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Patient_Safety_Learning

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Everything posted by Patient_Safety_Learning

  1. Content Article
    Soon-to-be parents hired a woman they believed would act as a licensed midwife. But she in fact belonged to a radical society that was linked to baby deaths around the world. Read more of the Guardian’s investigations into the Free Birth Society via the link below.
  2. Content Article
    On 13 March 2025, Prime Minister Sir Keir Starmer announced the abolition of NHS England, the arm’s-length body responsible for overseeing, planning, funding and delivering the health service – with its functions to be merged back into the Department of Health and Social Care (DHSC). In response, the Nuffield Trust and the Institute for Government have come together to examine how this change can be used to create a more effective centre for the health service – and how such a complex transition can be managed well. While recognising the expertise and experience of those leading the process within government, our work seeks to draw out wider lessons from history and other sectors to give the reform of the DHSC the best chance at success.
  3. Content Article
    the hub is home to a growing number of networks for people involved in patient safety. These communities of interest provide forums to share knowledge and good practice. Members include people who work in patient safety such as patient safety specialists, patient safety partners, clinicians, organisational leaders with responsibility for patient safety,  governance or risk. In this blog Claire Cox, Associate Director at Patient Safety Learning, reflects on key highlights and achievements from the networks throughout 2025. It has been another uplifting year of growth and development for the networks we host on the hub — our shared space for learning and improving patient safety. These networks are owned and driven by their members, whose energy, knowledge, and experience shape everything they do. Patient Safety Learning is proud to support them, helping create welcoming communities where ideas can be shared, challenges explored, and collaboration can thrive. Together, these networks continue to offer rich and valuable insights from those working on the patient-safety frontline, guiding us all towards safer care. Patient Safety Management Network (PSMN) Celebrating is fourth birthday this year, the PSMN continues to go from strength to strength, having grown to now include more than 2000 members. Key highlights from this year include: Working with experts from the Care Quality Commission (CQC) and NHS Resolution to create a new Frequently Asked Questions (FAQs) resource on Duty of Candour. Providing evidence which informed the Health Services Safety Investigations Body’s report looking at how staff fatigue impacts on patient safety. Embarking on the creation of the Network’s second book, following on from the successful publication last year of Patient Safety: Emerging Applications of Safety Science. Experts from within and outside the network sharing their expertise and wisdom at the weekly meetings, inspiring discussions for the better understanding of safety risk, and sharing good practice for wide dissemination and improvement. At the beginning of 2026 we are planning to embark on a new series of meetings inviting Network members to share their examples of investigations with each other. We all investigate differently and bring our own approaches to problem-solving. This is a chance to share not only the approach individual network members take, but also the recommendations made and the lessons they learnt along the way. This is an example of how this network has become a trusted space for sharing and discussing often complex and challenging issues. Patient Safety Education Network (PSEN) The PSEN is a network for those who teach any element of patient safety or provide learning from patient safety incidents. This year the Network has featured a number of engaging discussions on topics including: The use of Post Transformative Simulation Briefing to design and test systems and processes, drawing on resources shared by the Association of Simulated Practice in Healthcare. Discussing with a presenter from NHS England the Safe Learning Environment Charter and what it means for those working in patient safety education roles. Discussing a new training resource, now available for free on the hub, intended to help people facilitate an interactive workshop, bringing SEIPS (Systems Engineering Initiative for Patient Safety) to life. This was developed at a joint PSMN and PSEN symposium held last year. Patient Safety Partners Network (PSPLN) The PSPN includes Patient Safety Partners, in both paid and voluntary roles within NHS organisations, whose role is to improve patient safety. Key highlights from this year include: Hosting a session with the Patient Safety Commissioner for England discussing her work and how to build on, and increase, the impact of the work of Patient Safety