Patient-Safety-Learning
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Content ArticleThe healthcare sector is undergoing significant transformation driven by workforce shortages, role imbalances, and technological advances. Traditional health professions, characterised by advanced knowledge and self-regulation, face challenges from two key trends. First, there is a growing reliance on less-trained workers, such as nursing assistants and physician associates, to fill gaps, raising concerns about patient safety and the quality of care. While these roles can assist in simpler tasks, their expanded responsibilities—often exceeding their training—can lead to adverse outcomes, particularly in critical medical scenarios. Second, the rise of automation and artificial intelligence (AI) offers both opportunities and risks. While AI shows promise in reducing administrative burdens and aiding specialized tasks like image recognition, its limitations hinder its broader adoption, such as reinforcing biases and failing to reason diagnostically. This editorial argues that uncritical reliance on these developments risks compromising healthcare quality. It calls for evidence-based policymaking, robust oversight and updated regulatory frameworks to ensure patient safety while adapting to these shifts.
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Content ArticleIn this blog, patient safety consultant Suzette Woodward examines the issues that need to be tackled to foster a safer culture in the health system. She discusses the importance of creating clarity around values and behaviours, fostering psychological safety, making sure positive feedback is given, learning from good practice and understanding the working lives of healthcare staff.
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Content ArticleThis study in JAMA explored whether measures of patient care experience change after private equity acquisition of US hospitals. The study showed that patient-reported care experience, an important dimension of care quality, worsened after private equity acquisition of US hospitals.
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Content ArticlePROMPT (Practical Obstetric Multi-Professional Training) is an evidence-based training package for local maternity staff, previously associated with improvements in maternal and neonatal outcomes, reduction in litigation related to preventable harm and improved safety culture. PROMPT has previously been disseminated internationally using a train-the-trainer model. However, this has been associated with variations in uptake, fidelity and impact. In Wales, the project was supported by Welsh Government, and a structured scaling plan was developed, encompassing ongoing implementation support from a multi-professional team. This study describes the approach and process measures for national scaling of PROMPT across 12 obstetric-led maternity units in Wales.
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Content ArticleThis annual report from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) provides information relating to people aged 10 and above who died by suicide between 2012 and 2022 across the UK and Jersey. It also presents findings on the number of people under mental health care who have been convicted of homicide, and those in the general population in the UK.
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Content ArticleJuvenile idiopathic arthritis (JIA) is an autoimmune disease that affects around 10,000 children aged under 16 in the UK. It is a chronic disease and many patients will continue to have JIA into adulthood. JIA causes inflammation, pain and stiffness in joints, and can be have a big impact on a child's life. This study by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) looked at the quality of care provided to patients diagnosed with JIA. Patients were randomly selected for inclusion in the peer review process if their diagnosis had been made between 1st April 2019 and 31st March 2023, and they were diagnosed or experienced symptoms before their 16th birthday. Data included 374 clinician questionnaires and the assessment of 290 sets of case notes. In addition, 122 organisational questionnaires were returned along with 130 primary care questionnaires, survey responses from 68 parents/carers and 117 healthcare professionals. The study report includes recommendations highlighting areas that are suitable for regular local clinical audit and quality improvement initiatives.
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Content ArticleAdverse drug events, including adverse drug reactions and medication errors, pose a significant threat to health, leading to illness and in severe cases death. This systematic review aimed to assess the effectiveness of different interventions aimed at healthcare professionals to improve the reporting of adverse drug events. The authors concluded that, compared to usual practice, the number of adverse drug reaction (ADR) reports submitted may substantially increase following an education session, paired with reminder card and ADR report form, and may slightly increase with the use of a standardised discharge form method that makes it easier for healthcare professionals to report ADRs.
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Content ArticleIt has long been known that a focus on early intervention and prevention in the early years can prevent ill health in the future. With the mental and physical health outcomes of children in England on a downward spiral, the new government’s commitment to raising ‘the healthiest generation of children ever’ has been warmly welcomed by the children’s sector. This blog by Jessica Holden, Policy Adviser at the King's Fund, looks at whether this sentiment will be met with the action needed to address the scale of the challenge.
