reflects a desire to get “peace of mind” for worrying symptoms quickly and on demand. Adults are placing a premium on being able to book appointments at a convenient time and location, often opting for private clinics near their workplace so they can pop out during lunch breaks.
David Hare, the chief executive of IHPN, said: “This latest research from IHPN shows that going private for vital scans and tests is becoming increasingly normalised, with speedy access to appointments and the ability to receive results often within 48 hours a key attraction for patients looking for much-needed peace of mind and value for money.
“This is particularly the case for younger people, who are accustomed to high quality, convenient and personalised services in many other aspects of their lives, and hugely benefit from the increasing number of private diagnostics services available near their homes and workplaces.”
Read full story (paywalled)
Source: The Times, 14 April 2025
Patient Safety Learning

A warning from Wales for Wes Streeting

As the English government sets about reorganising the NHS, Robert Royce discusses the lessons it can learn from devolved healthcare in Wales 
Since 2009, NHS Wales has operated without a purchaser-provider split, the internal market or payment by results (PbR). In its stead, seven integrated health boards were created, funded by block allocations. NHS Wales was explicitly to be a plan-led health system based on “co-operation, collaboration and partnership working”.
The Welsh Government also believed that the creation of health boards would facilitate a shift in the balance of care. That has not transpired, as can be illustrated by the proportion of total spend going to primary care.
In 2013-14, health boards were spending about 25% of their total budget on primary care. In 2022-23 (last nationally available figure) it was down to around 19 per cent. The January 2025 Hywel Dda University Health Board meeting stated that between 2015-16 and 2024-25 its proportion of total expenditure on primary care had dropped by 6 per cent. The picture across the rest of Wales is probably the same, because in Wales overall the number of qualified GPs is essentially unchanged between 2021 and 2024, whilst hospital consultant whole time equivalents had gone up by 13.1%.
This has taken place despite an organisational structure and funding system supposedly designed to do the opposite. The same can be said for achieving financial balance. There was an expectation that health boards would provide (and then deliver) plans that would ensure they would operate within their allocations – something that has failed to transpire.
Read full story (paywalled)
Source: HSJ, 16 April 2025
Patient Safety Learning

Streeting accused of prematurely hailing success of elective scheme

Ministers have jumped the gun by claiming a flagship elective programme has been “busting through the backlog at twice the speed”, an independent analysis has concluded.
The Health Foundation has exclusively shared its analysis of the Further Faster scheme with HSJ. The scheme is run by the national Getting It Right First Time programme and seeks to improve the efficiency of elective care, especially outpatient services.
Wes Streeting last month declared that waiting lists fell “130 per cent faster in areas where the government scheme is in action than the national average” over the four months between October 2024 and January 2025. Twenty trusts, known as the FF20, are involved in putting the GIRFT ideas into action.
However, the authors of the first detailed study of Further Faster,  conclude that “it is too early to draw firm conclusions” about its success, and warn “plans for roll out of such schemes must be based on robust evidence that they work”.
Read full story (paywalled)
Source: HSJ, 14 April 2025
Patient Safety Learning

Trust orders review into breast cancer services

A North East trust has begun a full review of its breast cancer services after finding unexplained variation in its surgical practices.
County Durham and Darlington Foundation Trust said feedback from national audits and external reviews suggested its approach to surgery may differ from that seen elsewhere in the NHS.
In a statement, CDDFT said the audit findings did not necessarily mean breast cancer surgery carried out at the trust was unsafe, however, “we felt it was important to take a closer look to ensure we are delivering the highest quality care”.
The trust said it does not yet know how many patients would see their care covered by the review, and refused to say what time period it would cover.
The review includes input from internal teams and external experts, including a review by the Royal College of Surgeons. The trust has also commissioned an external review of governance to ensure a “fair, balanced, and independent perspective”.  
A new clinical lead has been appointed for the service, and two new consultants hired to address “capacity challenges”. Other steps include strengthening the role played by multidisciplinary teams through stronger coordination and clinical governance, as well as “maintaining close oversight at senior clinical and executive levels”.
Read full story (paywalled)
Source: HSJ, 17 April 2025
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