Patient_Safety_Learning
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Content Article
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Katie Dawson is a hypothyroidism sufferer and needs specific treatment to keep herself well. In this opinion piece, she explains why she resorted to sourcing her own medication from abroad. Katie builds on the safety concerns raised in a recent blog by Mary Saunders, and calls for an individualised care approach to hypothyroidism, so that everyone can access the treatment they need. -
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Julie Smith is a Patient Information Topic leader for the hub, a consent expert, and Content Director at EIDO Healthcare. In this two-minute video, Julie shares five things you should know about consent, focusing on: accessible information your options time additional consents changing your mind. -
Content ArticleDeveloped by Dr. Murray Johns in 1990 and refined in 1997, the Epworth Sleepiness Scale (ESS) is a cornerstone in sleep medicine for assessing daytime sleepiness. With over 10,000 citations on Google Scholar, its global adoption underscores its reliability and utility. For example, its simplicity enables quick administration in busy clinics. Consequently, this article provides researchers and clinicians with a detailed exploration of the ESS’s features, applications, and clinical value, equipping them with insights to enhance sleep disorder research and practice.
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Sandra Igwe MBE is the Founder and CEO of The Motherhood Group and a Topic leader for the hub. In this blog, she talks about The Motherhood Group’s involvement in a recent roundtable event to discuss the Independent National Maternity and Neonatal Investigation. -
Content ArticleHealth Service Journal has looked at the time in post for all trusts’ CEOs as of 1 January 2026. The median average time in post was two years and seven months, while the mean was three years and eight months. The time in post includes “interim” or “acting” stints at the trust in question. It measures time at this particular trust, regardless of shared posts, although these are recorded in notes. Access the data via the link below.
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Content ArticleIn this letter, Samantha Jones OBE Permanent Secretary Department of Health and Social Care writes in response to the questions at the Public Accounts Committee hearing on 20th November 2025 into the costs of clinical negligence. The letter responds to the following unanswered questions on the topic of clinical negligence only: 1) Never events: How often do they result in clinical negligence claims? 2) Complaints: How quickly are complaints responded to, and is that data published? 3) Inquests: Will the use of conditional fee agreements in inquests impact patient safety? Also included are sections where she shares insights on: 4) General Practice Indemnity (GPI) schemes five-year financial forecasts. 5) Detail on work ongoing to engage firms on the transparency of conditional. fee agreements between claimants and their solicitors.
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The Fatigue Severity Scale (FSS) was developed by Lauren B. Krupp, Nicholas G. LaRocca, Joseph Muir-Nash, and Alfred D. Steinberg. First published in 1989 in the Archives of Neurology, the FSS has since become a cornerstone in fatigue assessment. Indeed, its significance is underscored by over 7000 citations on Google Scholar, highlighting its widespread adoption and utility in both clinical and research settings. Consequently, professionals can leverage this tool to enhance patient care and advance research in conditions where fatigue is a prominent symptom. This article offers an in-depth exploration of the FSS, providing researchers and clinicians with actionable insights into its structure, validation, applications, and overall value in understanding and managing fatigue. -
Content ArticleDr Ron Daniels is joined by journalist and campaigner Kath Sansom, founder of Sling The Mesh, to discuss the complications linked to surgical mesh and why fully informed consent is crucial for anyone considering surgery. Drawing on her own experience and a decade of advocacy, Kath shares how inadequate information and follow-up have left thousands facing life-changing pain and recurrent infections – some of which can progress to sepsis. Together, the pair explores how to improve patient safety, strengthen regulation, and ensure every voice is heard.
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Content ArticleIn this article for the Federation of American Scientists, authors share a set of recommendations that align with the National Quality Strategy of Centers for Medicare and Medicaid Services (CMS) goal for zero preventable harm in healthcare. Working with Patients for Patient Safety US, which co-led one of Strengthening Pathways conversations this spring with the Johns Hopkins University Armstrong Institute for Patient Safety and Quality, the issue brief outlines a bold, modernised approach that uses Artificial Intelligence technology to empower patients and drive change. FAS continues to explore the rapidly evolving AI and healthcare nexus.