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In this podcast interview series, NHS whistleblower Peter Duffy and Patient Safety Learning’s Chief Executive Helen Hughes explore how the healthcare system responds when its staff raise concerns about patient safety. In each episode, Helen and Peter interview someone who has spoken up about patient safety issues in healthcare organisations, or who works to help staff raise concerns where they see unsafe care. In this episode, Helen and Peter speak to Dr Jayne Chidgey-Clark, the National Guardian for the NHS about how to create organisational cultures where staff are safe, and feel safe, to speak up about concerns. They reflect on the results of the latest NHS Staff Survey and discuss some of the issues relating to NHS manager regulation. They also talk about how regulatory bodies and other national organisations can work together to streamline safety and improvement recommendations so that they are simpler for organisations to implement. Reflecting on the gap that exists between organisations identifying cultural problems and finding solutions that make a difference, Jayne describes the need for a multi-layered approach that places safety and quality on an equal footing with financial and productivity targets. Subscribe to our YouTube podcast to keep up to date with the latest episodes. View a transcript of this interview Read a blog from Peter and Helen about the interview series -
Content ArticleProfessor Shin Ushiro is Executive Board Member at the Japan Council for Quality Health Care (JQ) and Deputy Director and Professor of Patient Safety at Kyushu University Hospital. In this guest blog for HSSIB, Professor Ushiro gives a brief overview of the history of patient safety in Japan, looks at similarities with other countries and outlines the work of the International Patient Safety Organisations Network.
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Content ArticleHistorically, policies about patients waiting to go into surgery have stated no food for six hours before surgery, clear fluids until two hours before surgery and then ‘Nil By Mouth’ (NBM) until their operation. In practice, it can be difficult to predict when the operation will start, so some patients are kept starved for hours. This can cause dehydration and discomfort. Sip Til Send is a worldwide initiative allowing patients to sip small volumes of water (or similar fluid) while waiting before surgery until they are sent for to have their operation. Allowing people to sip water until they are sent for by the operating theatre team means that they are hydrated and more comfortable with less nausea, fewer headaches and a lower chance of needing an intravenous drip. This webpage includes: Details of the new protocol List of contraindications (when the protocol should not be used) Tips for implementation Patient information leaflet
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Content ArticleThe use of surveillance technologies including CCTV, body-worn cameras and wearable sensors is becoming increasingly common in inpatient mental health settings. Surveillance of this kind is commonly justified as an effort to improve safety and cost-effectiveness. However, the use of surveillance technologies has been questioned in light of limited research conducted and the sensitivities, ethical concerns and potential harms of surveillance. This systematic review aimed to: map how surveillance technologies have been used in inpatient mental health settings. explore how they are experienced by patients, staff and carers. examine evidence regarding their impact.
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Content ArticleThis US study explored how the cervical cancer screening experiences of women with physical disabilities (WWPD) can be improved. Interviews with WWPD indicated that access to self-sampling options would be more comfortable for cervical cancer screening participation. The authors highlight that these findings that can inform the promotion of self-sampling devices for cervical cancer screening.
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Content ArticleThis study looked at attitudes towards, and perceptions of, participating in clinical trials among patients with cancer and their relatives. It explored what factors are associated with their willingness or hesitation to engage. The researchers carried out a survey of 978 patients with cancer and their relatives in Turkey. They found that willingness to participate and knowledge about clinical trials were limited and highlight the existence of significant gaps in understanding and persistent concerns about participation.
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Content ArticleThis large retrospective study used data from the US National Cancer Database to look at factors associated with timely surgical care among Asian and White women with breast cancer and highlight the importance of evaluating disaggregated ethnic and racial data. Their findings showed that there was no difference between Asians and Whites with respect to receiving surgery within eight weeks. However, disaggregating Asian populations identified disparities among Southeast Asian women, with only 78% having timely surgery, relative to East Asian women (83%) and South Asian women (84%). Compared to East Asian women and South Asian women, Southeast Asian women had statistically significantly higher rates of comorbidities and advanced cancer stages as well as socioeconomic barriers, including lower education levels and income levels. They were also less likely to be treated at high volume or academic hospitals and were less likely to receive breast conserving therapy. Southeast Asian women were the only Asian subgroup significantly less likely than White women to receive timely surgery.
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Content ArticleIn the US, compounding drugs are medications produced by compounding pharmacies, who typically make personalised versions of medications, such as custom dosages, combinations or allergen-free options. In this JAMA article, US journalist Kate Ruder looks at patient safety concerns linked to the rapid increase in demand for anti-obesity medications including semaglutide and tirzepatide. Kate highlights how high demand, ensuing scarcity, prohibitive costs and restrictive insurance coverage have fuelled the production of compounded versions of these medications under a provision allowing compounding pharmacies to make copycats during drug shortages. Concerns have been raised about the quality of ingredients, accuracy of doses and the supply of counterfeit medications by companies selling fake products, as well as about the potential for user error when they give themselves the medication.
