Patient Safety Learning

The purpose of this study was to identify which, and to what extent, demographic and operational factors are indicative of likelihood for a new call handler or paramedic to remain in role within the first two years of employment at an ambulance trust using data held in the trust’s bespoke data warehouse. Several factors showed a significant contribution to the likelihood of remaining in post within an ambulance NHS Trust. Among the findings, short-term sick leave in the first two years of employment was associated with increased retention for paramedics. In addition, female call handlers were found to have increased retention and paramedic retention increased with time outside of ‘job cycle time’ (JCT) activities (ie, activities other than responding to calls). This study presents a method for extracting new insights from routinely collected operational data, identifying common drivers and specific predictors for retention among the ambulance NHS workforce. It emphasises the importance of workforce-centred retention strategies, highlighting the need for non-JCT time, which in turn would allow paramedics to have time to reflect and recuperate to avoid burnout and attrition. The study also suggests that a lack of sick leave might indicate a lack of trust and self-care culture, potentially leading to paramedic staff attrition. Our approach to retention analytics provides a new mechanism for trusts to monitor and respond to their attrition risks in a timely, proactive fashion.

On 9 May 2025, the WHO Patient Safety and Quality of Care Unit hosted a webinar on Patient Engagement for Patient Safety, as part of the WHO Global Patient Safety Webinar Series, bringing together health care leaders and patient advocates from around the world. The webinar highlighted the importance of engaging patients and families, as emphasised in Strategic Objective 4 of the Global Patient Safety Action Plan 2021–2030. Participants heard diverse global perspectives and real-world examples demonstrating how partnerships with patients and families are being operationalised to improve safety and quality of care. The panel featured speakers from Greece, Saudi Arabia, Singapore, Uganda and the United States. Discussions focused on practical strategies, implementation challenges and opportunities for action in strengthening patient and family engagement.

The US has traditionally been the largest donor to health programmes in low- and middle-income countries. In January 2025 almost all such funding was stopped and prospects for resumption are uncertain. The suddenness of the funding cuts makes it difficult for national programmes to adapt. This preprint* paper estimated the impact of these cuts on outcomes for four health areas that have been a focus of US assistance: HIV, tuberculosis (TB), family planning (FP) and maternal and child health (MCH). *Note: Preprints are early-stage research papers that have not been peer-reviewed.  The authors conclude that a complete cessation of US funding without replacement by other sources of funding would lead to dramatic increases in deaths from 2025-2040: 15.2 (9.3-20.8) million additional AIDS deaths, 2.2 (1.5-1.9) million additional TB deaths, 7.9 million additional child deaths from other causes, 40-55 million additional unplanned pregnancies and 12-16 million unsafe abortions. There has been great progress in improving global health in the last few decades. This progress has given hope of reaching many of the ambitious Sustainable Development Goals for 2030. However, the recent funding cuts threaten to change these trajectories and lead to sharp increases in avoidable mortality for the poorest countries. Even a partial restoration of US funding would combat the most severe effects and provide time for national programs to adjust to the new funding landscape.

NHS Race and Health Observatory Review of Neonatal Assessment and Practice in Black, Asian, and Minority Ethnic Newborns highlighted the need for educational resources to help healthcare professionals assess babies with dark skin tones, who are at higher risk of developing jaundice and experiencing delayed diagnosis and treatment. This new infographic for health care professionals, “10 Steps to spot Jaundice in Black and Brown babies” was designed by Dr. Helen Gbinigie, Neonatal Consultant at Medway Hospital and Clinical Lead for KM LMNS; and Dr. Oghenetega Edokpolor, ST5 Paediatric Trainee at Medway Hospital, in collaboration with the NHS Race and Health Observatory. It’s a vital tool in pursuing the Observatory’s aims to reduce neonatal ethnic health inequalities.

Understaffing by nursing staff in hospitals is linked to patients coming to harm and dying unnecessarily. There is a vicious cycle whereby poor work conditions, including understaffing, can lead to nursing vacancies, which in turn leads to further understaffing. Is hospital investment in nursing staff, to eliminate understaffing on wards, cost-effective? This longitudinal observational study analysed data on 185 adult acute units in four hospital Trusts in England over a 5-year period. The study found that exposure to registered nurse understaffing is associated with increased hazard of death, increased chance of readmission and increased length of stay, while exposure to nursing support understaffing is associated with smaller increases in hazard of death and length of stay but reduced readmissions. Rectifying understaffing on inpatient wards is crucial to reduce length of stay, readmissions and deaths. According to the National Institute for Health and Care Excellence £10 000 per QALY threshold, it is cost-effective to eliminate understaffing by nursing staff. This research points towards investing in registered nurses over nursing support staff and permanent over temporary workers. Targeting particular patient groups would benefit fewer patients and is less cost-effective.

