Mark Hughes

This HIMSS flagship event is Europe’s leading digital health conference. With expert-led sessions, it’s a chance for health tech leaders to network, share ideas, discuss real-world data and build partnerships. Attendees include CIOs and senior executives, health providers and payers, C-Suite tech leaders and entrepreneurs, and government officials. You can find the programme for the event here. You can find registration details here.

The National Patient Safety Plan of the Republic North Macedonia is based on a comprehensive assessment of the situation conducted in December 2022, with technical support from the WHO Office for Quality of Care and Patient Safety in Athens. Its vision is that the Republic of North Macedonia will be an environment where no patient will experience harm from an adverse event and every patient will receive safe health care that will be timely, equitable, and available everywhere. Mission To implement policies, strategies and practices that are based on evidence, patient experience, appropriate system design, healthcare workforce and partnership in order to eliminate all sources of preventable risks and harm to patients and healthcare workers. Main dimensions The main dimensions for the advancement of the patient safety framework, consequently contributing to the improvement of the quality of care across the country are: Adopting policies that will eliminate preventable harm in health care Establishing stable health care systems Safety of clinical processes Involving the patient and their family in the care Education, skills and safety for healthcare workers Information, research and dealing with risks Synergy, partnership and solidarity For each of these domains, a group of objectives, activities, subjects in charge of the activities, a rough timeline and possible sources of financing have been developed in a period that is synchronized with the National Health Strategy of the Republic of North Macedonia, until 2030. These elements of the national plan are drawn from the existing results of research, accreditation standards related to the safety of patients, other legal regulations, the mission of international consultants conducted in December 2022, medical practice guides, WHO policy recommendations and other documents. Considering the context of the current healthcare system and patient safety situation in the Republic of North Macedonia, four core priorities arise from the main dimensions of the National Plan: Training of healthcare professionals Awareness and patient engagement Establishment of the Committee for Patient Safety Data infrastructure and IT-based systems to support patient safety interventions

To support the implementation of the National Patient Safety Plan of the Republic of North Macedonia, this handbook provides a structured framework using the Plan-Do-Check-Act (PDCA) cycle and focuses on six core intervention areas, including infection prevention, medication safety, surgical safety, safe birth practices, capacity strengthening, and error-reduction strategies. It emphasises stakeholder engagement, monitoring and evaluation, risk management, and sustainability planning. By providing a clear roadmap, this initiative aims to foster a culture of patient safety and improve health-care quality in North Macedonia.

In this episode Dr Paul Grime, Chairman of the Safer Healthcare and Biosafety Network, is joined by Professor Peter Brennan, consultant surgeon and leading voice on Human Factors in healthcare. Together they explore how better understanding of Human Factors can improve staff and patient safety, reduce error, and shift culture away from blame. Drawing on insights from aviation, real-life NHS incidents, and Peter’s extensive research, this conversation tackles everything from toxic hierarchies and communication breakdowns to the power of kindness and just culture. Safety Talks is a podcast series as part of the Safety for All Campaign, launched to shine a light on the symbiotic relationship and benefits of integrating the approach to deliver healthcare worker safety and patient safety.

Patient safety is the core foundation of healthcare quality. Unsafe care is a significant challenge globally, due to unsafe practices, processes, or structural inefficiencies within healthcare organisations, which in turn lead to patient safety incidents. This white paper from ISQua aims to address these challenging issues by providing a comprehensive framework to improve patient safety in hospitals and other healthcare settings. The white paper focuses on four foundation pillars that it identifies as critical for embedding patient safety into healthcare systems: 1) Advocacy and Leadership Advocate for prioritisation of patient safety within hospital policies, practices, and culture. Ensure that patient safety is embedded as a core organisational value in every level of healthcare delivery. Establish a strong hospital governance structure that ensures leadership commitment to patient safety and accountability. 2) Health Worker Education and Safety To empower health workers with the knowledge, skills, and tools to be proactive agents of patient safety within healthcare organisations through continuous education and training programmes. It prioritises the physical and psychological well-being of healthcare professionals to enhance workforce resilience to deliver safe and effective care. 3) Patient, Family and Carer Engagement and Empowerment To empower and engage patients, families, and carers in patient safety efforts. To ensure effective collaboration between healthcare providers and patients to improve safety and quality of care delivery 4) Improvement in Clinical Processes Adopt evidence-based practices to manage patient safety risks in clinical care. Ensure standardising care, utilising technology, and measuring progress and effectiveness.

