Patient Safety Learning

This guidance sets out the relevant principles of good practice if you are involved in any criminal or regulatory proceedings, and want to know whether you should report this to the General Medical Council. 

Hospitalised patients in the US tended to have a lower chance of dying or being readmitted within 30 days when they were treated by female physicians rather than male clinicians, a recent study published in Annals of Internal Medicine found. The difference in outcomes for patients examined by female vs male physicians translated into 1 fewer death per 417 hospitalizations, and 1 fewer readmission per 208 hospitalizations, according to the researchers. The data were based on about 776 900 Medicare beneficiaries aged 65 years or older who were treated by more than 42 100 clinicians.

Every year millions of children in England spend time in hospital. Most children are in hospital only for a short period, often just after they are born or during brief periods of illness. However, for a number of children, hospital becomes a place they spend months and sometimes years of their lives. For the first time, this report shows how long children spend in hospital over their childhoods through new analysis of NHS data. This report sets out why children are waiting to be discharged and what their experience of delayed discharge is like. For some children, time they spend in hospital waiting to be discharged is avoidable. That is particularly true for two groups of children. First, children with serious and complex medical needs. While advances in modern medicine are making a monumental difference in giving them a stronger chance in life, the systems that surround these children – community and primary care, children’s social care, palliative care, housing and education – have not kept pace. The Children’s Commissioner’s office has focused on what this means for children who are waiting in hospital, ready to be discharged. Second, for some children admitted to hospital with social, emotional, behavioural and/or mental health needs. For children admitted with these needs but who do not meet the criteria for inpatient mental health services, their experience waiting in hospital for the right care and support in the community is similarly rooted in challenges facing health, social care and education which has resulted in them being let down, and being admitted to hospital in crisis - waiting for the right therapeutic support in the community. This report brings together data on how long children spend in hospital across their childhoods, alongside the voices and experiences of families, health and care professionals working in hospitals, hospices, community nursing teams and care providers. It sets out the issues facing children whose hospitals stays are being prolonged or more frequent because the support they need to be in the community is not in place.