What should we do in order to improve quality and safety in medicines management? How beneficial is it to design the medicines management system—for example, the tasks, tools and physical environment—to support effective working versus making people adapt to the systems in which they find themselves? This question arises when considering, among other problems in healthcare delivery, that of confusing look-alike, sound-alike (LASA) medicine names, which persists as a threat to medication safety despite much discussion and examination.  In this editorial, Denham L Phipps discusses the recent paper by Lambert et al who sought to validate a test battery for assessing the suitability of a given drug name on the basis of that name’s potential to be confused with others. See our Error traps gallery on the hub

The fundamental importance of having enough registered nurses present to deliver care is well supported by evidence. Lower registered nurse staffing levels are associated with higher risks to patients and poorer quality care.  The Royal College of Nursing has issued their position statement on registered nurse staffing levels for patient safety, care quality and cost effectiveness. The RCN has a duty to uphold standards in nursing, support all members of the nursing team and lead the way towards safe and effective care. In relation to safe staffing, the RCN Nursing Workforce Academy (launched as part of the RCN Institute of Nursing Excellence) is leading the way by: Launching refreshed nursing workforce standards, making explicit what we see as the fundamentals needed to underpin safe and effective care delivery. Sharing the evidence on safe staffing (this article has highlighted some key references, but a more formal summary of the evidence is being produced). Bringing together the nurse staffing guidance that exists for each specialty and making explicit where there are recommended registered nurse to patient ratios. Taking forward the RCN’s commitment to ‘safety critical redlines’ – minimum nurse to patient ratios to protect patients and staff from harm caused by low registered nurse staffing levels. Our forthcoming ‘nest’ community platform will offer all relevant resources, latest publications and networking opportunities.

Dementia is caused by different diseases, including Alzheimer’s disease and vascular dementia, which affect memory, thinking and the ability to perform daily tasks. The number of people being diagnosed with dementia is increasing. In February 2025, nearly half a million people in England had a dementia diagnosis. The likelihood of developing dementia, becoming an informal carer or both in a lifetime in the UK is 55% (around 1 in 2). This Care Quality Commission (CQC) report looked at people's experiences of living with dementia when using health and adult social care services, including the experiences of families and carers. It sets out the main themes that influence whether an experience is good or poor, and what health and care services are doing to improve these experiences. CQC will use the findings in this report to help shape their work to define what good care looks like for people with dementia and inform the next phase of CQC’s Dementia Strategy. The CQC Dementia Strategy has 6 core objectives: CQC will co-produce evidence-based statutory guidance for what good dementia care looks like and link to good practice guidance under our assessment framework. CQC will apply the statutory guidance across their regulatory activity. CQC will use their independent voice to tackle inequalities and encourage improvement and innovation. The CQC will be a dementia-friendly and inclusive organisation to benefit our staff and the wider public. CQC staff will receive comprehensive dementia training and work with partners to influence training and competency for the health and social care workforce. CQC will actively work in partnership with key stakeholders to collectively affect real change. Work will be focused on the following areas: Developing statutory guidance and defining good practice CQC will work towards achieving objective 1 to develop statutory guidance. CQC will: involve people with lived experience, carers and a wide range of other stakeholders in co-production, ensuring the guidance is led by the voice and experiences of people who use services carry out research into the characteristics of effective dementia care, including learning from other countries and regulators, as well as further information gathering to develop a robust evidence base on which to build the statutory guidance principles. Learning and development needs of CQC’s workforce To ensure they are effective in our regulation of services for people with dementia, CQC will ensure that they understand and respond to the learning needs of their own staff in this area. This includes carrying out a learning needs analysis, defining learning objectives and developing training and guidance for CQC staff aligned to the statutory guidance we publish. Engagement and communication CQC will apply a wide range of tools and approaches to involve people, carers, key stakeholders and CQC staff in the development of this work. They will continue to work collaboratively with other key stakeholders and policymakers on joint improvement ambitions and actions that enable good dementia care, in areas like workforce, system pathways and technology. They will share updates on our work with the public, providers and other partners and share future opportunities to get involved.

This episode of ByteMed explores the critical role of patient and caregiver voices in shaping healthcare, with Chris Johnston and Alies Maybee from the Patient Advisors Network (PAN)—a Canadian not-for-profit dedicated to empowering patients and caregivers to drive meaningful healthcare improvements. They discuss how PAN fosters a community of practice, connecting and supporting patient and caregiver partners at all experience levels. Learn how their expertise helps healthcare organizations make better decisions and why active patient involvement is essential for creating a more effective, patient-centred system.

