Mark Hughes
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Everything posted by Mark Hughes
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Content ArticleMartha’s Rule is a patient safety initiative empowering patients, families and carers to raise concerns if their loved one’s condition is getting worse and their concerns are not being responded to. As the implementation partner for Martha’s Rule, the Health Innovation Network supports its delivery through the regional Patient Safety Collaboratives. In this blog looks at this in practice, with Elaine and Diane sharing their experience of calling Martha’s Rule into action.
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Content ArticleThe report analyses spending, demand, staffing and performance across the NHS, specifically in relation to hospitals and general practice. It is intended to provide a comprehensive stocktake to date of the inheritance left by the previous Conservative government and the decisions made since the Labour Party came to power in the UK in 2024.
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Content ArticleTo be authorised for use in the National Health Service (NHS) in England, digital health technologies (DHTs) must meet two mandatory clinical risk management standards, DCB0129 and DCB0160. Meeting these standards is intended to demonstrate that risks from design and use have been assessed and mitigated. NHS organisations must not procure a DHT without DCB0129 assurance and must not deploy one without DCB0160 assurance. Despite legal requirement, no public data exist on how many DHTs are in use in the NHS or how many are assured. This study, published in the Journal of Medical Internet Research, aimed to determine the number of DHTs in use in the NHS in England and assess their assurance status against mandated clinical safety standards. Its findings indicated that more than 10,000 DHTs currently in use lack documented assurance against clinical safety standards, and that in a typical NHS trust, 3 out of 4 digital tools influencing patient care do not demonstrate compliance with minimum legal or clinical safety requirements.
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Content ArticleThe US National Aeronautics and Space Administration (NASA) will be familiar to most across the world. Leading highly dangerous and innovative space travel, NASA has gone from a blame culture in the 1960s to an environment that keeps safety at the forefront and a top priority. NASA culture aims to ensure that staff work safely through balancing challenges and risks, feel comfortable communicating safety issue sand learn from both successes and error. This article, published in The Annals of The Royal College of Surgeons of England, outlines NASA’s safety journey considers what surgeons can learn from this in seeking to improve both patient safety and culture.
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Content ArticleThe risk that sleep deprivation and fatigue among healthcare staff pose to patient safety is often overlooked, which can be detrimental to patient safety and outcomes. Prolonged shifts, night duties, and inadequate rest all contribute to fatigue, impair clinical judgment, and increase the likelihood of errors. This research article aims to assess the prevalence of sleep deprivation and fatigue among healthcare professionals, examine its association with patient safety incidents, and provide recommendations to mitigate fatigue-related risks in high-acuity clinical settings.
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In this feature article for The Telegraph, Rosa Silverman explores difficulties the NHS has communicating with patients. She shares the experiences of several patients and speaks to representatives from organisations including The Kings Fund, Patient Safety Learning and the Royal College of General Practitioners, on what can be done to improve this. -
Content ArticleThis report sets out the findings of new research conducted by Healthwatch England to inform the Government’s first-ever men’s health strategy for England. They commissioned a nationally representative poll of 3,575 men aged 18+ in June 2025 and also drew on local Healthwatch engagement, with men from diverse backgrounds, spanning a wide range of ages, ethnicities, occupations, and areas.
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Content ArticleIn this blog John Tingle, Associate Professor at Birmingham Law School (University of Birmingham), discusses the concept of blame in relation to patient safety. He considers how this relates to the current NHS patient safety policy framework and clinical negligence litigation , outlining tensons between the two.