Partners. Contributing to the development of new guidance that offers a clear, structured approach to patient and family involvement in After Action Reviews (AARs), a learning tool used with the Patient Safety Incident Response Framework in the NHS. A lively debate on the topic of staff fatigue and its impact on patient safety, summarised in a blog by Network member Sue Strudwick. Regular discussions between individual PSPs as to how their roles are developed, the work they’re engaging in and the impact that they’re having. The launch of an Advisory Group to provide strategic, collaborative, and representative input into the development, delivery, and future direction of the PSPN, ensuring it is shaped by those with lived experience and diverse perspectives. This network provides a valuable space for PSPs, some of whom are still establishing themselves in role and are benefitting from the vibrancy of Trusts who have embraced PSPs and the insights they bring. Patient Safety Paediatric Leaders Network (PSPLN) This is an invited network for anyone who is a strategic-level decision maker in a specialist children’s hospital or unit with a leadership responsibility for patient safety and/or quality. Co-hosted with Great Ormond Street Hospital (GOSH), this is a space for leaders to reflect on challenges, seek advice, share perspectives and examples of good practice. The group varies its approach to its monthly meetings, alternating between general discussions and specific topics, often informed by an invited speaker. In response to a ‘what three things keep you awake at night, the Network members agreed to move into a ‘Community of Practice’ model and created a multi-disciplinary and multi-organisational project focused on reducing the risk of avoidable harm associated with parenteral nutrition for babies and children. This project has embedded a SEIPs (Systems Engineering Initiative for Patient Safety) based approach to risk assess current arrangements across all the network members’ Trusts. Jointly project managed by GOSH and Patient Safety Learning, it is bringing together the expertise and experience of parenteral nurses, neonatologists, pharmacists, patient safety experts and many more to develop solutions to often challenging issues and create the opportunity to standardise good practice. Keep an eye out for more information about this on the hub in the new year. Safer Surgery and Invasive Procedures Network (SSIPN) This is a group for healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. It was recently re-launched following a merger of the NatSSIPs Network with another voluntary network focused on improving patient safety in surgery. In 2026, this Network will meet every two months, with practical sessions focused on improving patient safety in surgery and implementing the National Safety Standards for Invasive Procedures 2 (NatSSIPs). Its next session on 4th February will be focused on approaches to implementing checklists for the purpose of standardising procedures and communication in surgical settings. Join a network You can apply to join any of our networks by signing up to the hub today. When you complete the registration form you’ll see a section called ‘Join a private group’, please tick the box by the relevant Network. If you are already a member of the hub, please email [email protected]. New networks We are always exploring and developing new networks. Our plans for 2026 include new networks for safety leaders and primary care, If you have an idea for a network and want to get involved in developing and supporting one, please let us know by email at [email protected].
  4. Content Article
    This article, published on About Lawsuits website, says Women are still filing transvaginal mesh lawsuits, as older implants continue to fail long after the products were removed from the market.
  5. Content Article
    International medical graduates (IMGs) make up a significant proportion of general practitioners (GPs) in high-income countries such as the United Kingdom (UK), the United States of America (USA), Australia, and Canada. This paper published in International Medical Education, compares views about IMGs with their own views in relation to the timing of GP placements in GP specialty training programs in the UK. It presents an inductive thematic analysis of focus groups with GP specialty trainers and trainees (149 participants across 32 focus groups), examining opinions about the ideal timing of GP placements
  6. Content Article
    NHS Resolution share a number of Case Stories on their website. These are illustrative based on a range of examples of real events. NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff.  You can access the case stories via the link below.
  7. Content Article
    This resource helps healthcare professionals in taking actions to reduce medication safety inequalities across the system. Through sharing innovative practices, it aims to inspire healthcare professionals (HCPs), and supports the translation and replication of improvement initiatives across the system.