Operational guidance to support health boards boards undertaking perinatal adverse event reviews incorporating the additional reporting required of maternity services. See also Maternity and neonatal (perinatal) adverse event review process for Scotland: Operational guidance to supplement the HIS national framework

NHS England previously published official statistics using National Reporting Learning Service (NRLS) patient safety incident data: the National Patient Safety Incident Reports (NaPSIR), and Organisation Patient Safety Incident Reports (OPSIR).  NRLS was withdrawn on 30th June 2024, and replaced by the Learn from Patient Safety Events (LFPSE) service, which has been operating since July 2021. This is the first experimental publication of statistics relating to LFPSE, and as a result there are some key differences between NRLS and LFPSE which should be considered when interpreting this data.  Summary: In 2024/25 Q4, 827,397 events were recorded to LFPSE, the majority of which were recorded as patient safety incidents (96.78%). Where a degree of harm was recorded (n = 739,413), the majority of incidents (93.65%) recorded low or no physical harm to patients. 799,718 incidents recorded a service area. The majority of these (58.7%) reported occurring under acute, general or specialist services. The remaining were spread primarily across mental health, community, and maternity services. The national reporting lag (median difference between occurrence and reporting of an incident) was 0 days for 2024/25 Q4. In the financial year ending March 2022 (the latest period for which data was published), the median lag for reporting into the NRLS was 20 days. The majority of NHS Trusts (72.1%) recording to the LFPSE have a reporting lag of 0 days. For the remainder of organisations, reporting lag ranged from 1 to 6 days. The figures in the report are a snapshot of a live-data system (as at 13 May 2025). Any figures reported are subject to change as records get updated into the system. NHS England aim to add reporting rates next month once bed days data for the period is published.

At 10.45am on 23 November 2024, Peter Anzani sadly died from a pulmonary embolism in Birmingham Heartlands Hospital. He had been admitted to hospital the day before and was receiving treatment for a community acquired pneumonia when he suddenly and unexpectedly collapsed due to a pulmonary embolism. Peter had previously suffered a number of falls at home in August and September 2021 and was subsequently diagnosed with suffering a spontaneous infection of the cervical vertebral canal which caused a complete spinal cord injury and left him tetraplegic. This made him more vulnerable to chest infections and pulmonary embolisms which he experienced in the years that followed. There is no evidence of any human intervention that rendered his death unnatural.  Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be:  1a Pulmonary Embolism 1b 1c 1d II Pneumonia Spinal cord injury resulting in Tetraplegia Matters of concern To The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust I considered evidence from a [REDACTED] who indicated at paragraphs 20-21 of his statement, “I did not see any record of his pulse, blood pressure or oxygen saturation. The normal practice is to complete these observations, and I would expect this to be done, especially with him presenting with chest issues. However, I am unable to comment why this was not recorded or confirm that these were carried out. (21) This is a learning point for the department, and I have taken steps to ensure this learning is taken forward by theTrust. I have alerted the Sister in charge of the Spinal Injuries Outpatients’ Department and requested that adequate measures are taken to ensure that all observations made are recorded in the outpatient forms…” It was unclear whether this was a single one-off event involving human error or indicative of a wider and systemic issue involving a lack of training. There was no evidence before the court that this “learning point” had been actioned or that any adequate steps had been taken to ensure proper and accurate recording of records by staff. There is a real risk of future deaths occurring where staff do not have adequate training and that patient records are not being properly completed. To NHS England / Department of Health and Social Care I heard evidence that The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (“The Trust”) have been experiencing difficulties with patient waiting lists – due to both an increase in the quantity of patients being treated and staffing shortages – which has led to patients waiting longer than is reasonable or necessary for reviews and treatments. As part of the inquest, there was evidence that Peter Anzani himself had been waiting for nearly a year for a follow-up review, which should have been carried out after no more than 6 months. I heard evidence from representatives of the Trust that they have repeatedly requested additional funds for workforce development and expansion to assist with cutting patient waiting lists and waiting times. I understand that an initial Workplace Funding Review was submitted in 2023 but was rejected by NHS England due to a funding shortage. I understand that a further Workplace Funding Review was submitted in the Autumn of 2024, but in February/March of this year, NHS England indicated that the same would again be rejected under a “no growth policy”. Whilst naturally I am aware of the pressures on the public purse and on the NHS generally, it is concerning to hear that the Trust do not appear to be being adequately supported financially by NHS England, and do not currently appear to be able to address their workplace staffing issues without additional financial support (which does not appear to be forthcoming). It is obvious that where patients are waiting for longer than is reasonable or necessary for treatment or reviews, there is a real risk of deaths occurring. No patient should be waiting longer than absolutely necessary for treatment. In light of HM Government’s decision on 13 March 2025 to abolish NHS England and for its role to be subsumed within the Department of Health and Social Care, this report is being sent to both Agencies to consider, as it relates to issues of both a local and national significance.