Mark Hughes
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Everything posted by Mark Hughes
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Content ArticleGlobally, there is increasing evidence that incorrect penicillin allergy labels negatively affect patient outcomes, antibiotic prescribing and antimicrobial resistance, leading to growing concern about this patient safety issue and how to resolve it. While many millions of patients worldwide have incorrect penicillin allergy labels, there are too few specialist allergists and a lack of ‘point-of-care’ tests to address this problem. Numerous research studies now provide evidence of the feasibility and importance of widening access to penicillin allergy assessment. This article draws on a discussion between researchers from two UK-based studies (SPACE and ALABAMA), in collaboration with key stakeholders including patient representatives, on shaping a high-level implementation plan to facilitate widening access to penicillin allergy assessment in the UK. It describes the basis of the implementation plan and summarises the key actions required for successful delivery.
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Content ArticleDelays in discharging patients from hospital affect people’s physical and mental health, and make it harder to admit others to hospital. This joint report by the Auditor General for Scotland and the Accounts Commission warns this has a significant effect, despite impacting only around three per cent of hospital patients. In Scotland, people medically ready to leave spent 720,000 unnecessary days in hospital in 2024/25. Whilst the full financial impact is unknown, the cost to the NHS in hospital days alone is an estimated £440 million a year.
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Content ArticleHealthwatch is your health and social care champion. If you use GPs and hospitals, dentists, pharmacies, care homes or other support services, they want to hear about your experiences. You can share your views with them via this online form.
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Content Article
On the 8th January 2026, the Health Services Safety Investigations Body (HSSIB) published a new report looking at patient safety risks associated with the use of temporary care environments, more commonly referred to as corridor care. In this article, Patient Safety Learning sets out its reflections on the report’s findings. -
Content ArticleThis report is intended for healthcare organisations, policymakers and the public to help reduce patient safety risks in relation to temporary care environments. It summarises the analysis and findings of the Health Services Safety Investigations Body's (HSSIB’s) investigation, and provides a safety observation and learning prompts for organisations to consider when managing temporary care environments. You can read Patient Safety Learning's response to this report here.
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This webinar, hosted by the Royal College of Surgeons of Edinburgh, will provide a fascinating look inside how NASA manages risk, ensures that its culture supports safe human spaceflight and provides extraordinary leadership to explore the unknown. Aims To explore NASA’s approach to risk management and safety culture, demonstrating how effective leadership fosters an environment where every team member’s expertise is recognised, encouraged, and leveraged to enhance safe and reliable performance Learning Objectives By the end of this webinar, attendees should be able to: Understand the universality of risk: To recognise that risk is an inherent feature of all complex systems and tasks including across aerospace, healthcare, and other high-stakes environments. Examine the role of leadership in shaping safety culture: To understand how expert leadership develops, nurtures and sustains a robust safety culture that supports effective risk management. Apply cross-industry lessons to healthcare practice: To identify practical insights from NASA’s approach to safety and teamwork and to consider how leaders in health and care can empower teams, enhance organisational learning and reduce the risk of harm. Register here. -
Content ArticleDespite clear national guidance, patients who have complications where a difficult airway can be anticipated, continue to experience avoidable harm. This article explores the implementation gaps that contribute to this risk and highlights how systems thinking can illuminate the barriers, using post-thyroidectomy haematoma as an illustrative case. In this case, the patient experienced a “near miss”, despite a quality improvement project related to management of this airway emergency being successfully introduced. The near miss provides an opportunity for learning. Using systems tools to analyse the case, the authors demonstrate how deeper diagnostic work can reveal complexity, latent system vulnerabilities and opportunities for more effective, sustainable interventions. Moreover, by applying a systems lens, the authors seek to show that organisations can better design, measure and monitor such patient safety initiatives to build genuine resilience.
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Content ArticleCommissioned by NHS England Specialised Commissioning team in July 2024, this operational review of NHS adult gender dysphoria clinics (GDCs) in England was led by Dr David Levy, with the support of a panel of clinicians and other key stakeholders. The aim was to determine whether the operation and delivery of the GDCs meet the requirements of the non-surgical interventions service specification and consider the safety and effectiveness of the GDC service.
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Content ArticleThe Medicines and Healthcare products Regulatory Agency (MHRA) regulates medicines, medical devices and blood components for transfusion in the UK. This roundup provides a summary of their latest safety advice for medicines and medical device users. It includes details of medicine recalls, medical device field safety notices and details of how to report drug reactions and device incidents.
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Content ArticleFormal investigations are central to how NHS employers often address workplace conflicts and allegations of misconduct. However, there has been almost no scrutiny of why (and when) they are authorised, how they are conducted, and the impact they have on staff well-being, staff behaviours, workplace culture and patient care. The existing literature on workplace investigations shows that they may have significant implications for staff directly involved and, potentially, for the wider organisation’s culture and patient care. Moreover, such investigations are regarded as crucial evidence should an individual pursue an Employment Tribunal claim. Though there is research on what might constitute the standards for an effective and fair investigation, there is no statutory regulation of workplace investigations (or investigators), nor are there accepted standards that employers are expected to ensure investigators follow in the NHS. This research has sought to understand the impact of NHS workplace investigations through the eyes of those subject to them. In doing so, we have sought to understand the “lifecycle of an investigation” and the key roles of influence, most notably those of investigators, both internal and externally commissioned.
