Patient Safety Learning

A group of 30 senators is pressing HHS Secretary Robert F. Kennedy Jr. to reverse the cancellation of roughly 150 federal patient safety research grants and restore the funding behind them. In a letter dated 12 August, led by Senators. Richard Blumenth and Tammy Baldwin, the lawmakers called on HHS to rescind terminations that took effect on 15 July and disrupted nearly 200 research programs across 30 states. All 30 senators are Democrats. The grants were awarded by the Agency for Healthcare Research and Quality, the only federal agency dedicated to health services research. The senators said the agency has obligated just 5% of its extramural grant funding since 1 October, leaving roughly $200 million unspent for the fiscal year. “This unprecedented action … undermines decades of taxpayer investments to improve healthcare delivery, patient safety, and health outcomes for all Americans,” the senators wrote. The letter cited projects cut midstream, including maternal emergency training in Connecticut, fall-risk reduction in rural Colorado hospitals, an effort to curb unnecessary antibiotic use in Utah and research using AI to predict hospitalisations in Wisconsin. Read full story Source: Becker's Hospital Review, 18 August 2026

In patient safety incidents (PSIs), nurses often act as ‘second victims’, experiencing multifaceted distress, including psychological, physiological and professional burdens. In recent years, qualitative studies on nurses as second victims have increased; however, the evidence remains fragmented. The aim of this study was to synthesise qualitative evidence on nurses as second victims after PSIs and provide implications for developing a multilevel support system. The study found that nurses’ second-victim experiences after PSIs are multidimensional, dynamic and shaped by incident severity, individual appraisal, organisational culture and accessibility of support. A just culture–based support system may help reduce blame and silence, promote psychological safety and facilitate recovery. Nursing managers should recognise nurses’ postincident disequilibrium as a second-victim response and embed structured support into PSI management. Strengthening just culture, psychological safety, peer support, confidential psychological care and protected recovery time may reduce blame, silence and help-seeking barriers, thereby facilitating nurses’ recovery and safeguarding patient safety.

Hospital discharge delays hit their highest level on record in July. An average of 14,054 patients a day remained in an acute bed at least two weeks after they were declared medically fit to leave, according to the latest NHS England data analysed by HSJ. That is 12% up on July 2025 and beats the previous high of 13,965, set in January 2023, even though delays normally run lower in summer. Other NHSE figures show delays are also getting longer. Patients discharged in June waited an average of 0.95 days beyond their discharge ready date, up 19% on a year earlier. The increased delays were down to steep rises in waits for social or intermediate care. Delays directly related to hospital or other NHS services showed no change. Much of the growth is the result of cases in which patients’ needs were still being processed or had not been arranged, rather than directly down to a lack of care capacity. Senior NHS officials are understood to be concerned about the rise in delayed discharges. They are most concerned about the breakdown of agreements on intermediate care provision made between the NHS and councils amid budget strain and restructures. This is resulting increased care home and step-down capacity built up during the winter becoming unavailable, despite ongoing high demand. Health and social care secretary Yvette Cooper has claimed the discharge system was “all a mess”. Read full story (paywalled) Source: HSJ, 25 August 2026

Millions of women in England who have missed cervical screening appointments will be offered free home testing kits on the NHS. The move comes amid concerns that only two-thirds of women attend in-person cervical screening appointments when asked to do so, leaving as many as 4 million women not up to date. The rollout is being described as a “gamechanger”, offering a “discreet and convenient option” to encourage more women to get screened. The kits contain a swab to collect a sample from the vagina. This is then posted back to the NHS free, where it is tested in labs for high-risk human papillomavirus (HPV). If high-risk HPV is detected, patients will then be asked to attend a cervical screening appointment with a clinician. Starting on Tuesday, eligible women between 30 and 65 who have not attended screening appointments will be sent invitations via the NHS app, text message, email or letter. Dr Sue Mann, national clinical director for women’s health at NHS England, said: “Screening saves thousands of lives each year by preventing cancers and catching them earlier, but only around two-thirds of women are attending cervical screening appointments when invited by the NHS. “Offering millions of women an alternative test they can do from the comfort of their own homes will be a gamechanger – making it easier than ever for them to get tested for HPV.” Read full story Source: The Guardian, 25 August 2026

