Patient Safety Learning

Equity and access are central to safe, fair, and people-centred healthcare. Yet many patients continue to face financial, geographic, cultural, and system-level barriers that limit their ability to receive timely and quality care. This webinar, organised by the WPA Asia Pacific Region Steering Committee, will bring together experts, patient advocates, and health leaders to explore how patient organizations can help identify barriers, generate evidence, influence policy, and improve access to services, medicines, and diagnostics. Through expert presentations and a focused panel discussion, the session will highlight regional experiences from the Asia Pacific region while offering insights relevant to a global audience. Speakers will share practical examples of patient-led action, collaboration with health authorities, and approaches that strengthen fairness, accountability, and sustainable system improvement. Learn about the main equity and access challenges experienced by patients, with emphasis on the Asia Pacific region. Hear expert insights on how patient organizations can drive policy and service improvement. Discover practical examples of patient-led initiatives that strengthen fairness, accountability, and access to care. Gain understanding of how patients and patient organizations can work with health authorities to improve health system performance. Register

The latest NHS staff survey highlighted an unacceptable reality. One in five Black and minority ethnic staff are subject to racism from patients and 14% experience similar harassment from colleagues. From verbal attacks by patients, to incidents on the journey to and from work, many staff from ethnic minority backgrounds are navigating environments that simply don’t feel safe. This has real consequences on wellbeing, retention and whether people feel able to fully show up at work. Leaders and managers are often left holding difficult questions: What does meaningful support look like when harm is ongoing, not isolated? Why do current responses, even when well-intentioned, fall short? What does it take to create safety when parts of the system feel unsafe? This free online lunch and learn will be a space to reflect honestly on the impact of racist abuse and focus on what leaders can do differently. It will explore how leaders can offer protection, respond with clarity and build conditions to help staff feel safer and more supported. Join if you want to: strengthen your response to racist abuse in real situations move beyond policy into practical leadership understand what meaningful support looks like from a staff perspective lead in ways that actively contribute to safety, not just intention. There will be time at the end for a Q&A session. We hope to see you there. Register