This is a brief summary of a Westminster Hall debate in the House of Commons on the 27 March 2025 concerning the first anniversary of The Hughes Report on valproate and pelvic mesh. What is a Westminster Hall Debate Westminster Hall debates give Members of Parliament (MPs) an opportunity to raise local or national issues and receive a response from a government minister. Any MP can take part in a Westminster Hall debate. The Hughes Report The Independent Medicines and Medical Devices Safety Review, published in July 2020, highlighted the scale of avoidable harm related to three medical interventions: hormone pregnancy tests, sodium valproate and pelvic mesh implants. One of the Review’s key recommendations was that separate redress schemes should be established for patients adversely affected by these interventions. Published on the 7 February 2024, the Patient Safety Commissioner for England set out options for redress for two of these interventions, pelvic mesh and sodium valproate in The Hughes Report. It recommends the government creates a two-stage financial redress scheme – an interim scheme to enable the identification of all those harmed ensuring patients receive financial redress quickly – and a main scheme. You can find Patient Safety Learning’s reflections on the first anniversary of this report’s publication here. House of Commons debate In the discussion MPs highlighted individual cases from their constituents relating to pelvic mesh and sodium valproate and also discussed: The need to confirm a timeline for the Government's response to The Hughes Report. Considering whether there is scope to implement a sunshine-style piece of legislation to ensure the transparency of payments made by industry to the healthcare sector. The difficulties of getting financial redress outside of a Government scheme. On mesh, it was noted that of the 1,252 legal cases initiated between 2014 and 2024, only 356 were settled in or out of court with damages, but 678 were concluded without any such damages being awarded. Concerns about specialist mesh removal centres being run by clinicians who have inserted mesh. Considering whether the initial interim payment of £25,000, proposed by the report, could be prioritised ahead of finalising arrangements for the main payment. Responding on behalf of the Government to this debate was Ashley Dalton MP, Parliamentary Under-Secretary of State for Public Health and Prevention. She noted that: The previous Government had held a consultation on the principle of mandatory reporting for industry payments made to the health sector. The Department of Health and Social Care was now considering options regarding payment reporting, with an aim to publish a response later this year. The Government is still considering all the options and the associated costs before responding to The Hughes Report’s recommendations. She stated that she would write to Baroness Marron to clarify timescales around this.

Diagnosis is complex and iterative, therefore liable to error in accurately and timely identifying underlying health problems, and communicating these to patients. Up to 15% of diagnoses are estimated to be inaccurate, delayed or wrong. Diagnostic errors negatively impact patient outcomes and increase use of healthcare resources. This Health Working Paper from the Organisation for Economic Co-operation and Development (OECD) defines the scope of diagnostic error and illustrates the burden of diagnostic error in commonly diagnosed conditions. It also estimates the direct costs of diagnostic error and provides policy options to improve diagnostic safety. Key findings of this report included: Most people will experience at least one diagnostic error in their lifetime, sometimes resulting in severe patient harm, as it is estimated that 80% of all harm caused by delayed or misdiagnosis may be preventable. Tests, tools, diagnostic procedures and information systems are proliferating across healthcare settings to help patients and providers identify the exact nature of health problems. Despite these technological advances, health systems may still fail to identify and communicate health conditions correctly or in a timely way. Diagnostic errors negatively impact patient outcomes and increase the use of healthcare services, with associated increased costs. An estimated 2.6 million diagnostic errors occur in the United States each year, resulting in approximately 371,000 deaths and 424,000 permanent disabilities due to misdiagnosis. The report estimates that the direct consequences of diagnostic error on healthcare budgets account for 17.5% of total healthcare expenditure. In the United States this would amount to USD 870 billion each year. Deficits in health system design and governance, clinical environments, and individual provider competencies can drive poor diagnostic outcomes. Internationally, guidelines and standards on accurate and timely diagnosis for health conditions can be lacking and not systematically adopted. Even a relatively modest target of halving diagnostic