More patients at Northern Care Alliance NHS Foundation Trust (NCA) hospitals will die avoidable deaths unless major changes are made, a retired consultant doctor has said in an urgent warning. Dr Glyn Smurthwaite, 65, was a consultant at Salford Royal who worked there from 1995 to 2024 and said it is ‘utterly unsafe’ and ‘toxic’. It comes as dozens of patients have died or come to harm at NCA hospitals due to treatment delays and staffing errors according to the trusts’ own reports, with a workforce which is under extreme pressure and facing high levels of staff absences over sickness. The NCA manages hospitals in Salford, Bury, Oldham and Rochdale, treating more than a million patients. The Manchester Evening News (M.E.N) has spoken to patients who were treated at NCA hospitals, with experiences of people ‘screaming in pain’ while staff were ‘too busy’ to help, and a 76-year-old who spent 36 hours on a trolley in A&E and claimed she became ‘really poorly’ after experiencing the NCA’s standards of care. Lengthy delays at NCA hospitals were linked with ‘28 deaths’ and 56 issues of ‘severe harm’, while problems diagnosing illness led to ten deaths last year. The Northern Care Alliance said that it is facing challenges but is working to address concerns. “I was appointed in 1995 and I left because the place was crumbling and toxic in 2023 early 2024,” Dr Glyn Smurthwaite said. “I’ve been a campaigner ever since because the place is utterly unsafe, and it’s led by an utterly incompetent out of touch board who don’t have a clue what’s happening on the shop floor. “It was failing miserably before the NCA was envisaged. It started to go wrong I would say 2008 or 2009, at this point around 2010 certainly things were getting worse.” The retired consultant said there was a ‘system of governance that utterly failed and was incompetent’, and has called for the removal of the current board of directors. Read full story Source: Manchester Evening Post, 23 August 2026

A leading surgeon in Northern Ireland has said colleagues from across the UK and Ireland felt they had no option but to intervene when it appeared politics not patient safety was influencing discussions on the provision of emergency general surgery (EGS). The surgeons issued a statement after Health Minister Mike Nesbitt resigned following a fall out with Ulster Unionist Party (UUP) leader Jon Burrows over withdrawing EGS from Causeway Hospital. Damian McKay, an Ulster Hospital surgeon, said he and others were "concerned, disappointed and frustrated". The new Health Minister Robbie Butler has said his decisions will be based on "expert evidence opinion" as well as the "voices of the people". McKay, who is a general and colorectal surgeon, was speaking on behalf of the three surgical associations in the UK and Ireland who issued a joint statement on Friday in response to the disagreement. Burrows had declared he would never support the withdrawal of the EGS service during a public meeting, a view Nesbitt said he only discovered by "monitoring the media". The surgeons said "recent developments" risked further delaying the implementation of the 2022 review of EGS services in Northern Ireland, which recommended having the service at fewer sites. McKay told BBC News NI: "The key message should always be patient safety first and political votes second. "Health outcomes should not be dictated to by Facebook and social media groups – it should be determined by evidence and the evidence around Causeway has been there since 2025." Read full story Source: BBC News, 24 August 2026

More than 100,000 additional men are living with prostate cancer in the UK compared with 2020, according to new estimates from Macmillan Cancer Support. Data from the charity reveals that over 68,000 men receive a prostate cancer diagnosis annually across the country, representing roughly one diagnosis every eight minutes. The organisation estimates that approximately 600,000 men are currently living with the condition, up from about 500,000 four years ago. Prostate cancer remains the most frequently diagnosed form of cancer in the UK. However, Macmillan warned that widespread “myths” surrounding the disease could be preventing men from seeking vital checks. Dr Anthony Cunliffe, lead medical adviser at Macmillan Cancer Support, said: "One of the biggest misunderstandings I hear is that feeling well means you cannot have prostate cancer. "Many people are surprised to learn that, in reality, prostate cancer often develops without symptoms in its early stages, which is why it’s important to have a conversation with your GP if you’re worried." Read full story Source: BBC News, 22 August 2026