The NHS has seen a 6 percentage point increase in public satisfaction, the first rise since 2019, according to the latest findings from the gold-standard survey of public attitudes to the NHS and social care, analysed by the Nuffield Trust and The King’s Fund and surveyed by NatCen. Key findings Satisfaction with the NHS In 2025, 26% of British adults were ‘very’ or ‘quite’ satisfied with the way in which the NHS runs – a statistically significant 6 percentage point increase from 2024. Around half of respondents (51%) were dissatisfied with the NHS in 2025, a statistically significant fall of 8 percentage points compared to 2024 when it was 59%. This is the first increase in satisfaction since 2019, and the largest fall in dissatisfaction in more than 25 years. People under 35 (20%), supporters of Reform (20%) and people in Wales (18%) were significantly less satisfied with the NHS than the survey average. Despite the increase in satisfaction only 16% of respondents thought the standard of NHS care would improve in the next 5 years compared to 53% who said they expected care to get worse. Satisfaction with different NHS services Satisfaction with GP services was 35% and dissatisfaction was 45%. Neither was a statistically significant change on the previous year. Just over 1 in 5 respondents (22%) said they were satisfied with NHS dentistry, with 54% saying they were dissatisfied. These are similar results to the previous year. 22% of respondents said they were satisfied with A&E services. Dissatisfaction was 53%. In 2024, 19% said they were satisfied with A&E services, although the change is not statistically significant. 37% of respondents were satisfied with inpatient and outpatient hospital care, an increase of 5 percentage points since 2024, although not statistically significant. 29% were dissatisfied – no change on last year. Attitudes to NHS standards, access and staffing Half of respondents (50%) were satisfied with the quality of NHS care in 2025, and 28% were dissatisfied. There was no statistically significant change since 2024. Only a minority of respondents were satisfied with waiting times for GP appointments (27%), hospital appointments (16%) and in A&E (14%). There were no statistically significant changes compared to last year. Only 12% agreed that ‘there are enough staff in the NHS these days’. 71% disagreed. There was no significant change compared to 2024. Attitudes to NHS financing and efficiency 9% of respondents said that the government spent too much or far too much money on the NHS, 22% said that it spent about the right amount and 66% said that it spent too little or far too little. There were no statistically significant changes compared to 2024. Only 13% of respondents agreed that the NHS spends the money it has efficiently. 55% disagreed with this statement. There was no change compared to 2024. When asked about government choices on tax and spending on the NHS, the public remain closely divided between raising taxes and spending more on the NHS (45%) and keeping taxation and spending at the same level (43%). Only 8% would choose to cut taxes and spend less on the NHS. There was no statistically significant change since 2024. Supporters of the Green party (70%) and the Labour party (57%) were significantly more likely to support higher taxes and higher NHS spending than supporters of Reform (32%) and the Conservative party (30%). NHS priorities and principles On being asked what the top three most important priorities for the NHS should be, both making it easier to get a GP appointment and improving A&E waiting times were selected as top priorities by 46% of respondents, followed by 45% for waiting times for planned operations and 43% for increasing the number of NHS staff. People aged 18–64 were more likely than those aged 65 and over to prioritise A&E waiting times (48% vs 38%) and increasing NHS staff (46% vs 35%) whereas those aged 65 and over prioritised prevention and staying healthy (48% vs 36%). As in previous years, a large majority of respondents agreed that the founding principles of the NHS should ‘definitely’ or ‘probably’ apply in 2025: that the NHS should be free of charge when you need to use it (89%), the NHS should primarily be funded through taxes (81%) and the NHS should be available to everyone (74%). There has been some decrease across the past five years in the proportion who think these principles should ‘definitely’ or ‘probably’ apply since the questions were first asked in 2021. The greatest decrease over time has been support for the principle that ‘the NHS should be available to everyone’. Support for the principle that the NHS should be available to everyone varied significantly by supporters of different political parties, with 68% of Labour supporters agreeing this principle should ‘definitely’ apply compared to 45% of Conservative supporters and 30% of Reform supporters. Social care In 2025, 14% of respondents said they were satisfied with social care. 49% were dissatisfied with social care – a statistically significant decrease from 2024 when this figure was 53%. The top three priorities for social care were helping people stay independent at home for as long as possible (46%), making social care more affordable to those who need it (45%) and improving the quality of social care services (44%). When asked about government choices on tax and spending on social care, 51% said the government should keep taxes and spending on social care at the same level as now. 38% said the government should increase taxes and spend more on social care. 6% said the government should reduce taxes and spend less on social care. Support for increasing taxes and spending more on social care was lower than for the NHS – it was 45% for the NHS. The difference was statistically significant.

Productivity-enhancing technologies remain the big hope for sustaining a high-quality NHS in future. The Health Foundation Chief Executive, Jennifer Dixon, looks at efforts to adopt AI applications quickly and at scale. Learning from the world’s most technology-enabled health care providers, Jennifer draws on case examples from some familiar places, such as Kaiser Permanente, the Mayo Clinic, Johns Hopkins Hospital, Massachusetts General Hospital and Memorial Sloan Kettering Cancer Centre. And some less familiar, such as Samsung Medical Centre (South Korea), Changi General Hospital (Singapore) and the Rigshospitalet in Denmark. Common ingredients for success While the regulatory environment for each country is different, some common ingredients for success are emerging. Across these examples we tended to see: Significant investment made over the years in their data infrastructure. Some kind of innovation centre or hub allowing access by in-house clinicians and scientists, and by vendor partners, to test ideas using patient-level data. A balanced approach to AI development – part in-house, often led by clinicians, and part procured from an AI vendor. A centre or unit focused on AI governance, including standard agreed rules for testing AI in real-world contexts. These focused on going beyond the early-stage development of AI models to investigate how things panned out ‘on the ground’ when implemented. Partnerships with large technology companies, such as Amazon Web Services, Microsoft and Google, stretching over years. Built-in training for staff on how to develop, test and use AI effectively. Many of these health facilities focused on AI to tackle challenges common to many settings, such as: Improving productivity and releasing clinical capacity, particularly by reducing administrative burden and improving operational efficiencies. Reducing waiting times by enabling earlier clinical interventions, streamlining processes and pathways, and speeding up discharge. Improving safety and clinical outcomes via predictive analytics to identify high-risk patients or post-operative complications. Promoting personalised medicine, combining genomics, imaging and electronic health record data to advance research and provide tailored treatments.