error rates would not only reduce considerable patient suffering and distress but could free up as much as 8% of healthcare expenditure. Across OECD countries, this would equate to USD 676 billion a year. Setting out what policymakers can do to improve diagnostic safety, the paper suggests the following set of actions: Clinical directors should foster changes in medical work culture and clinical environment for peer feedback and multidisciplinary approach to patient diagnosis and review. Patient perspectives and preferences should be taken into account when making and reviewing a diagnosis. Medical specialty associations should set national or international standards and guidelines for ordering diagnostic testing and interpreting results, to minimise diagnostic error, harms and wasteful healthcare expenditure. National patient safety agencies should routinely collect, report and publish quality assurance indicators for error and safety for diagnosis of common conditions such as cancer screening, mental health disorders and sepsis. Health financing should report on regional or institutional variations or anomalies in expenditure and reimbursement for diagnosis rates or diagnostic testing, indicative or poor quality care. Healthcare insurers and providers should review policies for financing and reimbursement of diagnostic practices that do not conform to best international practice or guidelines in order to enable healthcare expenditure savings. Healthcare systems should leverage digital health architecture to prioritise development of integrated health information flows between patients and different healthcare providers, to ensure timely and systematic follow-up and communication of diagnosis. The use of language learning models and AI to analyse multiple clinical, biomedical and radiological patient data sources to achieve a more accurate and timely diagnosis requires clinical validation and ongoing refinement, but may be of use in conditions where clinical diagnosis is currently challenging or reliable diagnostic testing is lacking.

This year’s World Patient Safety Day (WPSD 25) on 17 September is focused on the theme “Safe care for every newborn and every child”. This article explains the aims of the event and the areas it will cover. You can now read Patient Safety Learning's World Patient Safety Day blog to mark this year's event here. Wednesday 17 September 2025 marks the sixth annual World Patient Safety Day. World Patient Safety Day aims to: increase public awareness and engagement enhance global understanding work towards global solidarity and action by World Health Organization (WHO) Member States to enhance patient safety and reduce patient harm. The theme of this year’s event is “Safe care for every newborn and every child”.[1] Ensuring safe care for patients is a fundamental priority, yet newborns and children remain especially vulnerable to patient safety risks. While the reported level of patient safety incidents relating to newborns and children receiving healthcare varies, studies suggest that adverse events occur across all care settings, with higher risks among critically ill children, particularly those in intensive care or requiring complex medical interventions. Some studies report rates as high as 91.6% in intensive care settings and up to 53.8% in general care settings.[2] To bring attention this critical issue, “Safe care for every newborn and every child” has been selected as the theme for World Patient Safety Day 2025, emphasising the need for stronger measures to protect children from preventable harm. The Global Patient Safety Action Plan 2021–2030 recognises paediatric and newborn safety across multiple strategic objectives, including designing safe clinical processes, strengthening health workforce competencies, engaging patients and families and establishing learning systems to prevent harm. Objectives of World Patient Safety Day 2025 Under the slogan “Patient safety from the start!”, WHO is calling for urgent action to eliminate avoidable harm in paediatric and newborn care. Addressing this challenge requires comprehensive efforts across key patient safety areas, such as safe childbirth and postnatal care, medication safety, diagnostic safety, immunisation safety, infection prevention and early recognition of clinical deterioration. World Patient Safety Day 2025 aims to drive meaningful improvements and reaffirm every child's right to safe and quality care. As part of this, it has set four objectives: Raise global awareness of safety risks in paediatric and newborn care in all health care settings, emphasising the specific needs of children, families and caregivers. Mobilise governments, health care organizations, professional bodies and civil society to implement sustainable strategies for safer care for newborns and children as part of broader patient safety and quality initiatives. Empower parents, caregivers and children in patient safety by promoting education, awareness and active participation in care. Advocate for Strengthening research