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In this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on the charity’s work and key patient safety developments in the past 12 months. She also looks ahead to the new year, considering the UK Government’s forthcoming 10-Year Health Plan and new Patient Safety Learning projects in 2025.  At Patient Safety Learning we seek to harness the knowledge, enthusiasm and commitment of healthcare organisations, professionals and patients for system-wide change and the reduction of avoidable harm. Avoidable harm and patient deaths because of unsafe care remains a global problem. The World Health Organization (WHO) estimates that 1 in every 10 patients is harmed while receiving hospital care, and 50% of that harm is preventable. In 2019, NHS England stated in its NHS Patient Safety Strategy that there were around 11,000 avoidable deaths annually in the UK due to safety concerns. However, in practice, this figure is now likely to be a significant underestimate, given the ongoing enormous strain faced by the healthcare system. Now more than ever we need to continue to make the case that persistence of avoidable harm at current levels is not acceptable. We need to transform our approach in healthcare so that patient safety is not just seen as another priority but as a core purpose of health and care. the hub and its networks Five years on since we launched the hub, our platform to share learning for patient safety, we have seen it continue to grow in members, content and impact. This year, the hub has surpassed 1 million site visits since October 2019 and now has nearly 7,000 members. In the past few weeks, in two new blogs, we have been highlighting the work we have done this year and the most popular pieces of content featured on the hub: Patient safety and the power of collaboration the hub's top patient safety picks of 2024, the hub is also home to a growing number of networks for people involved in patient safety. These communities of interest are informed by subject matter experts, providing forums to share knowledge and good practice. They include patient safety specialists, patient safety partners and organisational leaders with patient safety expertise. They provide a rich and valuable insight from what we term the ‘patient safety frontline’. They highlight the ‘work as done’ reality of healthcare, the challenges in delivering safe and effective care, and examples of collaboration and good practice for wider sharing and implementation. In September, together with the Patient Safety Management Network and the Patient Safety Education Network, we held our first Patient Safety Symposium. This was a practical workshop-based event for patient safety professionals, focused on the application of Patient Safety Incident Response Framework (PSRIF) tools and methods. This was very positively received and we are exploring how we can deliver more practical PSIRF-focused events in the new year. If you are interested in joining one of the networks or would like to set up your own network on the hub, please do get in touch at [email protected]. Global perspective There have been a number of new international patient safety developments of note in the past 12 months. In April, the Sixth Global Ministerial Summit on Patient Safety took place in Santiago, Chile. I was delighted to be able to attend this event, which focused on how countries are implementing their patient safety strategies within the framework of the WHO Global Patient Safety Action Plan. A key theme at this event concerned the 'implementation gap'—the difference between what we know and recommend to improve patient safety and what is done in practice. This mirrored issues we had been highlighting in the UK the previous month with the Health and Social Care Select Committee on progress in meeting patient safety recommendations. There have also been several new international patient safety publications this year: The Patient safety rights charter—this outlines patients’ rights in the context of safety and promotes the upholding of these rights. The Global patient safety report 2024— setting out the WHO’s assessment of the current state of patient safety across the world. The economics of diagnostic safety—a new Organisation for Economic Co-operation and Development (OECD) report assessing key drivers and barriers of diagnostic safety. Taking the pulse of quality of care and patient safety in the WHO European Region—a cross-sectional analysis of patient safety across 53 countries. On Tuesday 17 September the sixth annual World Patient Safety Day took place. In support of this year’s theme, ‘Improving diagnosis for patient safety’, we shared a series of blogs on the hub related to this. These contributions came from many different perspectives, including patients, researchers, healthcare professionals and charities. To close out the year, this month I attended the annual Institute of Healthcare Improvement (IHI) Forum in the United States. This reinforced to me that we truly are a global family for patient safety, despite the many different healthcare systems, resourcing levels, policy and government contexts. Many of the challenges and issues raised by participants at this event were similar to what we encounter in the UK: Pressures on the capacity of health systems to deliver safe, effective and timely care. Leaders not treating patient safety as a core purpose of health and care. Hostile cultures where exhausted and fearful staff are not supported to speak up. A lack of engagement with patients and families. A common theme is that we are still not transforming healthcare for patient safety at anywhere near the pace or impact that we need to. However, I also heard great examples of health systems changing cultures and driving improvement with safety huddles, empowering staff and actively supported by organisational leaders. The Patients