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Content ArticlePatient_Safety_Learning posted an article in Australian Commission on Safety and Quality in Health CareThe Medication Management at Transitions of Care Stewardship Framework (the Framework) describes a stewardship approach to support safe and high-quality medication management at transitions of care. It is designed to be incorporated into existing organisational systems, processes and clinical practice. The Framework includes four elements: Governing committee Multidisciplinary stewardship team Medication management activities Monitoring, evaluation and reporting
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Content ArticleKenhtè:ke Midwives is a primary healthcare provider providing culturally-appropriate maternal and newborn care to Indigenous families living on the Tyendinaga Mohawk Territory and surrounding areas of southeastern Ontario. Tewahséhtha (Miranda Brant) is a Midwife and Erin Ferrant is Administrative Lead. Recognising that birth is a deeply vulnerable time, Kenhtè:ke Midwives works to protect clients from physical, emotional, and cultural harm by fostering trust, honouring traditions, and supporting individual needs. In this blog for Healthcare Excellence Canada, Tewahséhtha and Erin explain how through strong relationships and open communication, Kenhtè:ke Midwives ensures that every birth is safe, respectful, and centred on the whole person.
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Content ArticleStarting in 2019, the Agency for Healthcare Research and Quality (AHRQ) supported the development of a series of papers on different diagnostic safety topics. The purpose of the papers was to develop, based on research conducted to date, more resources to improve diagnostic safety and quality, during a time when research to improve diagnostic safety was still an emerging field as compared to research to understand and prevent treatment-related mishaps. The papers fall under two types—either a "call to action" or a "state of the science." The majority of these papers were published as AHRQ issue briefs, but several were also published in peer reviewed journals and made open access. Read more via the link below.
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Content ArticleAmbiguous or unnecessary radiologist recommendations for additional imaging (RAIs) can lead to excessive imaging use and diagnostic errors. The purpose of this paper was to determine the cumulative impacts of multifaceted technology-enabled interventions aimed at optimising RAI on RAI rate, actionability, and resolution over an 8-year period. Authors conclude that multifaceted interventions to optimize RAI improved the rate, actionability, and resolution of RAI.
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Sling The Mesh offers support and advice to people suffering complications from surgical mesh implants used in prolapse, incontinence, hernia repair, and certain breast surgeries, including cancer reconstruction. Language barriers leave many without access to vital information, support, or justice. So they have launched #NoLanguageLeftBehind – a campaign to ensure mesh complications are recognised and addressed everywhere, regardless of language. The campaign has translated their core blog into 21 languages and aims to: Raise awareness globally: No woman should suffer in silence because of language. Empower communities: Provide multilingual resources for patients, families, and advocates. Highlight risks when doctors won’t: Bring attention to the impact of mesh marketing. -
Content ArticleOn 12 February 2023 at 3:00pm, Mohamed Abdisamad underwent a Non-Therapeutic Male Circumcision (NTMC) by a circumciser who was recommended to Mohamed’s parents and requested by them to perform the procedure on their son. Following the procedure, the wound appeared to be healing well. However, 3 to 4 days following the procedure, symptoms of illness started to manifest. On Sunday 19 February, Mohamed’s mother contacted the emergency services due to concerns about Mohamed’s deteriorating condition. Upon presentation to the paramedic, a decision was made to transport Mohamed to Hillingdon Hospital by an ambulance and, during the journey, Mohamed had a cardiorespiratory arrest. Despite the resuscitation efforts by the paramedics and hospital staff, Mohamed was declared dead at 23:55 on 19 February 2023.
