Mark Hughes

Listening to the voices of workers is essential for a safe and effective healthcare for workers, patients and the public. Freedom to Speak Up Guardians provide an opportunity for organisations to learn from these voices which may not otherwise be heard. Freedom to Speak Up Guardians are required to report non-identifiable information on the cases they receive both locally to their boards and senior leadership and to the National Guardian’s Office. This report summarises the data shared by Guardians about the speaking up cases they received between 1 April 2023 and 31 March 2024. There were 32,167 cases raised with Freedom to Speak Up Guardians in 2023/2024. This is the highest number of cases recorded, a 27.6% increase from 2022/23. Other key headlines from this report include: 18.7% of cases raised included an element of patient safety/quality (a marginal drop compared to 19.4% in 2022/23). 19.8% of cases reported included an element of bullying or harassment (a 2-percentage point fall compared to 2022/23). One in every three cases raised (32.3%) involved an element of worker safety or wellbeing (an increase from one in every four cases in 2022/23). Two in every five cases (38.5%) involved an element of inappropriate behaviours or attitudes. 9.5% of cases were raised anonymously. Detriment for speaking up was indicated in 4% of cases (the same as in 2022/23). Related reading Patient Safety Learning, We are not getting safer: Patient safety and the NHS staff survey results, 26 March 2024.

Safety is a core dimension of health care quality, and measurement of patient safety culture in Organisation for Economic Co-operation and Development (OECD) countries is increasingly conducted as part of efforts to monitor patient safety and to contribute to health system performance assessment. This Health Working Paper looks at the findings of the second OECD pilot on patient safety culture. This occurred in 2022-2023 and in total took data from 648,209 health care providers from 14 countries. A positive patient safety culture is associated with several benefits, including better health outcomes and patient experiences, as well as improved organisational productivity and staff satisfaction and retention. Looking at patient safety culture in OECD countries, this report builds on a previous analysis of patient safety culture measurement and the findings of the first OECD pilot data collection on patient safety culture in 2020-2021. Key findings from this include: The domain of staffing and work pace (that there are enough staff to handle the workload, staff work appropriate hours and do not feel rushed, and there is appropriate reliance on temporary or float staff) remains the lowest scoring domain on average for countries. Less than half of respondents felt that there were safe staffing and work pace levels in their work environment there remains high levels of perceived punitive response to error in hospital work environments. The highest scoring domains related to interpersonal relationships in the workplace. These were teamwork and supervisor, manager, or clinical leader support for patient safety. There remains significant international variation in the performance across countries. Several domains— including, response to error, handoffs and information exchange, and organizational learning—continuous improvement—had an over 20 percentage point difference between the best and worst performing countries. Following two successful pilot data collection efforts to assess the feasibility of collecting and reporting data on patient safety culture, the OECD will now begin to collect Patient Safety Culture indicators as part of its core data collection to provide insights on the state of patient safety among OECD countries.

This is the recording of a webinar on hosted by the Safety for All Campaign to present findings from a survey on violence and aggression sustained by nursing and midwifery students in a UK university. The findings were presented by Dr Kevin Hambridge, Lecturer in Adult Nursing (Education), Francis Thompson, Associate Professor in Mental Health Nursing (Education) and Dr Matt Carey, Associate Professor in Child Health Nursing – Acute Care, all from the University of Plymouth. The results highlighted worrying trends of verbal violence or aggression, physical violence and sexual violence towards students. The responses also highlighted a culture of acceptance among students who have been programmed to see violence at work as part of the job. There was a detailed question and answer session following the presentation in which webinar attendees asked questions about prevention, protection and collaboration.  