on patient safety in paediatric and newborn care. You can find campaign materials from the WHO for the event here. Calls to action and key messages Patients and caregivers - Be your child’s safety champion. Stay informed. Stay involved. Speak up. Track and share: keep notes on symptoms, medications and appointments. Share everything with your health care team. Keep informed: learn about common medical conditions in children and what to watch out for. Understand hospital safety protocols, such as handwashing and visitor restrictions. Have your say: take part in the decisions being taken about your child’s care. Ask and confirm: always ask about treatments. Double-check names, allergies and medications before interventions. Trust your gut: if something feels off, speak up. You know your child best. School-aged children (6+ years) - Be a patient safety star, speak up for your safety! Speak up: tell an adult if you feel sick, are hurting, or if something feels wrong during your care. Try your best to describe what you’re feeling, like pain or tiredness. Stay safe during care: share your name, birthday and allergies with your doctor or nurse. Ask what your medicine is for. If you get a cut or scrape, ask how to keep it clean while it heals. Be a germ buster: wash your hands often. Cover your cough or sneeze with your elbow or a tissue. It’s okay to remind others to do that, too. You can help: if something doesn’t look or feel right, tell an adult. Health practitioners - Deliver care that’s safe and child-centred. Tailor care to the child: adjust for age, weight and development. Verify a child’s identity before any intervention and check for allergies. Prevent harm: watch for the main causes of harm such as medication errors, health care-associated infections and diagnostic errors. Act early: spot signs of deterioration. Respond promptly. Partner with parents and children: communicate clearly. Listen actively. Encourage questions and involve them in the decision-making. Coordinate and learn: share information clearly across teams. Report incidents to improve care and contribute towards improvement efforts. Health care facility managers - Make safe care the standard for every child, everywhere. Streamline safety: apply WHO quality of care standards. Establish core safety systems such as patient identification, safe medication, infection prevention, and care escalation. Support the workforce: ensure staff are trained in safe paediatric care skills. Foster teamwork, open communication and standardized care. Make care child-friendly: provide appropriate child-friendly spaces and equipment. Use data to improve care: establish a safety culture. Support incident reporting by staff and caregivers. Track safety indicators and act on insights. Policy-makers and health care leaders - Invest in safe care for children. Save lives and resources. Embed paediatric safety within policy: integrate safety into national health policies and strategies. Invest in safer care: build workforce capacity and equip facilities with the tools, training and infrastructure needed to keep children safe. Lead with data and learning: strengthen data systems. Promote a culture of safety and learning. Engage communities: involve civil society, patient advocates, child protection groups and educators in building safer systems and promoting patient safety in schools. Teachers, educators and school health staff - Empower children to participate in their health care. Empower children: teach them to speak up, ask questions and share symptoms or concerns. Create safe spaces: listen with empathy. Reduce fear around health care. Promote safety education: partner with health workers. Build children’s hygiene habits, health literacy and awareness of patient safety. Practice and celebrate: recognize and praise children when they make safe health decisions, such as regular handwashing and coughing into the elbow. Civil society organizations and advocacy groups - Raise awareness. Mobilize communities. Demand safe care for every child. Raise awareness: promote health literacy. Share clear, accessible information on patient safety risks and the prevention of harm. Promote equity: advocate for safe care in all settings, especially those in low-resourced, marginalized or humanitarian settings, where risks are greatest. Amplify voices: represent patients in health dialogues. Co-create safer systems with health workers. Share your views and experiences on the hub Do you have experiences or views around the theme of this year’s World Patient Safety Day that you would like to share? You can share your thoughts with us by commenting below (sign up here for free first), submitting a blog, or by emailing us at [email protected]. References WHO. Announcing World Patient Safety Day 2025 – Patient safety from the start!, 18 March 2025. Dillner P, Eggenschwiler LC, Rutjes AWS, Berg L, Musy SN, Simon M et al. Incidence and characteristics of adverse events in paediatric inpatient care: a systematic review and meta-analysis. BMJ Qual Saf. 2023;32:133–49.

