Patient_Safety_Learning

Sepsis is a life-threatening condition that occurs when the body’s response to an infection causes damage to its own tissues and organs. Early recognition and treatment are vital to save lives. This series of short videos (each under two minutes), produced by Patient Safety Learning in collaboration with The UK Sepsis Trust, aims to raise awareness of the key signs and symptoms of sepsis. Featuring Dr Ron Daniels, Founder and Chief Medical Officer of The UK Sepsis Trust and Topic Leader for the hub, these videos outline what to look out for across different age groups. Videos include: Spotting the signs of sepsis in adults and young people (1 minute) Spotting the signs of sepsis in school-aged children (90 seconds) Spotting the signs of sepsis in children under five years old (2 minutes) Related content Please also see our other video in this series: Sepsis risks in rural communities

Sepsis is a life-threatening condition that occurs when the body’s response to an infection causes damage to its own tissues and organs. Early recognition and treatment are vital to save lives. This 5 minute video, produced by Patient Safety Learning in collaboration with The UK Sepsis Trust, explains the sepsis risks that need to be considered in rural communities. Featuring Dr Ron Daniels, Founder and Chief Medical Officer of The UK Sepsis Trust and Topic Leader for the hub, we look at: The factors that affect rural communities. How these can impact sepsis outcomes. What healthcare professionals can do to support good outcomes. What support there is for healthcare professionals. This is part of our wider sepsis awareness series which includes a series of short videos on spotting the signs of sepsis in adults and children. Related content:

Pressure ulcers, or bed sores as they are often called, can affect people of all ages. They can lead to serious complications and immense pain for patients, so prevention and awareness is key. Patients with mobility difficulties, conditions affecting blood flow (such as Type 2 Diabetes), and those over 70 are particularly vulnerable.  Stop Pressure Ulcer Day is organised annually by the European Pressure Ulcer Advisory Panel and aims to bring knowledge to a wider audience to reduce the harm caused by pressure ulcers.  In support of the campaign, we're shining a spotlight on a selection of fantastic resources that have been shared with us via our patient safety platform - the hub.  Click on the headings below to read more about each resource. 1. Conducting a systems review of pressure ulcers in the intensive care unit Pressure ulcers within the intensive care unit have long been recognised as a persistent and complex patient safety issue. In this blog, Patient Safety Learning's Associate Director Claire Cox shares how she adopted a systems approach using the Systems Engineering Initiative for Patient Safety (SEIPS) model to review pressure ulcers. 2. Implementing the aSSKINg pressure ulcer care bundle – a blog by Susan Martin In this blog, Susan Martin, a Tissue Viability Specialist Nurse at East Sussex, describes how she implemented the aSSKINg model (assess risk; skin assessment and skin care; surface; keep moving; incontinence and moisture; nutrition and hydration; and giving information or getting help) for pressure ulcer prevention into her Trust. 3. Skin Assessment: Assessing skin on patients with darker skin tones in relation to PU prevention In this 56 minute presentation by The Society of Tissue Viability, Jacqui Fletcher looks at how wound care and pressure ulcer prevention can be improved for patients with darker skin tones. 4. PURPOSE-T (Pressure Ulcer Risk Primary or Secondary Evaluation Tool) PURPOSE-T (Pressure Ulcer Risk Primary or Secondary Evaluation Tool) is an evidence-based pressure ulcer risk assessment instrument that was developed by the University of Leeds using robust research methods. PURPOSE-T identifies adults at risk of developing a pressure ulcer and supports nurse decision‐making to reduce that risk (primary prevention), but also identifies those with existing and previous pressure ulcers requiring secondary prevention and treatment. It uses colour to indicate the most important risk factors and forms a three‐step assessment process. 