Taking place on Tuesday 10th December 2024 at the Royal College of Physicians in London, the third annual Safety For All conference provides an opportunity to hear from the nation’s leading voices in healthcare worker safety and patient safety and to network with frontline healthcare workers, unions, key decision makers in public and private healthcare, and patients. This event is hosted by the Safer Healthcare and Biosafety Network and Patient Safety Learning as part of the Safety For All campaign. Launched in 2021, the Safety For All campaign is focused on driving improvements in and between healthcare worker safety and patient safety, highlighting how poor staff safety standards and practice impact adversely on patient safety and vice versa. It is championing the need for a systematic and integrated approach to improve safety practice for staff and patients across health and social care so that the sum is greater than the parts. The conference will be hosted by Dr Rob Galloway, A&E Consultant at Brighton and Sussex Hospital NHS Trust, and regular columnist in the Daily Mail, and with keynote speakers including the CEO of the Royal College of Nursing, and Professor Charlotte McArdle, Deputy Chief Nursing Officer for Patient Safety and Improvement, NHS England. Sessions include; Sustainability Mental health Violence at work Antimicrobial resistance Implementing the Patient Safety Incident Response Framework (PSIRF) Register here.

Clinical communications and data sharing should focus both on the needs of patients and staff and safety to turn insights into better patient care. With the demands of patients greater than ever before, the demands placed on clinical staff have only increased in all areas of healthcare. Care teams need to work smarter with a quick and coordinated response to patient incidents by communicating critical notifications and other clinical and operational systems to the right care team members, enhance communication and simplify workflow throughout the process. This Safety For All webinar will delve into the transformative journey undertaken by South Eastern Health & Social Care Trust and the Royal National Orthopaedic Hospital to enhance clinical communications. Attendees will learn about the strategies and innovations implemented by these institutions to improve the clinical workflows, efficiency, effectiveness, and improving clinical quality using their clinical communication system. The session will cover key lessons learned, best practices, and the tangible benefits achieved through their efforts. Join us to gain valuable insights into how these leading healthcare organisations have successfully navigated their path to excellence in clinical communications. Register here.

The first ever World Health Organization (WHO) global report on patient safety aims to provide a foundational understanding of the current state of patient safety across the world, aligned with the Global Patient Safety Action Plan 2021-2030. It contains insights and information beneficial to health care professionals, policy-makers, patients and patient safety advocates, researchers – essentially anyone involved or interested in the improvement of health care and patient safety globally. In this report, the WHO initially sets out the burden of harm to patients, noting the following key messages: Unsafe care is a significant global public health issue, with more than one in ten patients experiencing harm in medical care settings – half of which could be preventable – leading to millions of deaths and substantial economic costs annually. The burden of unsafe care disproportionately affects low- and middle-income countries, where the majority of patient harm and associated deaths occur. Vulnerable populations, including older adults, children and ethnic minorities, face higher risks of patient harm, highlighting the importance of tailored interventions for safety of these groups within health care systems. Globally, 1 in 20 patients suffer from preventable medication harm, highlighting a significant challenge across health care systems. Specifically, over half (53%) of this harm arises at the prescribing stage, pointing to a crucial need for improving medication safety practices. Highly specialized care settings, such as intensive care, emergency and surgical units, are associated with the highest rates of patient harm, including both overall harm and preventable harm. In primary care, an estimated 7% of patients experience harm. It also summarises the financial and economic burden of unsafe care, noting the following key messages: Unsafe care significantly burdens health care budgets, consuming up to 12.6% of total health expenditure in high-income countries, translating into approximately $878 billion annually. Patient harm’s financial impact varies by setting: in acute care, complications inflate costs; in primary care, adverse drug events and misdiagnoses lead to unnecessary hospital use; and in long-term care, conditions such as pressure ulcers add significant expenses, showing the broad economic effects of unsafe care. Patient harm significantly reduces productivity and increases income loss, imposing indirect costs on economies that can surpass direct health care costs. Improving patient safety could have profound economic benefits, potentially increasing global economic output by 15% over two decades. The global willingness to invest in preventing patient harm, potentially averting US$1.17 trillion annually in costs, underscores the strong rationale for health care systems to prioritize patient safety. Effective patient safety interventions, such as the WHO Surgical Safety Checklist and strategies to prevent healthcare-associated infections (HCAIs), offer high returns on investment, demonstrating that targeted efforts to improve care safety are not only medically beneficial but also economically wise. The report then takes a global overview of patient safety initiatives and progress made around the world, looking at this against each of the strategic objectives set out in the Global Patient Safety Action Plan: Policies to eliminate avoidable harm in health care High-reliability systems Safety of clinical processes Patient and family engagement Health worker education, skills and safety Information, research and risk management Synergy, partnerships and solidarity The infographic below provides a high level summary of progress made against core indicators in the Global Patient Safety Action Plan (these percentages refer only to the 108 countries that completed the corresponding survey).