for Patient Safety US Project Pivot is very exciting—a huge collaboration to identify what patient experiences and outcomes need to be reported to the US government for patient safety. Also, the Centers for Medicare and Medicaid Services mandatory reporting of all hospitals against patient safety domain statements, which reinfores a safety management systems approach, something that we support and are promoting through our work. At this event, we also followed up discussions from the Global Ministerial Summit earlier in the year about an exciting new initiative by several international and national patient safety agencies. We will have more details to share on this in 2025. Patient safety standards Since Patient Safety Learning was founded in 2018, we have been engaging with organisations looking to improve patient safety. A consistent theme has been the need for Trusts, Integrated Care Boards (ICBs), Independent Care Providers and individual hospitals to have access to expert advice to help them become true learning entities within a reliable Safety Management System (SMS). This year we have continued to support organisations in this area through our patient safety standards framework. Our patient safety standards are a world first—a set of unique standards with detailed evidence-based outputs, outcomes, behaviours and actions necessary for successful delivery. They have been developed from 20 years of research with inputs from NHS England’s Patient Safety Strategy, as well as learning from inquiries, policy and good practice within UK and international healthcare, including the WHO Global Patient Safety Action Plan. This year, and moving into 2025, will we continue to work with healthcare providers and use the ‘What Good Looks Like’ standards framework to help organisations assess their patient safety performance and help them develop organisation patient safety improvement strategies and action plans. If you work for an healthcare organisation and would like to know more about this, please contact us at [email protected]. Policy and influencing As well as sharing topical policy blogs and responding to public consultations on patient safety issues, we have published two new policy reports this year. In March, we looked in detail at responses to the NHS Staff Survey 2023 in We are not getting safer: Patient safety and the NHS staff survey results. The report looks specifically at survey responses on reporting, speaking up and acting on staff patient safety concerns. In this report, we make the case that the latest results indicate that blame cultures and a fear of speaking up continue to persist in a significant part of the NHS. Coupled with findings of patient safety inquiries and whistleblower testimonies, we argue that there needs to be a more transformative effort and commitment to creating a safety culture in the NHS In June, we held a virtual roundtable session with a select group of experts to discuss patient safety risks and avoidable harm associated with electronic patient record (EPR) systems. Drawing on the findings of this event, we published a new report in July, Electronic patient record systems: Putting patient safety at the heart of implementation. This outlines the key patient safety risks associated with choosing and introducing new EPR systems and identifies 10 principles to consider for safer implementation. Subsequently, we received a positive response to this report from Baroness Gillian Merron, Parliamentary Under Secretary of State for Patient Safety, Women’s Health and Mental Health. She acknowledged these concerns raised and highlighted plans by the Government to review clinical risk standards (standards DCB0129 and DCB0160) for the use of digital health technologies in 2024/25. This review was announced last week and is something that we will be contributing to in the new year. Looking ahead to 2025 The next year could prove to be a major crossroads for patient safety in the UK. Early in the year we anticipate the publication of the first part of an independent review of patient safety across the health and care landscape in England. We contributed to this review last month and eagerly await its outcome. This is expected to be followed in the Spring by the Government’s 10-Year Health Plan for health and care. We believe that patient safety must be at the core of this. With the forthcoming publication of the 10-Year Health Plan, in my view it is imperative that NHS England updates the NHS Patient Safety Strategy later next year. Much has changed since its initial publication, ranging from the impact of the Covid-19 pandemic to the introduction of Integrated Care Systems and a change of Government this year. If patient safety is to be taken seriously in the next 10 years, at a bare minimum the Strategy requires a major update and evaluation of progress to date. But it must not be a ‘silo’ strategy; patient safety must be integral to the new 10-Year Plan. We are also looking forward to a number of new projects in the new year, supported by the recent appointment of our new Director and Associate Director. This includes: A Patient Safety Forum, in partnership with Public Policy Projects, at the Royal College of Physicians in February. Speaking up for safety: A new interview series about raising concerns and whistleblowing. Welcoming the Patient Safety Commissioner for England to a meeting of the Patient Safety Partners Network in February. Working with the Association of British HealthTech Industries to develop a new patient safety white paper. Patient safety needs to be central to the healthcare sector in the new year. At Patient Safety Learning we will continue to listen, learn and promote the voice of the ‘patient safety frontline’, both healthcare professionals and patients. We welcome your engagement and collaboration. Please do contact us to find out more and shape our work to improve patient safety.