5. PSIRF planning – Pressure ulcer example scenario The Patient safety incident response framework (PSIRF) represents a new approach to responding to incidents. Under PSIRF, those leading the patient safety agenda within provider organisations, together with internal and external stakeholders (including patient safety partners, commissioners, NHS England, regulators, Local Healthwatch, coroners etc), decide how to respond to patient safety incidents based on the need to generate insight to inform safety improvement where it matters most. Key issues must first be identified and described as part of planning activities before an organisation agrees how it intends to respond to maximise learning and improvement. This guidance has been developed collaboratively between Stop the Pressure Programme, National Wound Care Strategy leads and members of the Patient Safety Team, with the support from the Patient Safety Incident Response Framework (PSIRF) Implementation and Working Groups. 6. Embedding skin tone diversity into undergraduate nurse education: Through the lens of pressure injury This study, published by the Journal of Clinical Nursing, explores health disparity in on-campus undergraduate nurse education through the analysis of teaching and teaching material exploring pressure injuries. 7. Measuring standards of care, not negative outcomes (Interview with Head of Nursing Quality) In this interview, Head of Nursing Quality Gavin Porter talks about his positive, team-focused approach to improving pressure ulcer outcomes. "Counting the number of pressure ulcers doesn’t really tell you about the standards of pressure ulcer care. I wanted to look at things differently; to focus more on the interventions and good practice that helps keep patients safe." 8. Sign up to safety - pressure ulcers (Barts Health NHS Trust) In this six minute video, Barts Health NHS Trust explains the measures frontline medical staff can take to help avoid the risk of pressure ulcers using the SSKIN acronym. 9. This Is Nursing podcast: We don't want a good wound. We want to prevent them! Alison Schofield, Tissue Viability Clinical Nurse Specialist, discusses the challenges facing her role in this current world of nursing, the impact of COVID-19 has had on the delivery of community tissue viability services and on people in receipt of the services in care homes and in their own homes. 10. Incidence of hospital-acquired pressure injuries and predictors of severity in a paediatric hospital Hospital-acquired pressure injuries (HAPIs) pose significant challenges in healthcare and cause increased patient suffering, longer hospital stays and higher healthcare costs. Children in hospital face unique risks, but evidence about this remains scarce. This study in the Journal of Advanced Nursing aimed to identify and describe HAPI admission incidence and severity predictors in a large Australian children's hospital. The authors found that HAPI injuries in paediatric patients are unacceptably high. They argue that prevention should be prioritised and the quality of care improved globally. They also call for further research to develop targeted prevention strategies for these vulnerable populations. 11. Reducing hospital-acquired pressure injuries in a cardiothoracic intensive care unit Hospital-acquired pressure injuries are a significant patient safety concern. The US Centers for Medicare & Medicaid Services tracks hospital-acquired pressure injuries as a patient safety indicator. Healthcare organisations with higher-than-expected rates may incur penalties. The aim of this study was to reduce the prevalence and incidence of hospital-acquired pressure injuries in the cardiothoracic intensive care unit. 12. Safeguarding adults protocol: pressure ulcers and raising a safeguarding concern Pressure ulcers are a significant challenge for the patients who develop them and the healthcare professionals involved in their prevention and management. They can result in serious complications and avoidable harm, with patients with mobility difficulties at particularly risk from this. This guidance from the Department of Health and Social Care is designed to help practitioners and managers across health and care organisations to provide caring and quick responses to people at risk of developing pressure ulcers. For more resources, see our dedicated Pressure ulcer section of the hub. Do you have a resource or story to share on pressure ulcer care or prevention? the hub is designed for frontline staff, patients, managers, and anyone else else with an interest in patient safety, to come together and share their insights. You can sign up today for free for full access to our library of resources and all of the benefits on offer to our members.

