Patient_Safety_Learning

In December 2022 Dylan Cope, a 9 year old boy, died of sepsis after being discharged from hospital. A coroner found the boy's death “would have been avoided if he had not been erroneously discharged”, and said what happened "amounts to a gross failure of basic care”. In this short film, created by Dylan's parents Corinne and Laurence Cope, we hear more about Dylan and the deterioration they witnessed before he died. Corinne describes how they have been working with Aneurin Bevan University Health Board and UK Sepsis Trust on a sepsis awareness campaign, including the development of new discharge safety netting leaflets. She also talks about how they are now working with other Health Boards in Wales, with the ambition of creating a consistent All-Wales approach to these issues. Corinne and Laurence first presented the film at The Big Conversation for Sepsis 2025, organised by Aneurin Bevan University Health Board. *Trigger warning* Some people might find the content of this film upsetting. 

James Andrews is a pharmacist currently working as a Superintendent for multiple outpatient pharmacies, including specialist cancer care. He is also a Topic leader for the hub.  In this blog, James explains the safety risks that come with handwritten prescriptions and the wider impact this has on patients, staff and the system. He highlights the importance of high-quality patient counselling and digitisation in reducing the risk of medication errors. The scale of the issue Prescribing a medicine is the most common patient intervention in healthcare and is the second biggest cost to the NHS after staffing [1]. It has been estimated that despite more than 104 million outpatient attendances a year[2] only 2% of hospitals have dedicated electronic outpatient prescribing systems[3] and the majority of outpatient prescriptions are still hand-written. In contrast, more than 95% of the 1.1 billion prescriptions issued by GPs each year are electronic[4]. While jokes about doctor’s handwriting are well known, we also know that poor-quality handwritten prescriptions can contribute to medication errors and risk patient safety[5,6]. Medication errors cost the NHS an estimated £98.5 million annually (excluding legal costs) and are linked to more than 1,700 deaths[7]. The patient safety risks of handwritten prescriptions As described by Anne Kinderlerer and Benjamin Ellis in in their blog[8], prescribers may have to make prescribing decisions without access to a patient’s full clinical information. This could result in: a harmful drug being prescribed, particularly in the context of increasing patient and therapeutic complexity an inappropriate dose being selected or the duplication of an existing therapy in the extreme, one drug intended for a patient may be accidentally prescribed for another because of a mix-up of paper prescriptions. Pharmacists responsible for clinically screening each outpatient prescription are spending large amounts of time trying to ensure that prescriptions are legible and legal. They want to make sure that the medicines prescribed are safe and effective in relation to the risks and benefits for the individual patient. Given all of this, and despite their best efforts, pharmacy teams may then also be forced to make clinical decisions without full information, compounding the initial prescribing risk to patients. Wider impact on patients, staff and relationships Patients may be left confused from mixed messages or unclear decisions, particularly at transitions of care. As this situation takes up significant clinical pharmacist resource it slows down the dispensing process, pushing up waiting times for patients. This creates workplace pressure which itself is an independent safety risk [9], and reduces the pharmacy team’s capacity for direct patient care. These secondary impacts are acutely felt by staff, reducing their satisfaction with work and leading to a staff retention risk. The impact is also felt at the primary and secondary care interface, as clinicians try to unpick and navigate prescribing decisions, drug choices and doses during transitions of care. This is complicated further when care crosses multiple integrated care boards (ICBs), each with their own prescribing formulary, creating frustrations and tension between clinicians. How to reduce the safety risk High quality patient counselling Outpatient pharmacy’s current highest-impact intervention is providing high quality patient counselling. It is important that patients know: what their medicines are why they have been prescribed them how to get the best outcomes with the least risks. Crucially, patients should also be able and happy to take their medicines, and here pharmacy teams have a critical role in providing patient counselling and support, as well as being available to answer questions or discuss concerns. This is particularly important for marginalised groups or those with lower health literacy. Outpatient pharmacies as integrated clinical-digital hubs Looking ahead, the NHS 10-Year Plan [10] may provide the foundation for more transformational change. The Plan aims to shift care to the community, prioritise prevention, and digitise access, and as medicines are a ‘golden thread’ throughout most patient pathways, outpatient pharmacy can be a critical enabler of these goals in pursuit of enhanced patient safety. Underpinning this ambition must be the digitisation of outpatient prescribing, which should be linked to the patient’s own record within the NHS App. Transforming outpatient pharmacies as integrated clinical-digital hubs would utilise existing infrastructure to deliver a high return from: maintaining careful management of high-risk and high-cost drugs reducing avoidable medication-related harm improving outcomes from medicines use reducing avoidable prescribing waste. Where needed, patients would be supported by pharmacy-enabled on-boarding to the NHS App, with the option for remote reviews and virtual consultations at the point of dispensing. Released clinical capacity could provide additional independent prescribing at ‘the front door’ (i.e. via A&E) and in high-impact specialties such as cancer, cardio-vascular disease and respiratory. Redeploying pharmacy expertise in this way would help to integrate prescribing decisions across the NHS, and improve patient safety. Share your insights Have you been affected by any of the points raised in this blog, as a patient, carer or member of staff? What changes would you like to see? Comment below to share your thoughts (sign up here first for free), or contact our editorial team at [email protected]. References NHS Digital, Prescribing. Accessed online 15/09/25. NHS Digital. Hospital Outpatient Activity 2023-24. September 2024. Accessed online 15/09/25. Ahmed Z, McLeod MC, Barber N, Jacklin A, Franklin BD. The use and functionality of electronic prescribing systems in English acute NHS trusts: a cross-sectional survey. PLoS One. 2013 Nov 20;8(11). NHS Digital, Electronic Prescription Service. Accessed online 15/09/25. Dave, T. How the standard of prescriptions received in a hospital outpatient pharmacy can be improved. The Pharmaceutical Journal, PJ (2010). Abramson EL, Barrón Y, Quaresimo J, Kaushal R. Electronic prescribing within an electronic health record reduces ambulatory prescribing errors. Jt Comm J Qual Patient Saf. 2011 Oct;37(10). Elliott, R; Camacho, E; Campbell, F. PREVALENCE AND ECONOMIC BURDEN OF MEDICATION ERRORS IN THE NHS IN ENGLAND: Rapid evidence synthesis and economic analysis of the prevalence and burden of medication error in the UK. The University of Sheffield. Report. 2024. Kinderlerer A and Ellis B. Patient safety in outpatients: What are the gaps in measuring and reporting harm? Patient Safety Learning's the hub. July 2025. Accessed online 15/09/25. Joint Royal Pharmaceutical Society of Great Britain and Pharmacy Practice Research Trust Symposium. Workload pressure and the pharmacy workforce: supporting professionals and protecting the public. Accessed online 15/09/25. NHS England. Fit for the Future: 10 Year Health Plan for England. Accessed online 15/09/25.