A new daily pill that treats diabetes and helps with weight loss will be available in UK pharmacies from Monday. Pharmacists said the move would be welcome for people who cannot use weight-loss jabs, but also issued a warning over the growing problem of fake, unlicensed or counterfeit versions of GLP-1 tablets. Orforglipron, known as Foundayo and made by the US pharmaceutical firm Eli Lilly, was authorised by the Medicines and Healthcare products Regulatory Agency (MHRA) earlier this month. The UK is the first country in Europe to approve it, after approving another weight-loss pill in June. “The UK is the first country in Europe where Foundayo is now available,” said Khalil Asmar, the vice-president of cardiometabolic health at Lilly Northern Europe. “We’re pleased that this means there is another oral treatment option for eligible UK patients alongside licensed injectable treatments.” Read full story Source: The Guardian, 24 August 2026

A leading hospital chief executive has championed in-house NHS technology that costs “a fraction” of major commercial systems – and said she does not use the federated data platform. Birju Bartoli, chief executive of Northumbria Healthcare Foundation Trust, said a custom electronic patient record system the provider has developed itself showed there was an alternative to paying “phenomenal” sums to big external tech firms. Ms Bartoli said: “We didn’t think we could afford [what commercial suppliers were asking], and it wouldn’t necessarily give us what we wanted. So the idea was born of: ‘Why don’t we just do it ourselves?’” The trust launched the system in 2023, had continued developing it, and it was a success with staff, she said. In a wide-ranging interview, she also cautioned that integrated health organisations – for which Northumbria is a forerunner – should not become a “fix all ills” answer to multiple problems, including social care. Read full story (paywalled) Source: HSJ, 24 August 2026

A safety event that affected four patients at Ascension Saint Thomas Hospital Midtown in Nashville, Tennessee, led to the hospital self-reporting to state regulators, according to a statement from the hospital’s CEO. Hospital leadership reported the event to state regulators and launched an investigation the day it occurred, President and CEO Shubhada Jagasia, MD, said in statement on 19 August, shared with Becker’s. The hospital declined to provide any specific clinical details about the safety event, citing patient privacy, though a local news station spoke with a family member of one of the affected patients. A woman told WKRN her mother-in-law became paralysed after receiving potassium during a knee replacement surgery at the hospital, the CBS affiliate reported 18 August. According to the patient’s daughter-in-law, Kristina Dorton, the 72-year-old woman underwent the knee replacement; the procedure itself was successful, but Ms. Dorton said the surgical team is believed to have administered potassium instead of the intended local anesthetic, bupivacaine, during spinal anesthesia. The patient was moved to the ICU afterward and, as of 18 August, has had no feeling, movement or pain response from her breastbone down, according to WKRN. The hospital has not confirmed the medication error or whether the same error affected the other three patients. Ascension Saint Thomas Hospital Midtown said it has identified the cause of the safety event and implemented corrective safeguards. “Our hearts are with the four patients and their families impacted by this event. On behalf of our leadership and care teams, I am deeply sorry for the harm caused to our patients,” Dr. Jagasia said. “We have met directly with each of the families to express our deep support, connected them with spiritual care teams, and ensured they have access to all appropriate resources and ongoing care needed. “Providing safe, high-quality care is at the core of everything we do, and any gap in meeting that standard receives our immediate, uncompromising attention.” Read full story Source: Becker's Clinical Leadership, 19 August 2026

The NHS e-Referral Service is a digital platform used to refer patients to service providers. It is frequently used for Advice and Guidance services, where clinicians in general practice to seek specialist advice about a patient’s care, either before or instead of referring them to hospital for specialist assessment. This page includes a number of case studies which provide insights into the implementation, benefits and use of the NHS e-Referral Service across primary and secondary care. They cover lessons learned, personal experiences and feature specific examples relating to Advice and Guidance services. Related reading on the hub: Advice and guidance services: Patient Safety Learning’s response to the latest HSSIB report