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Content ArticleFrequent attendance at A&E—when a person goes to A&E five times or more in a year—is often because someone desperately needs help and care yet they have nowhere else to turn. Unmet social, emotional and practical needs can drive their physical and mental ill health to crisis point. A&E too often serves as a last resort when someone has not received, or cannot access, appropriate care and support earlier. Supporting people to get the help they need before this point improves their health and wellbeing, and reduces pressures on A&E and ambulance services. This research from the British Red Cross aims to deepen understanding of the needs of people who frequently attended A&E in Dorset. The findings and recommendations set out in this report reflect the importance of addressing health inequalities and highlight areas for national and local focus to better support people who frequently attend A&E.
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Content ArticleThis is one of a series of Health Services Safety Investigations Body (HSSIB) investigations on the theme of patient safety in mental health inpatient settings. The investigation examined how providers conduct timely and effective investigations into deaths of patients receiving care in inpatient units or within 30 days of discharge. This included a review of local, regional and national oversight frameworks, as well as data collection mechanisms. The aim of the investigation was to understand how providers learn from deaths, and how they use that learning to improve. The investigation sought to understand the impact on individuals involved in the care of patients who died while in mental health inpatient care or shortly after discharge. It reflects the experiences of families, carers and staff. The investigation recognises the complex nature of mental health inpatient care and discharge. The findings present opportunities to improve systems and practices in mental health services, with potential relevance to other healthcare settings in England.
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Content ArticleThe number of people living with dementia in the UK is rising. Even if treatments can be developed quickly, the social care system needs to change in order to better support the growing numbers of people affected. This report by the Nuffield Trust sets out what the current challenges are with providing good social care for people with dementia, and makes recommendations about what needs to change to improve social care for people with dementia.
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In this podcast interview series, NHS whistleblower Peter Duffy and Patient Safety Learning’s Chief Executive Helen Hughes explore how the healthcare system responds when its staff raise concerns about patient safety. In each episode, Helen and Peter interview someone who has spoken up about patient safety issues in healthcare organisations, or who works to help staff raise concerns where they see unsafe care. Peter and Helen speak to Martyn Pitman, who worked as a consultant obstetrician and gynaecologist in the NHS for more than 20 years. Martyn describes how grievances were raised against him by colleagues after he shared concerns about the safety of maternity services at the trust he worked for. He believes these complaints were raised as a response to him speaking up about his patient safety concerns and they eventually resulted in Martyn losing his job and career. Martyn describes the impact of his experience over the last few years on his mental health and highlights the unrelenting support he received from individuals he had looked after throughout his career as an consultant. He talks about how the current legal and regulatory framework is ineffective in protecting whistleblowers from retaliatory action. He also shares why we need more effective ways to hold NHS leaders and managers to account and describes the role that regulation might play in this. Subscribe to our YouTube podcast to keep up to date with the latest episodes. View a transcript of thi -
Content Article CommentHi Barbara, I wasn't able to download it either - I will speak to the publisher and see whether they are able to make it downloadable.
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Content ArticleThis report from the All Party Parliamentary Group (APPG) on Eating Disorders highlights the urgent need for a national strategy to address the growing eating disorder crisis in the UK. It is based on evidence given by people with eating disorders, carers, healthcare professionals, managers and academics, alongside information obtained from Freedom of Information requests and data analysis. You can find out more about this report in this blog by Hope Virgo, author and Secretariat of the APPG.
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In this blog, Hope Virgo, author and Secretariat for the All Party Parliamentary Group (APPG) on Eating Disorders, examines the crisis that continues in eating disorder services in the UK and the devastating impact this is having on patients and their families. She highlights how failures in services lead to avoidable deaths. Hope shares the key recommendations from a new report by the APPG and calls for adequate funding and attention to ensure people with eating disorders receive the help they need to recover. -
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The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using a standardised, system focused methodology, into maternity events, including 237 maternal deaths. Pulmonary embolism (PE) remains one of the leading causes of direct maternal deaths in the UK, resulting in 1.5 deaths per 100,000 maternities from 2019-2020. This webinar will explore the findings from MNSI's investigation into maternal deaths following pulmonary embolism. Speakers: Dr Charlotte Frise Dr Louise Page Stephanie Smith Register for the webinar -
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The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using a standardised, system focused methodology, into maternity events, including 237 maternal deaths. This webinar will explore national patterns and safety recommendations from deaths in England in the first trimester of pregnancy. Speakers: Dr Charlotte Frise Dr Louise Page Dr vidya Sundar Register for the webinar