At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That’s why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples. We have collated 14 resources relating to men's health, including information about male cancers, men's mental health, how to engage men earlier and insights around the impact of traditional ideas of masculinity on patient safety. *Trigger warning: some of the content below focuses on suicide. 1 Men’s Health: How to improve health outcomes, knowledge, and behaviours This 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. 2 Men’s health: The lives of men in our communities Men in England are facing “a silent health crisis”, dying nearly four years earlier than women, while suffering disproportionately higher rates of cancers, heart disease and type 2 diabetes, according to a report by the Local Government Association. They are urging the Government to implement a men's health strategy similar to the women's health strategy of 2022. It wants men’s health to be recognised as “a national concern”. 3 Overcoming the barriers to engaging with prostate cancer Orchid is the UK’s leading charity for those affected by male cancer. In this interview, we speak to Ali Orhan, Chief Executive and Director of their Overcoming the Barriers to Engaging with Prostate Cancer project. Ali tells us how they are working alongside a network of volunteer community champions to improve awareness, support better outcomes and reduce health inequalities. 4 Prostate Cancer UK: risk checker Prostate cancer is the most common cancer in men, but most men with early prostate cancer don’t have symptoms. Use this risk checker to find out what you should do. 5 Samaritans Handbook: Engaging men earlier: a guide to service design This handbook from the Samaritans provides a set of principles upon which wellbeing initiatives for men should be based, drawn from what men have said is important to them. By following these principles, wellbeing initiatives are more likely to be effective for, and appeal to, men going through tough times before reaching crisis point. 6 Shifting the dial on mental health support for young black men In this blog, Kadra Abdinasir talks about how mental health services have failed to engage with young black men, and describes how services need to change to overcome the issue. She argues that delivering effective mental health support for young black men requires a move away from a crisis-driven response, to investment in system-driven, community-based projects. Kadra looks at learning from Shifting the Dial, a three-year programme recently piloted in Birmingham as a response to the growing and unmet needs of young black men aged 16 to 25. 7 Infopool prostate cancer patient resource This patient resource created by Prostate Cancer Research aims to equip patients and the public with information about prostate cancer. It contains information on testing and diagnosis, treatment choices, living with side effects, and clinical trials. 8 Men's Health - How can we take action? Here are our top 5 things to know and do Top tips for men on keeping healthy and advice on prostate and testicular cancer. 9 Prostate Cancer UK: Best practice pathway Developed to support healthcare professionals at the front line of prostate cancer diagnosis and care, Prostate Cancer UK's Best Practice Pathway uses easy to follow flowcharts to guide healthcare professionals deliver best practice diagnosis, treatment and support. 10 HSSIB report: Management of acute onset testicular pain This investigation reviewed the diagnostic and treatment pathway for testicular torsion. There was a predominant focus on delays and the human factors associated with the pathway. The investigation identified system-wide recommendations designed to prevent delays to the identification and treatment of testicular torsion happening in the future. 11 Prostate cancer: getting information and support This leaflet helps signpost people to support and information about prostate cancer, both nationally and regionally. 12 Why harmful gender stereotypes surrounding men’s approaches towards their feelings need challenging This blog explores men's mental health – how men are reluctant to seek support when they are struggling, why the suicide rate is so high, what initiatives exist to encourage men to seek help and what more could be done. 13 King's Fund blog: Inequalities in men’s health: why are they not being addressed? Almost half of England’s population is male, yet inequalities in men’s health seldom get specific attention. The women’s health strategy for England shone a light on the health care needs of girls and women through their life course, highlighting areas specific to their health – such as maternity and the menopause – and inequalities in health outcomes. But the wide, and widening, health inequalities experienced by men also require focus. 14 The incredibly obvious thing you should do about painful testicles Watch this short film about what to do if you experience pain in your testicle/s, by Cardiff Fertility Studies and the British Fertility Society, made in partnership with Orchid. Share your insights and experiences Have you, or a loved one, experienced any of the issues raised in this blog? Would you like to share your insights to help improve outcomes in men's health? Perhaps you work in men's health and can share some of the barriers to safe care and what you believe needs to change to improve outcomes. You can share your thoughts in the comments below (sign up first for free) or email our team at [email protected].