To explore current use of electronic patient record (EPR) systems, The Health Foundation commissioned a survey of 1,725 NHS staff members in England between July and October 2025 to better understand NHS staff views towards them. Staff views provide valuable intelligence about the performance of EPR systems in practice. And as the primary users of these systems, staff support is essential if EPRs are to be implemented and used effectively. Buy-in from staff can help EPR systems become more useful and reliable, improving data quality and increasing opportunities for refinement and innovation.  Key points The survey found that EPRs are in widespread use, with 83% of respondents saying they now use them as part of their job in the NHS. On balance, the NHS staff we surveyed were positive about the impact of EPRs in several areas and felt these systems are already improving both patient care (75%) and patient safety (73%). Yet 37% of staff also felt EPRs are not currently working well in their organisation. The survey points to a mix of frustrations and barriers to the effective use of EPRs, including having to use multiple EPR systems every day, a lack of real-time support and limited opportunities to give feedback on how they are working. An area of particular concern is training. Only around half (49%) of survey respondents had received training on how to use the EPR system for their role, and less than a third (28%) had received training on how to fix or troubleshoot problems. Unlocking the full value of EPRs will require coordinated action across the NHS to improve the integration of systems, training and support for staff. Without this, there is a risk that many of the potential benefits for productivity, safety and quality of care will remain unrealised. Related reading on the hub: HSSIB Investigation Report: Patient safety issues associated with electronic patient record (EPR) systems – a thematic review Patient safety and electronic patient record systems: Patient Safety Learning’s response to HSSIB report Electronic patient record systems: Putting patient safety at the heart of implementation

The All-Party Parliamentary Group (APPG) on Patient Safety welcomes the National Maternity and Neonatal Investigation (NMNI) led by Baroness Amos, and the opportunity to contribute to its work. To inform this submission, the APPG for Patient Safety convened a roundtable discussion in January 2026 bringing together bereaved families, senior clinicians, Royal College leaders, NHS England representatives, academics and patient safety organisations. The discussion reflected perspectives from those directly affected by maternity failures as well as those responsible for delivering and improving services. A clear consensus emerged across participants. The system is not short of inquiries or recommendations. Over the past decade, investigations into Morecambe Bay, Shrewsbury and Telford, and East Kent have exposed serious failures and produced hundreds of recommendations. Yet many of the same issues continue to recur: poor teamwork, weak accountability, defensive cultures and a failure to translate learning into sustained change. Participants emphasised that further operational recommendations alone will not solve these problems. Instead, the final report from the investigation should focus on a small number of structural reforms capable of transforming how maternity services are organised, led and held accountable. The APPG for Patient Safety has separately urged the Secretary of State for Health and Social Care to maintain the statutory independence of the Health Service Safety Investigation Branch (HSSIB) and not proceed with plans to fold HSSIB into the CQC. Drawing on the roundtable discussion, the APPG urges the investigation not to place disproportionate emphasis on staffing or funding. Both matter, but since 2014, per delivery there are now significantly more staff: 93.1% more neonatal nurses 29.7% more midwives 52.3% more obstetricians and gynaecologists That may have contributed to a fall in the perinatal mortality rate in England - meaning around 700 fewer baby deaths per year. The APPG therefore urge the National Maternity and Neonatal Investigation (NMNI) to look at structural reforms which, in the APPG’s view, are more likely to lead to an immediate improvement in safety and experience.

Double-checking of medication administration is a safety practice used in hospitals around the world. Independence is recommended as the key to effectiveness. Independent double-checking (IDC) requires each nurse to separately check the five rights (eg, right drug, dose). There is no empirical evidence that IDC is more effective in error detection than a single-nurse check. The aim of this study was to compare the effectiveness of IDC versus single-checking in detecting medication errors during administration, assess the time required and explore factors influencing performance, including nurse experience and social dynamics. It found that IDC improved error detection for experienced nurses, but not for early career nurses. Given its inconsistent benefits, resource demands and susceptibility to social loafing (defined as reduced individual performance when working in pairs), IDC may be unsuitable as a universal safety strategy. Strengthening single-checking competence and supporting clinical judgement may offer a more effective, scalable approach to improving medication safety.