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Content ArticleOn 14 October 2024, Dr Rebecca Martin, Medical Director for The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, wrote to the Chair of the Invited Review Mechanism (IRM) to request an invited service review of the Trust’s General Surgery surgical service. This report presents the findings of this review, conducted by the Royal College of Surgeons of England. They reviewed 17 cases – 8 original operations and 9 complication or return-to-theatre cases. 8 were judged to have involved care below the expected standard. The report also raises concerns about a toxic culture within the surgical team at the Trust.
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Content ArticleThis report, produced by NHS Resolution in collaboration with the Royal College of Obstetricians and Gynaecologists, analyses Obstetric Anal Sphincter Injuries (OASI) claims made by claimants between 2011/12 and 2021/22. It highlights common themes in OASI claims and provides guidance to help healthcare professionals prevent OASI where possible. It also identifies key areas of care that can be improved, ensuring better support for women affected by OASI.
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The Medicines and Healthcare products Regulatory Agency (MHRA) is seeking evidence on the regulation of artificial intelligence (AI) in healthcare to inform the recommendations of the National Commission into the Regulation of AI in Healthcare. This call for evidence closes at 11:59pm on 2 February 2026. -
Content ArticleFrom the 4 September to 16 October 2023 the Department of Health and Social Care held a public consultation seeking views on the possible introduction of regulations mandating the disclosure of industry payments to the healthcare sector. This report sets our the UK Government's formal response to the findings of this consultation.
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Content ArticleIn this blog Fredrik Matre considers the connection between patient safety and productivity, challenging the assumption that safety measures block productivity improvements. He makes the case for putting safety at the core of productivity planning. This blog has been published ahead of the Patient Safety Forum 2026, an event jointly hosted by Public Policy Projects and Patient Safety Learning, which features a panel session on “Aligning patient safety with productivity”.
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Content ArticleThe National Audit of Eating Disorders (NAED) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and funded by NHS England as part of the National Clinical Audit and Patient Outcomes Programme. In 2025 the NAED team conducted a comprehensive mapping of eating disorder service provision across England. This report provides an in-depth overview of NHS-funded and independent sector services for children, young people, and adults.
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Content ArticleIn this short discussion Professor Henrietta Hughes, Patient Safety Commissioner for England, speaks to ABHI Patient Safety Group Chair Greg Quinn and Vice Chair Steffanie Russell, following the publication of ABHI’s new report, Patient Safety System Foundations: A Call for Action. The conversation explores the role of system foundations in strengthening patient safety across healthcare.
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Content ArticleThis update presents statistics from the Learn from Patient Safety Events (LFPSE) service, a national NHS system for the recording and analysis of patient safety events that occur in healthcare. The LFPSE definition of a patient safety incident is something unexpected or unintended has happened, or failed to happen, that could have or did lead to patient harm for one or more person(s) receiving healthcare. This report shares the patient safety incident data from July to September 2025.
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Content ArticleIn this short discussion, Greg Quinn, Chair of ABHI’s Patient Safety Group, and Helen Hughes, Chief Executive of Patient Safety Learning, introduce ABHI Patient Safety System Foundations: A Call for Action. Together, they discuss the report’s key themes, the persistence of avoidable harm, the need for system learning and shared accountability, and the vital role of HealthTech as a trusted partner in improving safety for patients and healthcare workers.
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Content ArticleThe term ‘corridor care’ is inclusive of any non-designated clinical space. NHS England considers the delivery of corridor care in departments or wards experiencing patient crowding to be unacceptable and should never be considered standard. Patients should only be placed in corridors in extremis and for the shortest possible duration, to ensure the time patients are cared for in this environment is kept to a minimum. These principles have been developed to support point-of-care staff in delivering the safest and highest quality care possible when corridor care has been deemed unavoidable.
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Content ArticleThe Faculty of Intensive Care Medicine have developed this guidance in response to recurrent safety incidents concerning the connection and reconnection of both invasive and non-invasive breathing circuits. This was created to act as a resource to help in the design of local guidance and visual aids and is intended to be easily adaptable for use by individual units. It was subsequently recommended for this purpose in NHS England's National patient safety alert – risk associated with adult breathing circuits lacking a patent exhalation route, published on the 11 December 2025.
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Content ArticleThis national patient safety alert has been issued by the NHS England National Patient Safety team, in collaboration with the Faculty of Intensive Care Medicine. The alert is directed at organisations caring for patients on invasive and non-invasive breathing circuits who are required to develop local guidance and visual aids for circuit assembly, implement training on specific safety checks, and establish clear communication processes. All actions should be completed by 12 June 2026.
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Content ArticleIn this blog Professor Henrietta Hughes, Patient Safety Commissioner for England, considers the publication of the new report ABHI Patient Safety System Foundations: A Call for Action, which sets out a blueprint for how industry can contribute to this transformation. She reflects on this report and the importance of recognising that patient safety is not simply a clinical issue, but is a system issue.
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ABHI Patient Safety System Foundations: A Call for Action is a comprehensive report outlining how the HealthTech industry can work with partners across the system to reduce avoidable harm and strengthen safety for patients and healthcare workers. Developed with Patient Safety Learning, the report highlights the persistence of avoidable harm, the pressures facing the health system, and the far-reaching opportunities created by the NHS 10 Year Health Plan. It sets out ambitions for patients, healthcare providers, Integrated Care Boards, system leaders, regulators and industry. -
Content ArticleThe Maternity and Newborn Safety Investigations (MNSI) programme has published its 2025–27 strategy, building on its approach to improving maternity and newborn safety. The strategy focuses on supporting NHS trusts to spot risks sooner and act quickly to prevent harm, especially for communities that experience the worst outcomes.