The Patient Safety Partners Network (PSPN) includes Patient Safety Partners, in both paid and voluntary roles within NHS organisations, whose role is to improve patient safety. Patient Safety Learning provides a monthly drop-in session for the PSPN, sometimes with guests, to talk through topical and relevant issues. This facilitates information sharing, peer support and safe space for discussion.  The network met in October to discuss the topic of staff fatigue and its impact on patient safety, with an excellent presentation by Dr Laura Pickup.  In this blog Sue Strudwick, the Patient Safety Partner who chaired that meeting, reflects on the session and some of the key points raised by Laura and the members.  Dangerously normalised Fatigue in the NHS is a long-standing issue, one of the most persistent and often under-recognised. Many systems and rotas are built on the assumption that people will work long shifts, skip breaks, and pick up extra hours to make ends meet or fit around family life. For many staff, long shifts offer flexibility, but the cost can be impaired judgement leading to poorer care. Fatigue has become normalised, with staff continuing to work when exhausted, whereas in aviation and transport, strategies are in place to try to prevent fatigue impacting on safety. There’s also a collective fatigue across the NHS — exhaustion from years of uncertainty and constant change. Culturally, rest is often frowned upon. Few proper rest spaces exist, and napping or having a ‘proper’ break is often felt to be unacceptable. Staff may even fear that admitting to fatigue will lead to questions about whether they are up to the job. Fatigue is not a human resource issue – it’s a patient safety issue. Adding fatigue to risk registers When exhausted staff are making complex decisions, the consequences and risk to patients can be serious. Fatigue isn’t just about the individual staff member; it’s a systemic problem. Every healthcare organisation should have fatigue on its risk register because of its undeniable impact on patient safety. Part of the problem is that, unlike aviation or transport, healthcare still lacks a clear definition of fatigue. The Health and Safety Executive has one that could be used in the interim, so organisations do not need to wait before taking action. Regulation of fatigue risk management exists in other industries and should be part of regulation within the NHS. The need for strong leadership Addressing fatigue requires strong leadership and high-level backing. This isn’t about reminding individuals to ‘look after themselves’ — it needs a systems approach. Fatigue risk management should be treated like any other safety system, collecting and triangulating data from surveys, incident reports, and occupational health. Rostering and shift scheduling should support rest and recovery. High-risk groups, including mental health trusts, must be included. The General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) both acknowledge fatigue as a risk factor in adverse events, yet systemic solutions are still lagging behind the scale of the problem. Co-designing rostering solutions The NHS would struggle to function if every staff member worked strictly within fatigue limits. But that can’t justify accepting the status quo. Crucially, any solution must be co-designed with staff. Fatigue is a human issue, and change must balance patient safety, wellbeing, and service provision. Co-design helps ensure any policy works in practice — for patients and professionals alike. Healthcare support workers — who often work the longest hours for the lowest pay, especially need support. There also needs to be open thinking about creative solutions: could volunteers help reduce pressure if better supported? Are occupational health and wellbeing services being fully used? Final thoughts Fatigue is often one factor, in many, contributing to avoidable harm. The challenge of addressing the impact on patient safety is huge, but fatigue can be managed, mitigated, and made visible. We can start by formally recognising it as a risk, embedding fatigue management in safety culture, and highlighting it in Patient Safety Incident Investigations. Staff need to be empowered to speak up when they’re too fatigued to work safely. Patient Safety Partners can help shine a light on staff fatigue, its impact on patient safety and call for it to be added to risk registers throughout the NHS. How to join the Patient Safety Partners Network The Patient Safety Partners Network meets monthly in a virtual capacity and now includes nearly 200 Patient Safety Partners. These meetings provide a supportive and safe space for Patient Safety Partners to: discuss barriers and opportunities share successes discuss how they can use their collective voice to make a difference for patient safety. Only Patient Safety Partners working within NHS organisations in England can join, although experts are often invited to present or discuss specific topics. If you are a Patient Safety Partner, you can find out more about the Patient Safety Partner Network, and how to join here. Related reading Why we need to manage fatigue in the NHS – a blog from Nancy Redfern and Emma Plunkett Managing fatigue as part of a safety culture – a blog from Nancy Redfern, Emma Plunkett and Roopa McCrossan HSSIB Investigation report: The impact of staff fatigue on patient safety (24 April 2025) Fighting Fatigue Together campaign Share your insights Have you seen the impact of fatigue on patient safety? Have you personally been affected as a member of staff or a patient? Share your thoughts by commenting below (sign up here for free first) or you can contact our editorial team at [email protected].