Last month Public Policy Projects, in partnership with Patient Safety Learning, held their Patient Safety Forum 2025, as part of a new patient safety policy programme between the two organisations. Taking place at the Royal College of Physicians in London, in attendance were senior healthcare leaders, patient safety experts, representatives from the HealthTech industry, frontline healthcare professionals, patients, policy makers and the media. In this article, Patient Safety Learning’s Chief Executive, Helen Hughes, and Director, Clare Wade, look back at the day and share their reflections on the event. Digital health technologies are likely to be central to the successful delivery of the UK’s forthcoming 10-Year Health Plan. However, if we are to fully realise the benefits of new devices and innovations, patient safety needs to be at the heart of their development, implementation and use. In working towards this, it is vital that we bring together people from across the health and social care system who have the right knowledge, skills and experiences to contribute to this. We have therefore been delighted to partner with Public Policy Projects (PPP) over the past six months on a patient safety programme that culminated in our Patient Safety Forum on Thursday 27 February 2025. Leading up to this event, between October and December 2024, we hosted with PPP three roundtable sessions discussing patient safety through the lens of technology, digital innovation and data-driven transformation. The outcomes of these events are summarised in a new report, Patient safety in the digital NHS: user-centric approaches to technology and transformation.[1] The key findings of this report were reflected throughout the discussions at our Patient Safety Forum: A lack of user-centric design and interoperability between digital technologies is limiting scalable digital transformation and putting patients at risk. Digital clinical safety is being developed across the NHS, but a lack of resource and siloed working limits the ability for consistent monitoring of digital systems. A lack of understanding of digital technology and data is often tolerated among NHS leadership and the workforce is not adequately trained and/or supported to utilise digital technology. Opportunities to learn from the NHS patient safety reporting system are limited by a lack of data transparency and capacity for analysis. Digital poverty presents inherent patient safety risks where non-digital routes of access are not maintained, meaning digital transformation risks inadvertently widening inequalities. Introduction to the Forum To begin the event, Helen Hughes, Chief Executive of Patient Safety Learning, welcomed participants, sponsors and panellists to the Patient Safety Forum. The goals of the event and our partnership with PPP were to: Ensure that technology introduced to service delivery is patient centred and safe. Embed a culture of patient safety within UK healthcare. Support patient safety being a core purpose of Integrated Care Systems (ICSs) and to ensure the patient voice is core to the design of safety at system level. The initial keynote speech at the Patient Safety Forum was then provided by Jeremy Hunt MP, Chair of the All-Party Parliamentary Group on Patient Safety. He reflected on his first experiences of patient safety in his previous role as Secretary of State for Health and the scale of avoidable harm in the healthcare system. Jeremy spoke about a report published in December by Imperial Institute of Global Health Innovation and the charity Patent Safety Watch, which had highlighted the gap in healthcare between the UK and best performing OECD countries.[2] The report showed that if the UK matched the top 10% of OECD countries, this would equate to 13,495 fewer deaths per year. The report also underlined the cost of unsafe care in England, estimated at £14.7 billion per year. He also talked about the areas that he believes should be key patient safety priorities, identifying the following four areas: Creating a centralised system to collate and prioritise patient safety recommendations. To improving and revitalise the Care Quality Commission. To tackle cultural issues in the NHS, with reform of the clinical negligence system an important element of this. Not normalising avoidable deaths. Patient safety and Integrated Care Systems Following the morning keynote address, the first panel session of the Forum focused on the need to position patient safety as a core purpose across ICSs. This featured the following participants: Helen Hughes – Chief Executive, Patient Safety Learning Sir Liam Donaldson – Chair of North East and North Cumbria Integrated Care Board (ICB), Special Envoy for Patient Safety, World Health Organization Kate Provan – Associate Director Clinical Effectiveness and Improvement, NHS Greater Manchester Matthew Mansbridge – Senior Safety Investigator, Health Services Safety Investigations Body (HSSIB) Tim James – Clinical Director and Nursing Executive, Oracle Health UK Sir Liam Donaldson opened the first panel by explaining that when approaching patient safety as an ICB, it must be viewed through the lens of avoidable