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Content ArticleParenteral nutrition (PN) is recognised as a complex high-risk therapy. Its practice is highly variable and frequently suboptimal in paediatric patients. Optimising care requires evidence, consensus-based guidelines, audits of practice, and standardised strategies. Several paediatric scientific organisations, expert panels, and authorities have recently recommended that standardised PN should generally be used over individualised PN in the majority of paediatric patients including very low birth weight premature infants. In addition, PN admixtures produced and validated by a suitably qualified institution are recommended over locally produced PN. Licensed multi chamber bags are standardised PN bags that comply with Good Manufacturing Practice and high-quality standards for the finished product in the frame of their full manufacturing license. The purpose of this article, published in Clinical Nutrition, is to review the practical aspects of PN and the evidence for using such multi-chamber bags in paediatric patients. It highlights the safety characteristics and the limitations of the different PN practices and provides some guidance for ensuring safe and efficient therapy in paediatric patients.
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Content ArticleThis video series looks at systematic approaches to insulin safety, including: Part 1 Human Factors - A Journey of Discovery Part 2 SEIPS – The Swiss Army Knife Approach Part 3 - Summary & Applying the Learning
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Content ArticleIn this video series from the American Hospital Association, we hear from different patient safety leaders on topics including working together, quality and safety and learning from each other.
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Content ArticleFailures in consent are a leading cause of patient harm and litigation. NHS Resolution data shows claims for failures in informed consent have nearly doubled over the past decade. The NHS Long Term Plan emphasises empowering patients with choice and control—consent is central to achieving this. These consent principles from the Health and Care Professions Council are aimed at improving informed decision-making and reducing patient and service user harm. They were developed with a cross-sector working group including the Nursing and Midwifery Council, General Pharmaceutical Council, General Optical Council, General Osteopathic Council, the Patient Safety Commissioner, the Patients Association, and the Council of Deans for Health, supported by other regulators including the General Medical Council, General Dental Council and General Chiropractic Council.
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On 3 July 2025, the UK Government published its 10 Year Health Plan for England. In the following months there has been much commentary on the practical implications of this and how it will impact patient safety, and healthcare more broadly. This article brings together reflections from organisations and individuals on the Plan’s vision for the future of the NHS. -
Content ArticleThe American Hospitals Association (AHA) has worked with hospitals and health systems to share tools that help build a culture of patient safety adopt best practices around infection prevention and other critical safety topics share learnings so that hospitals can learn from each other’s experiences in improving safety. Visit their webpage with the resources via the link below.
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This study aimed to determine the number of digital health technologies (DHTs) in use in the NHS in England and assess their assurance status against mandated clinical safety standards. This is the first study to quantify both the scale of DHT deployment in NHS organisations in England and the extent of compliance with mandatory safety standards. Findings include: More than 10,000 DHTs currently in use lack documented assurance against clinical safety standards. In a typical NHS trust, 3 out of 4 digital tools influencing patient care do not demonstrate compliance with minimum legal or clinical safety requirements. These findings raise significant concerns about the risks posed to patients by these technologies; the capacity of organisations to assess and mitigate them; and the legal ramifications of when, not if, harm occurs. Crucially, failure to assure digital technologies poses a significant risk to one of the core ambitions of the NHS 10-Year Health Plan for England; safely transitioning from analogue to digital care models. These findings are unlikely to be unique to the NHS and should prompt health care systems worldwide to assess the risks posed by their DHT deployments. Read the full paper via the link below. -
Content ArticleOn 17 December 2025, Health and Social Care Secretary Wes Streeting MP, his Department’s Permanent Secretary Samantha Jones, and NHS England Chief Sir Jim Mackey were be questioned by the Health and Social Care Committee on a range of topical issues. This article highlights Question 171 in the session, asked by the Committee Chair, Layla Moran MP. This concerns the Government’s plans to respond to The Hughes Report, which set out options for redress for those who have been harmed by valproate and pelvic mesh.
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Content ArticleThis poster raises awareness of the different approaches safety-critical industries take to fatigue.
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Content ArticleThe NHS is striving to become the “most transparent health service in the world”, its deputy chief has said. In an exclusive interview with HSJ, NHS England’s interim deputy CEO David Probert also said he was hopeful the organisational turmoil in the health service would “settle down” next year and system leaders could start “to look forward”. Read the full article (paywalled) via the link below.
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