In this blog, Associate Director Claire Cox shares a video training resource developed for the Patient Safety Management Network Symposium. Claire explains how they used it to facilitate an interactive workshop, bringing SEIPS (Systems Engineering Initiative for Patient Safety) to life.  It's now available as a resource for you to use in your own organisation. It is simple to set up, highly engaging, and encourages teams to think beyond individuals and see the wider system in action. One of the highlights of our Patient Safety Management Network (PSMN) symposium, held in September 2024, was the opportunity to bring theory to life through video. Rather than simply talking about systems thinking, we invited participants to see it in action, and to experience how a structured approach such as SEIPS (Systems Engineering Initiative for Patient Safety) can help us understand and improve the realities of care. How we used the video The video was shared during the symposium as the centrepiece of an interactive workshop. Before watching, participants were given a brief introduction to the SEIPS framework and an outline of its five key elements: Person Task Tools and Technology Organisation Environment With this in mind, the group then watched the video, which depicted a scenario where the flow of work did not entirely match how it might be described in guidelines or procedures. This vividly illustrated the important distinction between Work as Imagined and Work as Done — a theme that ran throughout the symposium. The workshop exercise Each participant was given a blank SEIPS template. As the video unfolded, they were asked to note down observations: what did they see that related to each element of the system? For example: How were individuals adapting under pressure? What tasks created bottlenecks or risks? Did tools, technology or equipment support or hinder practice? What organisational factors or expectations were visible? How did the environment — layout, noise, interruptions — shape the situation? Crucially, the video did not show an outcome. This was intentional. It meant the group had to consider that the scenario could end in different ways: A positive outcome, where the patient’s blood samples were sent off on time and care proceeded as planned. Or a negative outcome, where delays meant the bloods were not sent off on time, potentially affecting the patient’s treatment. However, the actual outcome does not matter. What matters is that the vulnerabilities in the system — pressures, constraints, workarounds, and risks — were always present. Whether the patient’s bloods were sent successfully or not, those vulnerabilities still shaped the way the work was carried out. This underlines why observing Work as Done is always beneficial: it allows us to see the realities of practice, understand where systems are fragile, and identify opportunities to strengthen them before harm occurs. What we learnt This practical session reinforced some key messages from the symposium: Systems thinking is best learnt by doing. A short video can provide a powerful case study to apply frameworks like SEIPS. Work as Done is different from Work as Imagined. The gap is not about error or blame, but about understanding the realities of practice and why people adapt in the ways they do. Structured tools support richer discussion. The blank SEIPS template acted as both a guide and a prompt, helping participants to organise observations and uncover latent system factors. The outcome is secondary to the system. Whether the bloods were sent or delayed, the vulnerabilities in the work system remained. Recognising those vulnerabilities is where real safety improvement begins. A resource for you This video and SEIPS exercise is now available as a resource for you to use in your own organisation. It is simple to set up, highly engaging, and encourages teams to think beyond individuals and see the wider system in action. We've pulled together a guide to help people run a training session with the video. Training guide and templates Please feel free to use it with your colleagues — and we would love to hear back from you about how you used it and what the experience was like. Sharing across the network is one of the most powerful ways we can continue to learn together and strengthen patient safety.

This training guide was developed to help people facilitate an interactive workshop, bringing SEIPS (Systems Engineering Initiative for Patient Safety) to life. It is simple to set up, highly engaging, and encourages teams to think beyond individuals and see the wider system in action. If you'd like to use the video to run a workshop in your organisation, please see our helpful guide and templates below. Training guide Aim: To experience how a structured approach such as SEIPS (Systems Engineering Initiative for Patient Safety) can help us understand and improve the realities of care. 1. Introduce the SEIPS framework Before watching, participants should be given a brief introduction to the SEIPS framework and an outline of its five key elements: Person Task Tools and Technology Organisation Environment Many people will not be familiar with SEIPS. This video can be a helpful resource to share at this point -SEIPS Just a cup of tea. 2. Introduce the workshop exercise Each participant is given a blank SEIPS template (attached). Blank SEIPS template.docx Explain that shortly they will be asked to watch a video, and, as it unfolds, they should note down observations about each element of the system. For example: How were individuals adapting under pressure? What tasks created bottlenecks or risks? Did tools, technology or equipment support or hinder practice? What organisational factors or expectations were visible? How did the environment — layout, noise, interruptions — shape the situation? 3. Watch the video Next you can watch the video as a group. 4. Feedback discussion The video depicts a scenario where the flow of work did not entirely match how it might be described in guidelines or procedures. This illustrates the important distinction between Work as Imagined and Work as Done. Ask everyone to contribute their thoughts and notes to a discussion. What did they notice? How might the scenario have ended? An example of a completed template is attached. Populated SEIPS template.docx This can be used to help guide facilitation, or shared with participants after they have fed back their thoughts. Impact Crucially, the video does not show an outcome. This is intentional. It means the group has to consider that the scenario could end in different ways. The actual outcome does not matter. What matters is that the vulnerabilities in the system — pressures, constraints, workarounds, and risks — were always present. This underlines why observing Work as Done is always beneficial: it allows us to see the realities of practice, understand where systems are fragile, and identify opportunities to strengthen them before harm occurs. Your feedback We'd love to hear how you have used this resource and if you found it useful. Share your feedback with our team at [email protected].