In healthcare, we often talk about 'never events'—serious incidents that should not occur if appropriate systems are in place. But what happens when they do occur? I recently had the great pleasure of working with a group of anaesthetic resident doctor colleagues on a patient safety project that began with exactly that question. Within a short period in 2025, our large UK teaching hospital experienced two wrong-sided peripheral nerve blocks after six years without a single reported incident. We wanted to understand why. Looking beyond individual error Both incidents occurred during a major transition: we were moving anaesthetic records, consent forms and safety checklists from paper to digital. At first glance, the timing felt more than coincidental. After initial governance processes were completed, our team used the Patient Safety Incident Response Framework (PSIRF)[1] to explore what had happened. Introduced in the NHS in 2022, PSIRF promotes a systems-based approach rather than searching for a single 'root cause'. It examines how elements such as people, tasks, tools and technology, environment and organisational factors interact to increase risk. For us, this shift in perspective proved crucial. Instead of asking “who made this mistake?”, we were able to consider “what conditions made this error more likely?”. What we found: small gaps in a complex system We brought together a multidisciplinary 'learning MDT', combining insights from staff interviews and systems analysis. A clear pattern emerged: no single failure caused these incidents. Instead, multiple small vulnerabilities aligned. One issue stood out. In our previous paper-based system, clinicians used a 'Stop Before You Block' (SBYB) sticker—a simple but effective visual cue prompting a final safety pause before performing a nerve block. During the digital transition, this physical prompt disappeared. Other contributing factors reinforced the problem: Staff worked under cognitive overload, juggling interruptions, changing plans and high-acuity patients. Digital consent processes made SBYB checks feel more cumbersome, drawing attention away from the patient and towards the computer. Poor visibility of surgical site markings increased the barriers to performing SBYB. Ergonomic challenges in anaesthetic rooms made equipment setup frustrating. Time pressure on theatre lists encouraged task compression. In both cases, clinicians skipped the SBYB pause entirely—not out of negligence, but because the system no longer reliably supported it. These events didn’t reflect individual failure. They reflected a system under strain during organisational change. From insight to action: designing safer systems We knew we couldn’t eliminate complexity from clinical environments, but we could design systems that make the safe action the easy action. We developed a multi-faceted improvement plan. 1. Strengthening standards and education We updated our local guidance, aligning it with national recommendations from the Safe Anaesthesia Liaison Group and Regional Anaesthesia UK.[2] We rebranded it as the 'Prep Stop Block LocSSIP' (Local Safety Standard for Invasive Procedures). We promoted this through clinical governance meetings and delivered targeted teaching to consultants, trainees and anaesthetic practitioners. To support sustainability, we embedded a training video into the anaesthetic resident doctor induction programme and uploaded it to our intranet. 2. Fixing friction in the system We addressed practical barriers: Improved access to longer ultrasound cables. Standardised surgical site markings to improve visibility. Explored integrating anaesthetic complexity into theatre scheduling. Trialled LED signs to indicate when the anaesthetic room is in use; thus creating a 'sterile cockpit' by discouraging interruptions during anaesthetic procedures. Introduced electronic tablets so consent forms could be viewed alongside the patient and checklist. Each of these changes aimed to reduce cognitive load and create space for safer practice. 3. Introducing a physical safety barrier Our most impactful intervention was the 'Prep Stop Block Lid'. We designed a lidded box displaying a safety infographic. Clinicians place prepared local anaesthetic inside and cannot access it until they complete the SBYB pause. This shifts safety from memory to physical design, creating a clear pause point in the workflow. We refined the intervention through Plan–Do–Study–Act (PDSA) cycles with frontline feedback before wider rollout. What we’ve learned so far Early data show improvements in process measures, including increased visibility of the SBYB step. Audits of Prep-Stop-Block compliance suggest an improvement from 34% during digital transition to 100% at most recent review. However, we remain cautious. We are still in a 'zone of vulnerability', where changes are ongoing and their full impact is unclear. Because never events are (fortunately) rare, it will take time to determine whether these interventions reduce harm. That said, several key lessons have already emerged: Never events are rarely about individuals. They arise from system conditions that make errors more likely. Digital transformation can unintentionally remove safety cues. We must actively design these back into new systems. Education and policy are necessary but insufficient. The most reliable safety interventions are embedded into workflow, especially physical or procedural 'forcing functions'. A call to action If your department is undergoing digital transformation, take a moment to ask: “What safety cues might we be losing—and how will we replace them?” We need to move beyond simply digitalising existing processes. Instead, we should use these transitions as opportunities to design safer, more resilient systems from the ground up. Because when it comes to patient safety, 'never' is not a guarantee, it’s a goal we must actively work towards. References https://www.england.nhs.uk/long-read/patient-safety-incident-response-framework/ https://www.salg.ac.uk/salg-publications/stop-before-you-block/

This practical and engaging two-day course will explore how the SEIPS (Systems Engineering Initiative for Patient Safety) framework can be applied within health and care investigation and design to support safer, more effective systems and services. Whether you are involved in patient safety, investigation, quality improvement, service design or systems thinking, this course will provide valuable insight and practical tools to apply in your organisation. SEIPS in Health and Care Investigation and Design is an interactive two-day face-to-face course designed to introduce participants to practical systems-based investigation and design using the Systems Engineering Initiative for Patient Safety framework (SEIPS). Through collaborative workshops and realistic scenarios, learners will work alongside others to explore and analyse real-world incidents and system challenges commonly encountered across health and care settings. Participants will develop practical skills in identifying how people, environments, technologies, organisational factors, and workflows interact to influence safety, quality, and care outcomes. Delivered in a supportive learning environment, the course is facilitated by experienced faculty leading work across systems thinking, human factors, and safety investigation. Learners will have opportunities to discuss ideas, test approaches, and build confidence applying SEIPS methods through guided simulation and group-based activities. By the end of the course, participants will have developed a structured approach to investigating complex system issues and designing practical, system-focused improvements for health and care services. To find out more or book your place, please email: [email protected]