Parents of children with complex disabilities say a review into a therapy service has failed to answer key questions about their children's care. The report identified failings including staffing shortages and communication breakdowns within Sirona Care & Health's children's therapy service. But families say it does not fully address the issues that led them to speak out. In a statement, Sirona chief executive Jo Beer said it was a "balanced assessment" and the organisation was focused on "learning and improving". In December, families of children with scoliosis - curvature of the spine - said Sirona was failing to supply experienced physiotherapists to Claremont School in Bristol. This followed a decision from the healthcare provider to reduce the number of physiotherapists at the school and instead instruct unqualified teaching staff how to manage the condition. Among the parents is Claudia, whose son Matei attends Claremont School. She said she had faced a "huge battle" to make sure Matei's needs were fully met by his education, health and care plan (EHCP). An EHCP is a legal document for children and young people aged up to 25 who need more support, and identifies educational, health and social needs. On this basis, it sets out the support a child or young person is entitled to. With a number of complex physical disabilities including cerebral palsy, double scoliosis and a history of major hip surgery, Matei's family said they had to challenge the level of physiotherapy provision included in his EHCP. Read full story Source: BBC News, 21 August 2026

Hundreds of thousands of people with type 2 diabetes could benefit if the medicines regulator approves a new weekly jab which cuts the number of injections needed by 86 per cent. The National Institute for Health and Care Excellence (NICE) has recommended a weekly treatment which reduces the annual number of insulin injections from 365 to 52. However, the treatment is yet to be approved by the Medicines and Healthcare Products Regulatory Agency (MHRA). NICE approved insulin efsitora alfa in final draft guidance on Thursday. Health officials said they are awaiting the MHRA’s ruling on the treatment “to understand whether it could be rolled out on the NHS”. The treatment, also known as Onswik and made by Eli Lilly, is said to work as well as daily injections but only needs to be injected once a week. Officials said the reduction will particularly benefit people who need help injecting insulin, including frailer people and those with sight loss, limited hand movement, learning disabilities, people who have difficulty following the steps involved or those who struggle to stick to their treatment regimen. Read full story Source: The Independent, 20 August 2026

The NHS has some of the best leaders in the public service, but they often have a mindset that is too insular, according to a former ICB chief and senior civil servant. Mark Fisher, who retired from Greater Manchester Integrated Care Board in March, also said the health service makes a “fundamental error” by undervaluing partnerships with local government and others. Before joining the ICB in 2022, Mr Fisher held several senior posts in Whitehall, including director general of the Grenfell Tower inquiry and a director role in the Cabinet Office. Asked about NHS leadership, he told HSJ he found the service had “some of the best leaders you’d find anywhere in the public service”. But he added: “I do think, if the NHS has a fault, it does breed leaders whose focus is largely within the NHS, and it sees itself as being able to solve its own problems. That’s a category error, a fundamental error. Many of the solutions to the NHS’s problems lie outside the NHS.” Read full story (paywalled) Source: HSJ, 20 August 2026

The purpose of this guide is to empower those in the NHS people profession to secure buy-in from the board and senior leaders in promoting a positive workplace culture through the work of organisation development (OD). This guide sets out how to build understanding of OD and its value, get to know your senior leaders, make the strategic case for recognising OD and culture at board level, build a compelling case for investment, turn that case into action through OD strategy and initiatives, and promote your work and success. The guide concludes with a reflective tool to help you shape a well-rounded, evidence-informed case for OD by identifying the key questions to consider as you develop your argument.

Lack of compliance with safety standards means the NHS digital transformation agenda risks “unprecedented” patient harm, according to a new warning from researchers. The government’s 10-year health plan for England risks “propagating patient harm at an unprecedented scale” because of poor compliance with digital safety standards, according to research published this week. Shifting the NHS from analogue to digital is a core feature of the government’s 10 Year Health Plan for England, which was published in July 2025. But the authors of research published in the journal BMJ Innovations have concluded that the NHS lacks the safety architecture needed to support this digital transformation. The authors, from University College London, have warned that the digital ambitions of the plan risk placing an “unsustainable burden” on failing safety systems in the NHS. Read full story (paywalled) Source: Nursing Times, 19 August 2026