harm. Some of the issues discussed with the panellists were: The need to reduce variation across healthcare in how patient safety incidents and avoidable harm are both responded to and acted on. The difficulties of reducing avoidable harm while working against the backdrop of persistent blame cultures in parts of the NHS, which undermine efforts to learn and improve. The difficulties that organisations can face in attempting to respond to mismatched reporting requirements across various bodies in a complex operating environment. Errors occurring in weak systems, where services are performing at suboptimal level and with poor practitioner performance. We need to tackle the normalisation of deviation from good practice At Patient Safety Learning, we believe that greater action is required to create clarity about the role of ICBs and ICSs in patient safety. We set this out previously in in our 2023 report, The elephant in the room: Patient safety and Integrated Care Systems.[3] A HSSIB investigation report published this year echoed these points, highlighting the lack of overarching principles for ICBs and ICSs to take a consistent approach to safety management. [4] [5] With greater clarity around the roles, ICBs and ICSs have the potential to drive systemic improvements in patient safety. However, to do so effectively, they require enhanced tools, commitment and capacity that support patient safety. Culture and regulation The second panel session at the Forum focused on how patient safety improvement could be driven forward and supported through culture and regulation. This featured the following participants: Sue Holden – Executive Chair, Advancing Quality Alliance Dr Alan Clamp – CEO, Professional Standards Authority for Health and Social Care Norman MacLeod – Patient Safety Partner Moyra Amess – Director - Assurance and Accreditation, CHKS A key element of this panel discussion was how to create a psychologically safe culture in healthcare. This extended not just to creating a culture of incident reporting, but also ensuring staff and patients see clear examples of those reports being acted on for improvement. Psychological safety is when someone feels they are safe to speak up with ideas, questions, concerns or mistakes without fear of being punished or humiliated. We have a number of different resources available on this topic on the hub, our platform to share learning for patient safety. To overcome blame cultures in the NHS, the panellists all emphasised the importance of kind leadership: “Leaders have an active choice to be kind in healthcare, and it makes such a difference, it is hard in a pressurised system, but it is a choice we can all make.” Panel members also discussed some of the challenges for regulators and regulation, highlighting the following points: Regulators must prioritise safety over regulations. The need for the regulatory environment to continually evolve to meet new patient safety opportunities and challenges, such as the growing use of artificial intelligence (AI) in healthcare. Being clear on how to understand ‘what good looks like’, what organisations are doing to work towards this and how this is measured. Not subsuming safety within quality. Being alert to system failure in healthcare like the frogs in a saucepan analogy—the water heating slowly to the point of catastrophic harm because we have tolerated normalised deviance. Insight through triangulation of data—patient and, staff perspectives and experience and data. Harnessing information and sharing for patient safety The next panel session at the Forum was on the opportunities and challenges presented by the development of new systems for sharing and utilising patient data to improve outcomes. This featured the following participants: Professor Sam Shah – Professor of Digital Health, College of Medicine and Dentistry, Ulster University Jonathan Webb – Head of Safety & Learning, NHS Wales Professor Maureen Baker CBE – Former Chair, Professional Record Standards Body Mark Linggood – Director of Product Management, RLDatix A key area of discussion in this session was on the use of AI and the need to understand the advantages and limitations of this in improving the sharing and use of healthcare data. This included the use of AI in diagnostics, sentiment analysis and how it can support deeper organisational learning. Panel members also highlighted the following points: The need to improve interoperability—the ability of different systems, devices, applications or platforms to work together and exchange information effectively. This still presents significant barriers to sharing data in real-time. Difficulties that patients and families face in navigating the NHS and having control over their own care. This has recently been the subject of a new blog series we have published on the hub. The importance of clinical engagement in the design and procurement of digital systems. That the digital safety standards are essential and need to embraced, supported and championed by system regulators such as CQC, which unfortunately isn’t the case. Improving how we can share and use patient data, and the implications of this for patient safety, is an area we have previously looked at in detail around electronic patient record (EPR) systems. While EPR systems have the potential to improve patient treatment, increase efficiency and reduce the costs of healthcare, their implementation also comes with serious patient safety risks. In July last year, we published a new report on this topic, Electronic patient record systems: Putting patient safety at the heart of implementation.