In support of World Patient Safety Day 2025 and the theme, ‘Safe care for every newborn and child’, we published a series of specially commissioned guest blogs. These contributions have come from many different perspectives, including healthcare professionals, patients, public bodies and academics. Our World Patient Safety Day blog series 1. The safety issues affecting children in intensive care hub topic lead, Peter Sidgwick, consultant in the Paediatric Intensive Care Unit (PICU) and Associate Medical Director at Great Ormond Street Hospital, reflects on working in PICU and highlights some of the risks. He discusses the safety measures in place that mitigate these risks and keep children as safe as possible while they are in PICU. 2. Addressing racial inequalities in paediatric diabetes Dita Aswani and Fulya Mehta are both consultant paediatricians and NHS England national advisors for Children and Young adults’ diabetes. In this blog, they outline racial inequalities that persist in paediatric diabetes and present five key areas for change. In summary they talk about what healthcare professionals can do to reduce inequalities through their own practice. 3. The role of UK ambulance services in supporting safe maternity and newborn care Ambulance services play a pivotal role in ensuring the safety of mothers and their newborns during urgent and emergency situations. In this blog, Ann Moses, Patient safety response lead, and Stephanie Heys, Consultant Midwife, from the Northwest Ambulance Service consider this in more detail. 4. Evidencing the impact of culture on patient safety – a new tool from MNSI In this interview, Chris McQuitty, a clinical fellow at the Maternity and Newborn Safety Investigation (MNSI) programme, talks about a new patient safety tool, COMPASS (Culture of Organisations and its iMpact on PAtientS’ Safety). This is currently being piloted to help understand the impact organisational culture may have on patient safety in maternity settings. 5. Children with eating disorders: a patient safety focus Eating disorders are serious mental health problems that can severely affect the quality of life of children and their families. In this blog, Hope Virgo, an award-winning mental health campaigner, explores the patient safety issues affecting children with eating disorders and their families. Hope highlights how lack of investment and understanding is leading to avoidable harm and shares five key actions for change. 6. We need to make inclusive communication standard practice for children’s safety Communication challenges can make children particularly vulnerable to patient safety incidents. In this blog, Rachael Grimaldi, Co-Founder and Chief Medical Officer of CardMedic, talks about the importance of embracing inclusive communication not just as a ethical imperative, but a practical pathway to safer outcomes. 7. The Green Maternity Challenge: delivering safe, low carbon care Angela Hayes is a Nurse Fellow and Project Lead at The Centre for Sustainable Healthcare. In this article she tells us more about the Green Maternity Challenge and draws on three case studies to highlight it’s success in delivering low carbon, equitable and safe maternity care. The case studies look at local screening for newborn developmental hip dysplasia, supporting breast-feeding and reducing health-inequalities for Albanian-speaking women. 8. Patient safety in humanitarian settings In this article Anna Freeman, a nurse and quality of care advisor for Médecins sans Frontières / Doctors Without Borders, describes the challenges faced in assuring patient safety in humanitarian settings and offers suggestions for how international medical aid organisations can build patient safety systems.