Digital transformation is a foundational shift in the NHS 10 Year Plan, but compliance with statutory digital clinical safety standards (DCB0129/0160) is not monitored or enforced. A national cross sectional study found that 70.1% of digital health technology deployments across NHS England organisations lacked documented assurance. Through analysis of previously unpublished Clinical Safety Officer (CSO) workforce data and secondary analysis of freedom of information (FoI) responses, this study sought to identify drivers of low compliance to inform safety improvements. 239 NHS trusts and integrated care boards were surveyed by FOI request. CSO capacity (whole time equivalent, WTE) data were analysed. Qualitative data (unprompted free text commentaries) were analysed independently by two researchers applying a mixed approach: deductive content analysis (exemptions claimed) and abductive thematic analysis (volunteered explanations). Results found that 211 organisations responded. Mean CSO capacity was 1.1 WTE. NHS trusts reported higher capacity (mean 1.3 WTE) than integrated care boards (mean 0.4 WTE). Qualitative responses suggested the values overstated actual capacity, with CSO duties typically performed alongside clinical roles. Thematic analysis identified four mutually reinforcing drivers of non-compliance: lack of understanding of the standards, immature governance infrastructure and oversight, ineffective assurance processes and workforce fragmentation and role dilution

Young people who start vaping risk developing breathing problems and going on to smoke cigarettes, children’s doctors have warned. Child vaping is consistently linked with poor respiratory health, such as coughing, wheezing, bronchitis symptoms and asthma exacerbations, while vapes have been shown to act as a gateway to smoking cigarettes, according to one of the most comprehensive reviews of the available evidence so far undertaken by the Royal College of Child and Paediatrics Health. The review’s co-author, Prof Will Carroll, said: “Vaping should not be seen as a harmless part of growing up. The evidence shows clear links with respiratory symptoms, nicotine dependence and subsequent cigarette smoking, while concerns about wider impacts on young people’s health continue to grow.” He urged the government to quickly implement the new measures announced in July under the Tobacco and Vapes Act, which include plain packaging, moving vapes out of sight in shops, and restrictions on vape flavour names to move away from names inspired by sweets, desserts and alcohol in favour of simpler names such as “apple”. Read full story Source: Guardian, 20 August 2026

A national NHS leader has told HSJ he expects more maternity units to close, while analysis suggests dozens face similar problems to a hospital where births were suspended this month. Ex-Mid and South Essex Foundation Trust boss Matthew Hopkins, now NHS Alliance’s acute and ambulance director, told HSJ “there will be other Barnstaples” following the suspension of births at North Devon District Hospital due to a lack of senior doctors. He said problems facing NDDH – which sees fewer than 2,000 births per year – were likely to affect similarly sized units, many of which face the same issues with recruitment and clinical sustainability. For instance, they typically require similar levels of obstetric cover as larger facilities but find it harder to recruit to these positions as they are often located in rural, harder-to-reach, or coastal areas. HSJ understands dozens of units could face such challenges nationally, with 26 out of 155 consultant-led units recording fewer than 2,000 annual deliveries last year. Read full story (paywalled) Source: HSJ, 20 August 2026

Hospital incident reporting and patient concerns systems are widely used to detect and respond to patient harm. Despite increasing recognition of the link between equity and safety, equity remains poorly integrated into the design and function of these systems. Consequently, these systems risk obscuring or reproducing inequities rather than revealing and attending to them. This study examined how issues of equity are currently considered in research about hospital incident reporting and patient concerns systems and identify opportunities to more systematically include equity in how patient safety is addressed.

Accountability is not the enemy of patient safety. Avma’s CEO explores why openness, learning, and responsibility must coexist after avoidable medical harm.

Accessible communication means information and support that people can understand and use, whether that is British Sign Language (BSL) interpreting, large print, Easy Read formats or other reasonable adjustments. Everyone has the right to clear, accessible communication when using public services, whether that's understanding health information, navigating the benefits system or making decisions about care. In the UK, at least 1 in 5 people have a long-term illness, impairment or disability, while many more have a temporary disability. When communication falls short, it can exclude people, cause significant distress, and in some cases mean people cannot get the care or support they need. A Parliamentary and Health Service Ombudsman (PHSO) report looked at some of the accessible communication complaints people have brought to us, to shine a light on their experiences and encourage others to let their voices be heard. It shares case summaries and guidance to help people complain and help public services understand and learn from the issues raised.