[6] This outlined the key patient safety risks associated with choosing and introducing new EPR systems and identifies 10 principles to consider for safer implementation. Health inequalities and patient safety The focus of the final panel session of the Forum was on the connection between health inequalities and patient safety. This featured the following participants: Jono Broad – President Elect - Patient Safety, Royal Society of Medicine Sandra Igwe – Chief Executive, The Motherhood Group Professor Habib Naqvi MBE – Chief Executive, NHS Race and Health Observatory Jacob Lant – Chief Executive, National Voices Health inequalities often result in poorer outcomes for some patient groups, including impacting on their safety during care and treatment. Discussing these issues, panel members made the following points: Research has found that, in too many cases, black mothers are treated in an inhumane way by maternity healthcare professionals, including examples of the barriers in providing pain relief and a lack of empathy. The need to do more to ensure appropriate minority representation in healthcare organisation staffing and leadership. Addressing racial biases in medical devices, such as the accuracy of pulse oximetry, and recommendations of the Government’s review of unfair biases in their design and development more broadly. Vulnerable groups have longer wait times—as services do not cater for their needs, a ‘one size fits all’ strategy doesn’t work in healthcare. Health inequalities can lead to a breakdown in trust by communities, which leads to further patient safety issues if patients are reluctant or fearful of accessing services. Closing remarks At the end of the Patient Safety Forum, Dr Penny Dash, Chair of NHS North West London and the incoming Chair of NHS England, gave a keynote address.[7] Penny set out how she had approached her independent review into the patient safety landscape, commissioned by the Government to be published ahead of the 10-Year Health Plan.[8] [9] She noted the overcrowded and fragmented patient safety landscape, highlighting that her team had identified over 127 organisations in England involved in patient safety to some degree. Penny emphasised that quality should encompass productivity and efficiency as well as safety and effectiveness. She said: “We know that well-managed services lead to more efficient use of resources–that in itself is a big quality opportunity. We can actually do things for less that frees up money for more care.” Looking forward, she said she hoped the NHS would be given a “balanced scorecard” to measure quality, alongside the priorities in its annual planning guidance. She said there were many metrics available, but they could be “presented and brought into board papers” better than they were.[10] Reflections from Patient Safety Learning This was the first face-to-face event as part of our new patient safety policy programme with PPP. We had a magnificent line up of speakers with expert chairing of panels and a great turn out on the day. The Forum was significantly oversubscribed and we had a long waiting list that we had to close. We are sorry that not everyone was able to attend, next year we plan to make the event even bigger and better. We have received enthusiastic feedback from panellists, sponsors and participants, many saying that this was the best event on that topic that they’d ever attended. There was huge energy in the auditorium with conversations during the breaks that were equally inspiring, with people keen to push ahead on improving patient safety in their own organisations. There was also a supportive theme that ran throughout the discussions, with a number of panellists and participants stressing the need for greater kindness and empathy in the health service. Helen’s thoughts One personal story shared at the Forum that really resonated with me was shared by Sue Holden, Executive Chair, Advancing Quality Alliance. She recalled a time early in her career as a midwife when she had met with parents to share information as to why their newly born baby had suffered severe avoidable harm during the birth. At the end of the meeting, which she said had been at times challenging and emotionally hard for all, the father of the baby showed Sue two envelopes that he’d previously prepared. On opening the one passed to her, Sue found a financial donation to the hospital’s fundraising appeal. When she asked what was in the other one, the father explained that he was a solicitor and it was a prepared letter outlining the clinical negligence action he would have taken if faced with a lack of information and defensiveness. Sue described how this has always stayed with her, and I felt that this is a strong