In this joint statement, National Voices, The Richmond Group of Charities and 68 other health and social care organisations are calling on the Department of Health and Social Care to pause or extend the consultation process for the 10-year review of the NHS Constitution, ensuring that everyone is able to respond. Patient Safety Learning is one of the signatories of this statement.

An investigation published by BBC News has revealed that Electronic patient record (EPR) system failures have been linked to the death of three patients and more than 100 instances of serious harm at NHS hospitals trusts in England. In this short blog, Patient Safety Learning reflects of these issues and the importance of patient safety being at the heart of the development and implementation of EPRs. EPR systems are a way of managing clinical information with the intention of making this information more easily accessible for use by healthcare professionals. In A plan for digital health and social care published in June 2022, the Department of Health and Social Care set a target that all NHS Trusts should have an EPR system by March 2025.[1] In November last year, NHS England announced it was on course to meet this target, stating that 90% of NHS trusts have now introduced these new systems.[2] When implemented safely, EPRs can support and improve care and treatment by: Enabling staff to have a complete overview of patients’ care in real time. Removing the need for patients to have to share the same information multiple times. Freeing up healthcare professional time and resources. However, there are also a number of patient safety risks associated with their implementation and use, as highlighted in a blog by our Chief Digital Officer Clive Flashman in January.[3] In their investigation, BBC News found from a Freedom of Information (FOI) request sent to all acute hospital trusts in England (of which 116 responded) that:[4] 89 trusts confirmed they monitored and logged instances when patients could be harmed as a result of problems with their EPR systems. almost half recorded instances of potential patient harm linked to their systems. nearly 60 trusts reported IT problems that could affect patient care. more than 200,000 letters were not sent across 21 trusts. there were 126 instances of serious harm linked to IT issues, across 31 trusts. and three deaths across two trusts related to EPR problems. Commenting the findings of this FOI request, our Chief Digital Officer Clive Flashman said: “Poor implementations of EPR systems can lead to direct and indirect harm to patients. Often this is not associated with the IT system and goes unreported, so we have no data to show the true scale of the issue. We need more transparency in reporting and sharing knowledge so we can avoid patient safety problems and harm. This is a priority issue that must be addressed by those leading EPR implementations.” At Patient Safety Learning we believe that patient safety needs to be a core purpose of health and social care. Patient safety considerations need to be embedded through each stage of the process when organisations introduce EPRs: Development – patient safety must be at the heart of the initial creation and development of EPR systems. Consideration should be given to interoperability (the ability to work with other computer systems or software used by the organisation to exchange and make use of information). Rollout – it is vital as EPRs are introduced into organisations that the appropriate training is provided to staff. There also needs to be sufficient usability testing (testing how easy these systems are to use with a group of staff who will ordinarily be using them). Implementation – once an EPR is in place, monitoring how these are operating in practice and learning and acting on any incidents or near misses that take place relating to this. Reflecting on this, our Chief Executive Helen Hughes said: “We must invest in proper implementation so that the benefits of EPRs and health technology are realised and do not lead to avoidable and unintentional harm. Actively involving healthcare professionals is essential to ensure we are designing for safety in often very complex workflow processes, so we better understand and respond to risks and manage the mitigations.” References Department of Health and Social Care. A plan for digital health and social care; 29 June 2022. NHS Digital, 90% of NHS trusts now have electronic patient records; 16 November 2023. Clive Flashman, NHS England warns electronic patient records could pose ‘serious risks to patient safety’: what can we learn?, 10 January 2024. BBC News, NHS computer issues linked to patient harm, 30 May 2024.

The first ever World Health Organization (WHO) Global Report on Patient Safety will provide a comprehensive overview of patient safety measures globally, aligned with the Global Patient Safety Action Plan 2021–2030. It will include detailed analyses and summaries that highlight the burden of unsafe care and the strategies different countries are using to improve safety in health care. This WHO webinar will mark the launch of this report. Register here. agenda_global-patient-safety-report-2024-launch-webinar.pdf flyer_launch-event-global-patient-safety-report-2024.pdf