This course will: Introduce the NHS PSIRF and associated documents (PSIRP, PSII standards), and discuss how they apply in your context. Identify how to effectively oversee and support processes related to incident response. Discuss a just culture approach; maintaining openness, transparency and improvement focus. Consider the restorative aspect of just culture; how to ensure that further harm is prevented to those already harmed. Discuss the importance of communication and involvement of those affected – patients, families and staff. Establish the complexities of PSII commissioning and planning in your organisation. Explore managing complex investigations spanning different organisational, care setting, and stakeholder boundaries. Register

This course will: Introduce Human Factors For Healthcare; what is it and why does it matter? Ask we mean by ‘Systems Thinking’? Looking beyond the flawed concept of Human Error, utilising the SEIPS tool. Establish difference between simple, complicated and complex work, and how this might impact our approach to safety and performance. Look at different models of safety & risk across the spectrum of working practice; balancing the focus of rule based and adaptive working. Explore the impact of stress and cognitive load on decision making and how we can perform at our best under pressure. Discuss the key components of High Performing Teams, in particular the impact of Psychological Safety and how it can be developed. Provide a practical and tangible tool for addressing our physiological needs. Register

This course will: Introduce principles of restorative practice. Allow you to reflect upon the needs of patients, families and carers following an incident, and how an investigation can meet some of those needs. Review the Duty of Candour (regulations and practical application). Help you to signpost support for those suffering trauma, loss or stress. Address sharing findings effectively to facilitate wider learning. Discuss challenges/complexities associated with cases where there is more than on einvestigation. Register

This course will: Develop an understanding of PSIRF and systems based learning. Explore how Safety II can be integrated into an Incident Investigation. Facilitate understanding in how to effectively apply a response planning process. Demonstrate a diverse range of tools to investigate incidents, such as SIEPS. Discuss a range of tools for capturing every day work. Demonstrate a range of tools for synthesising information gathered, such as timeline mapping and work system scans. Provide an opportunity to discuss how to respond proportionately to patient safety incidents. Explain how to write an effective investigation report. Explore how to apply principles of safety science to understand causation. Look at conducting interviews; including recognising signs of shock and post-traumatic stress. Register

Join a conversation with industry experts on cyber risk, response and claims. With increasing and high profile cyber-attacks on both health and care organisations we discuss the issues that organisations face, what can be done prevent and minimise attacks, what to do if your organisation falls victim to an attack and the steps that should be taken to minimise the impact on your organisation which can far ranging in terms of patient safety, work force, and finance. Your panel of expert speakers: Richard Hearn - Divisional Director, Howden Dave Allen - CEO, Cysiam Vicki Bowles - Partner, Bevan Brittan Julie Charlton - Partner, Bevan Brittan Register

THIS Space is THIS Institute’s annual conference. We welcome anyone with an interest in the evidence for improving the quality and safety of healthcare. THIS Space aims to: share learning on what works in healthcare improvement, what doesn’t, and why stimulate innovation and fresh thinking on how we can improve care explore imaginative ways of understanding problems and evaluating solutions connect people who share a common goal of improving healthcare. Programme and register