metaphor for the choices we all make for patient safety. It made me think, how often do we, as clinicians, patient safety experts or organisational leaders, look the other way? Do we just follow process? Or do we embrace honesty, integrity and justice, putting patients and families at the heart of the work we need to do to take action for improvement. Many of the Forum participants shared their challenges in doing the right thing, raising questions about organisational culture and behaviours that don’t prioritise patient and staff safety. As Penny Dash said, we must role model the behaviour we want to see in others. We must listen and act with kindness. And as Sir Liam said, “'find harm', go looking for it, use data and analysis to understand it and address it.” Clare’s thoughts At a time when the NHS is grappling with the toughest challenges in its history, it was heartening to have so many enthusiastic, positive delegates join us last Thursday. Connections were made and reignited, and conversations about issues and how to combat them were shared. Although everyone is in no doubt of the hill we all have to climb, there was a collective voice keen to find solutions and make change happen. I met new people, listened to different perspectives and drew energy from being in such a positive space. Our keynote speakers offered their insights, and panel members brought opinions from their own experiences encouraging us to challenge beliefs. It's important that we all take these opportunities to refresh, engage and reenergise. Thank you to everyone who joined us, we hope to see you again soon. References Public Policy Projects. Patient safety in the digital NHS: user-centric approaches to technology and transformation, 28 February 2025. Imperial Institute of Global Health Innovation & Patent Safety Watch. National State of Patient Safety 2024: Prioritising improvement efforts in a system under stress, 12 December 2024. Patient Safety Learning. The elephant in the room: Patient safety and integrated care systems, 11 July 2023. HSSIB. Safety management systems: accountability across organisational boundaries, 13 February 2025. Patient Safety Learning. Patient safety across organisational boundaries: Patient Safety Learning’s response to HSSIB investigation, 13 February 2025. Patient Safety Learning. Electronic patient record systems: Putting patient safety at the heart of implementation, 31 July 2024. Department of Health and Social Care. Dr Penelope Dash confirmed as new chair of NHS England, 3 March 2025. Department of Health and Social Care. Review of patient safety across the health and care landscape: terms of reference, 15 October 2024. Patient Safety Learning welcomes a new review of patient safety across the health and care landscape, 15 October 2024. Health Service Journal. New NHSE Chair seeks ‘clear accountability and responsibility’, 4 March 2025.

Digital technology offers the opportunity to revolutionise patient care, supporting the NHS to become more efficient, productive, cost-effective, and importantly, safer. This report published Public Policy Projects, in collaboration with Patient Safety Learning, highlights that the NHS will fail to unlock these opportunities without the prioritisation of patient safety. It sets out that although there are examples of successful technology implementation across the NHS, patients continue to be put at risk as efforts to digitalise services are not adequately considering patient safety. Key findings from this report include: A lack of user-centric design and interoperability between digital technologies is limiting scalable digital transformation and putting patients at risk. Digital clinical safety is being developed across the NHS, but a lack of resource and siloed working limits the ability for consistent monitoring of digital systems. A lack of understanding of digital technology and data is often tolerated among NHS leadership and the workforce is not adequately trained and/or supported to utilise digital technology. Opportunities to learn from the NHS patient safety reporting system are limited by a lack of data transparency and capacity for analysis. Digital poverty presents inherent patient safety risks where non-digital routes of access are not maintained, meaning digital transformation risks inadvertently widening inequalities. Commenting on the publication of this report, Patient Safety Learning's Chief Executive Helen Hughes said: “Digital health technologies will be key to delivering the forthcoming Ten Year Health Plan. However, if we are to fully realise the benefits of these changes, patient safety needs to be at the heart of these developments. When designing and implementing new technologies in health and care, we need to take a user-centred approach, with patient safety at its core. As this report highlights, there are some promising examples of where this is already happening. Though as the recommendations set out, greater action is needed with system-wide collaboration, to ensure that the opportunities of new technologies are realised and the risks to patient safety are addressed. Patient safety needs to be at the centre of everything we do.”