  8. Content Article
    NHS England are looking for new patient safety partners (PSPs) to join NHS England’s National Patient Safety team. PSPs play a vital role in ensuring the voices of patients, carers, and families are at the heart of our work to improve safety across the NHS. Click on the link below for all of the role information and to apply. Deadline: 21 December 2025
  9. News Article
    A nurse who objected to sharing a female changing room with a transgender doctor has won a claim for harassment against NHS Fife but other allegations of discrimination and victimisation were dismissed. Sandie Peggie was suspended from her job in a hospital's A&E department after she complained about Dr Beth Upton - a biological male who identifies as a woman - using a female changing room. Read full story Source: BBC News, 8 December 2025
  10. News Article
    NHS England will intensify its crackdown on wasteful technology spending next year as part of “radically different” approach to funding, a national director has said. Alex Crossley, NHSE’s director of transformation, finance and delivery, said the NHS needs to be “more disciplined” with its approach to technology funding and that he would be “turning funding off” when productivity gains are not achieved. Read full story (paywalled) Source: HSJ, 5 December 2025
  11. Content Article
    Writing for HSJ, Andi Orlowski says the NHS has clung to false hopes that interventions, prevention programmes and AI will unlock spare cash, but real change requires decommissioning services and moving money, not just reducing activity.
  12. News Article
    Millions of patients are being offered no choice of provider when referred for secondary care and tests, contrary to national guidance, according to NHS England information. By law, patients are allowed to choose their provider when referred for a first appointment for consultant-led treatment. The NHS e-Referral Service is the NHS’s national digital system for booking and managing elective appointments and is used in primary care consultations to book appointments; as well as directly by patients via the “manage your referral” website or the NHS App. It was introduced in an effort to make referrals faster and more transparent, and it was claimed it would also lead to patients being offered more choice. Read full story Source: HSJ 9 December 2025
  13. News Article
    Hungry mothers, dirty wards and poor care are blighting England's maternity services while staff receive death threats for working in some units, according to a new report. Baroness Amos, who is chairing a review into maternity care, said that what she has seen so far "has been much worse" than she'd anticipated. Some women had felt blamed for their baby's death, while others suffered from a lack of empathy, care or apology when things had gone wrong, with poor and black mothers often at the end of discriminatory services. Health Secretary Wes Streeting, who set up the review, external, said "the systemic failures causing preventable tragedies cannot be ignored". Read full story Source: BBC News, 9 December 2025
  14. Content Article
    There are huge benefits when patient data is used responsibly to save lives and improve health and care. However, it is true that collecting and using patient data will never be totally risk-free. There must be robust measures in place to reduce the risks as much as possible. In this article (link below), Understanding Patient Data, looks at the concerns people have and what’s being done to reduce the risks.
  15. Content Article
    This article published by Boehringer Ingelheim, looks at how anchoring research and development and policy in patients' lived experience will ensure that healthcare decisions and innovations align with the realities of living with a condition - driving progress that truly reflects patients’ needs.
  16. Content Article
    In this LinkedIn article Risk Advisor, Paul Chivers argues that: "We continue to talk about “human error” as if it is a meaningful explanation for why things go wrong. It isn’t. It never was. And clinging to it holds organisations back from real improvement."