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The World Health Organization’s Global Smart Pharmacovigilance Strategy seeks guides countries in building and strengthening pharmacovigilance systems (activities related to detecting, assessing, understanding, and preventing adverse effects or any other drug-related problems). It is intended as a reference document for national regulatory agencies, expanded programmes on immunization and pharmacovigilance partners in countries. -
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This event brings together experts in patient safety and artificial intelligence with resident doctors and medical students. The summit will focus on how artificial intelligence (AI) is being safely and effectively integrated into healthcare to address the increasing pressures on the NHS. Discover how AI is transforming clinical practice, the real-world challenges of implementation, and the safety considerations being addressed to ensure responsible use. The event offers a rich programme of keynote talks, interactive workshops, and thought-provoking discussions, all designed to inspire fresh thinking and offer practical solutions to take back to clinical teams and organisations. Attendees will also have the opportunity to network with peers and leaders from across the healthcare sector. By attending this event, you will: Gain experience in presenting projects (either as one of the selected oral presentations, or during the mini poster presentations of all the accepted posters) Network with clinicians & students across the country, broadening ideas for patient safety improvements to take back to their teams Learn how AI is being safely implemented in the health service, its safety challenges, and the responsibilities of a clinician using AI The Patient Safety Section: Students and trainees' prize will also be presented and awarded at the conference. Register here. -
Content ArticleThis report sets out the findings of the independent review which looked at the response of NHS England to the service failures in children’s hearing services. It found that the failed or late identification of deafness has had a profound impact on many affected babies and children, and their families, and that initial estimates that nearly 300 children (as of May 2025) have come to harm is an underestimation. The review makes 12 key recommendations grouped into 3 themes: addressing the immediate areas for improvement with the NHS England’s Paediatric Hearing Services Improvement Programme placing services on a secure footing looking at commissioning, staffing, data, research and deaf awareness lessons for similar at-risk services to mitigate future crises, including workforce and culture changes
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Continuing with the JCI Patient Safety Grand Rounds, the next session of the Grand Round “Safety Culture and Leadership: Leading the Pathway to Safer Care” on 10 December 2025. This will feature a compelling conversation between internationally recognized leaders in the field – Prof Kok Hian Tan, Group Director & Senior Associate Dean at the SingHealth Duke-NUS Institute for Patient Safety & Quality (IPSQ), Singapore; Dr. Abdulelah Alhawsawi, Board Member, Joint Commission Resources, Former Director-General, Saudi Patient Safety Center, Kingdom of Saudi Arabia; Dr. James I. Merlino, Executive Vice President and Chief Innovation Officer, Joint Commission, United States of America; and Dr. Neelam Dhingra, Vice President and Global Chief Patient Safety Officer, Joint Commission International, Former Head, WHO Patient Safety and Blood Safety (2000-2024), Switzerland. JCI invites you to register now to be part of this important initiative, and please also share this information with your networks and social media channels. The registration is complimentary. Register. JCI-Grand-Rounds-Flyer 10 DEC.pdf -
Content ArticleThis study, published in BMC Nursing, used in-depth qualitative methods to explore the concept of patient safety culture and its dimensions from the perspectives of nurses working in the neonatal intensive care unit (NICU). Data was collected through in-depth semi-structured interviews with 15 NICU nurses working in Riyadh, Kingdom of Saudi Arabia. The study’s findings consider the influence of systemic barriers (staffing shortages, workload, communication gaps) and facilitators (teamwork, leadership support, peer mentoring). Furthermore, it brings out emotional and ethical dimensions of safety such as fear of blame, moral distress when unable to deliver optimal care.
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Content ArticleIn this blog, Fiona Garín McDonagh reflects on a conversation with Helen Hughes, Chief Executive of Patient Safety Learning, about the persistence of avoidable harm in health and care. She reflects on why progress in reducing this has been slow, how the implementation gap continues to undermine safety efforts, and why we must reframe patient safety as a system-wide priority, not just a frontline concern.
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Content ArticleThis report summarises the outcome of an unannounced maternity services inspection to the Royal Infirmary of Edinburgh, NHS Lothian on Monday 23 and Tuesday 24 June 2025. This inspection resulted in five areas of good practice, two recommendations and 26 requirements.
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Content ArticleThis annual report contains information on NHS England’s work in 2024/25. It highlights their achievements, challenges and how the organisation has performed against its priorities. It also incudes financial statements for 2024/2025.
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10 years ago, waiting 12 hours in A&E was a rarity. Now long waits are routine, happening during 1 in 10 major A&E attendances. In this report, the charity Age UK sets out the devastating impact that corridor care and long accident and emergency waits can have on older people. They argue that this is a crisis hiding in plain sight in our hospitals and that the Government need to act urgently to tackle this. You can find further articles and reports on the patient safety issues surrounding corridor care here. -
Content ArticleThis report from the Northern Ireland Public Services Ombudsman relates to the care and treatment the Northern Health and Social Care Trust provided to a patient. The patient, who was 85 years old at the time, has now sadly passed away. The complainant is the patient’s son. He said the Trust provided his father with substandard care, causing him severe bed sores. He found his father in a wet state on several occasions, indicating staff did not meet his toileting needs for extended periods of time. The investigation founding several failings in pressure damage care and treatment in this case. This included a failure to reassess the patient’s pressure ulcer risk appropriately; a failure to reposition the patient appropriately on several occasions; and a failure to develop an appropriate care plan for managing the patient’s incontinence. Its recommendation is that the Trust apologises to the complainant for the failures and injustice identified and that it provides refresher training on certain aspects of pressure damage care and treatment to relevant staff and reviews its protocol for managing patients’ incontinence.