This page includes a selection of key resources that support patient safety for newborn babies and children. It has been published alongside our own series of blogs of the same theme. It has been developed as part of our series for World Patient Safety Day 2025, which has the theme of Safe care for every newborn and every child. #Worldpatientsafetyday2025 #WPSD2025 Me first: children and young people centred communication A tool co-produced with children and young people to help health and social care professionals communicate with children of different ages and abilities. Safety portal (Royal College of Paediatrics and Child Health) Explore patient safety theory, learn about the NHS patient safety syllabus, share ideas for quality improvement and access summaries of the latest alerts and reports. Use what you learn to drive improvements in paediatric patient safety. WHO: Patient safety from the start! Protecting every child’s health journey This video, produced by the World Health Organization for World Patient Safety Day 2025, looks at the unique challenges children face in healthcare through the story of six-year old Amiya. Infection prevention and control (Great Ormond Street Hospital) This page explains what the Infection Control Team are doing to prevent hospital infections at Great Ormond Street Hospital (GOSH) and what patients, carers and families can do to help minimise the risk of infections during a child's stay. Podcast: Involving children, young people and their families in making healthcare safer (RCPCH) In this episode of the RCPCH podcast series, they speak with Dr Jane Runnacles, consultant paediatrician at St. George's Hospital, and Dr Victoria Dublon, paediatric diabetes consultant at the Royal Free Hospital. Both are champions of improvement work that puts the young person and their needs first. A parents’ guide to recognising jaundice in Black and Brown babies This infographic, designed by Dr Helen Gbinigie and Dr Oghenetega Edokpolor, in collaboration with FiveXMore and Bliss, serves as a guide for parents' for recognising jaundice in Black and Brown babies, including where and how to seek help. Download the guide. Do You Know My Child? Continuity of Nursing Care in the Pediatric Intensive Care Unit The objective of this US-based analysis, was to explore the delivery of continuity of nursing care in the PICU from the perspective of both parents and nurses. The healthiest generation of children ever: A roadmap for the health system (The Children and Young People’s Health Policy Influencing Group) The report and roadmap set out recommendations for how the health system can put babies, children and young people at the heart of everything it does. Maternity and neonatal safety champions toolkit (NHS England) This toolkit provides information and resources that will help you in your role as a safety champion to develop strong partnerships, promote positive professional cultures, and support the delivery of the safest care possible through best practice. Child Health Clinical Outcome Review Programme (National Confidential Enquiry into Patient Outcome and Death) The Child Health programme is one of four Clinical Outcome Review Programmes which are designed to help assess the quality of healthcare, and stimulate improvement in safety and effectiveness by systematically enabling clinicians, managers and policy makers to learn from adverse events and other relevant data. Avoiding Brain Injury in Childbirth (ABC) The Avoiding Brain Injury in Childbirth (ABC) programme aims to reduce avoidable brain injury in childbirth by improving care. This programme supports maternity teams with evidence-based tools and protocols to ensure consistent, timely, and coordinated care. Core20PLUS5 – An approach to reducing health inequalities for children and young people (NHS England) Core20PLUS5 is a national NHS England approach to support the reduction of health inequalities at both national and system level. The approach defines a target population cohort and identifies ‘5’ focus clinical areas requiring accelerated improvement.

World Patient Safety Day 2025 is dedicated to ensuring safe care for every newborn and child, with a special focus on those from birth to nine years old. This year’s slogan, “Patient safety from the start!”, emphasizes the urgent need to act early and consistently to prevent harm throughout childhood, and yield benefits across the life course.  They have listed out a set of goals, calls to action and key messages.  Goals Goal 1 Engage children and families Goal 2 Enhance medication safety Goal 3 Improve diagnostic safety Goal 4 Prevent healthcare-associated infections (HAIs) Goal 5 Reduce risks for small and sick newborns Whether you are a nurse, a doctor, a manager, or a patient safety or quality officer, these Goals are for you. Read more about each goal and how to sign up and be part of the WHO movement for safer care. Calls to action WHO has also shared their calls to action and key messages for the following groups: Patients and caregivers - Be your child’s safety champion. Stay informed. Stay involved. Speak up. School-aged children (6+ years) - Be a patient safety star, speak up for your safety! Health practitioners - Deliver care that’s safe and child-centred. Health care facility managers - Make safe care the standard for every child, everywhere. Policy-makers and health care leaders - Invest in safe care for children. Save lives and resources. Teachers, educators and school health staff - Empower children to participate in their health care. Civil society organizations and advocacy groups - Raise awareness. Mobilize communities. Demand safe care for every child. Read more calls to action for each group on the WHO website.