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Content ArticleSmart digital technologies are rapidly transforming perioperative care through tools such as clinical decision support systems, wearable sensors, and electronic checklists. Despite growing adoption, their specific impact on patient safety in the operating room remains insufficiently understood. This narrative review, published in the journal Patient Safety in Surgery, explores recent advancements in perioperative digital health and examines how innovations like AI-assisted systems, electronic WHO checklists, and physiological monitoring wearables contribute to safer surgical care. The evidence suggests that these tools can enhance complication detection, protocol adherence, and team communication. However, their effectiveness is tempered by challenges including alert fatigue, fragmented data systems, and added digital workload for healthcare staff.
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Content ArticleThis report is intended for healthcare organisations, healthcare staff, policymakers, higher education institutions and the public to help improve patient safety in how 12-lead electrocardiograms (ECGs) are carried out in ambulance services. It shares findings and recommendations from an investigation that considered the use of ECGs to help identify ST elevation myocardial infarction (a type of heart attack) and the support available to ambulance crews in making this identification.
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EventPatient safety remains inconsistent as a priority and there is a need for a forum through which stakeholders can engage in collaborative, challenging and meaningful debate. The Patient Safety Forum aims to provide this platform by convening the patient safety community to discuss how to embed patient safety as a core purpose of health and care. This event is hosted by Public Policy Partnerships, in partnership with Patient Safety Learning. Topics for discussion: Current and future opportunities to leverage technology and data to improve patient and staff safety The delivery of safer care to improve patient outcomes and efficiency - what is the role of technology within this? Optimising the patient safety benefits and minimising the risks of AI in healthcare The development of digital clinical safety in the NHS – delivering standards and mitigating patient safety risks Leveraging innovation to improve medicines safety Patient, family and carer engagement; why not listening is a huge patient safety concern and how to improve patient-provider interaction Safety management system approaches and organisational patient safety improvement planning Why leadership and culture matter for patient safety PSIRF and LFPSE progress; are we actioning learning to improve patient safety? Benefits of attending: Join high-level strategic conversations with patient safety industry leaders and NHS decision makers Unparalleled sector intelligence concerning patient safety from leading experts Shape the future of patient safety in the UK Gain key insights from our bespoke line-up of experts as they debate the health system’s biggest patient safety challenges Hear exclusive insights from PPP expert analysts Register here
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Content ArticleThis short animation from the National Guardian's Office highlights the unique role that Freedom to Speak Up champions can play in fostering a speaking up culture, alongside Freedom to Speak Up Guardians. It is designed for organisations to use for in internal communications, onboarding, and awareness campaigns to embed the Champion role effectively and ensure every voice is heard.
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Content ArticleHigh-reliability organisations (HROs), such as nuclear power plants, petrochemical plants, or aviation are complex systems in which safety is a critical component when it comes to achieving success and preventing catastrophic accidents. The WHO Global Patient Safety Action Plan identifies building high-reliability health systems and health organisations as a key objective in seeking to protect patients from avoidable harm. In HROs, upward voice (the willingness and ability of lower-status or frontline personnel to speak up about concerns, errors, near misses, or potential safety threats to those in higher authority) contributes to a proactive approach to safety and allows the early identification of potential problems before they cascade into tragic consequences. This study responds examines the relationship between upward voice and safety performance, and the mediating role of team learning in this relationship, looking at a sample composed of 617 workers from two nuclear power plants of the same organisation.
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Content ArticleArtificial intelligence (AI) is changing health and health care on an unprecedented scale. Though the potential benefits are massive, so are the risks. This article summarises issues discussed at The JAMA Summit on AI concerning how health and health care AI should be developed, evaluated, regulated, disseminated and monitored.
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Content ArticleOn the 8 September 2023 Keith James Hankin was admitted to Goring Hall Hospital for an elective surgical optical urethrotomy for long standing urethral strictures. Shortly after the procedure Mr Hankin developed sepsis and was transferred to Worthing Hospital later that afternoon. Despite supportive intensive care management Mr Hankin died at the hospital on the 11 September 2023. The Coroner’s report into his death identifies failings in the community management, pre-operative assessment, intra-operative and post operative care at Goring Hall Hospital on a background of poor clinical governance of the Community Urology Service (CUS) materially contributed to his death. She states that there was a gross failure to provide basic medical attention to Mr Hankin when he was dependent on it and concludes that Mr Hankin died from a recognised complication of a surgical procedure contributed to by neglect.
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