  17. Content Article
    On 28 November 2025,  the Covid-19 Airborne Transmission Alliance (CATA) sent an open letter to Baroness Heather Hallett, Chair of Covid-19 Public Inquiry. The letter outlines a number of concerns regarding the response of State bodies to the findings and recommendations contained in the Module 1 Report. You can read the letter here: 2025-11-29 Open Letter - CATA to Baroness Hallett (3).pdf Find out more about CATA and the Covid-19 Inquiry in the following blogs and presentations on the hub: Respiratory protective equipment: An unequal solution for healthcare workers? A blog by David Osborn Healthcare workers with Long Covid: Group litigation – a blog from David Osborn Covid-19 : A risk assessment too far? A blog by David Osborn CATA and the UK Covid-19 Public Inquiry: Presentation from David Osborn
  18. News Article
    A former resident doctor has been charged with sexually assaulting 38 patients who were in his care. The Crown Prosecution Service today announced charges against Nathaniel Spencer, 38, of Quinton, Birmingham for alleged offences at The Dudley Group Foundation Trust and the University Hospitals of North Midlands Trust. He faces 15 counts of sexual assault, 17 counts of assault by penetration, nine counts of sexual assault of a child under 13. Mr Spencer has also been charged with three counts of assault of a child under 13 by penetration, and one count of attempting to assault by penetration. Read full story (paywalled) Source: HSJ, 5 December 2025
  19. News Article
    A trust has linked the stillbirth of a baby to the disruption that followed the launch of an electronic patient record. A report to Sheffield Teaching Hospitals Foundation Trust’s board said that in September, reduced “oversight” in its Jessop Wing maternity unit meant a woman in labour was not triaged within the recommended time. An initial assessment – itself delayed – when she arrived, found a normal heartbeat, but by the time she was re-examined, no heartbeat could be detected, the paper said. It was later discovered the umbilical cord had become entangled around the baby’s body. Read full story (paywalled) Source: HSJ, 8 December 2025
  20. News Article
    The FDA has approved hyperbaric oxygen therapy to be marketed as a treatment for only 13 conditions – but some clinics are claiming that it can be used for more than 100. Touted as a cure for everything from wrinkles to autism, the treatment has been hyped by Robert F Kennedy Jr and various celebrities. Experts say it needs to be regulated. Warning: this article contains distressing content. Read full story Source: Guardian, 4 December 2025
  21. Content Article
    An American Hospital Association report found patient safety in hospitals and health systems across the nation continues to improve. The report, which uses data analysed by Vizient, examined key safety and quality metrics from the fourth quarter of 2019 to the second quarter of 2025. It found that despite caring for a sicker patient population, hospitals’ focus on safety led to improved patient outcomes and reduced infections.  The report also found:  •  Hospitalised patients in the second quarter of 2025 were on average nearly 30% more likely to survive than expected given the severity of their illnesses compared to the fourth quarter of 2019.  •  Hospitals’ efforts to improve safety led to more than 300,000 Americans hospitalised from April 2024 through March 2025 surviving episodes of care they would not have in 2019.  •  Hospitals cared for more patients in the second quarter of 2025 compared to the fourth quarter of 2019, with increases in volume by 4% and case mix index by 5% during this period. Patients in 2025 also had more complex and severe conditions.  •  Hospitals’ central line-associated bloodstream infections and catheter-associated urinary tract infections in the second quarter of 2025 were at lower rates than the fourth quarter of 2019.  •  Key screenings for breast and colorectal cancer increased 95% from the fourth quarter of 2019 to the second quarter of 2025.  Read the report via the link below.
  22. Content Article
    In this article from Hogan Lovells, authors argue that in the labyrinthine world of medical device manufacturing, process is king—but culture wears the crown. 
  23. News Article
    More than 1,000 patients across Kent, Sussex and Surrey are occupying hospital beds despite being medically fit to leave, according to the latest NHS figures. "Bed blocking" affects the availability of space for incoming patients, which leads to delays in A&E departments and delayed ambulance handovers. On 30 November, NHS data showed 462 patients in Kent and Medway, 118 in Surrey and 614 in Sussex were ready for discharge. The NHS said patients who wait longer to leave often have "complex" health and care needs. Kent and Sussex branches said they work with trusts and partners to find the right support. Read full story Source: BBC, 8 December 2025
  24. News Article
    Serious change in direction and leadership is needed to save Scotland’s NHS, a report has found. The review by Mike McKirdy, a retired consultant surgeon from NHS Greater Glasgow and Clyde and the former president of the Royal College of Physicians and Surgeons of Glasgow, warned “more of the same will not be enough”. Mr McKirdy said the founding principles of the NHS were “becoming strained and frayed” and that current trends risk “entrenching a two-tier system where access depends increasingly on ability to pay rather than clinical need”. Read full story Source: Grampian Online, 8 December 2025
  25. News Article
    The parents of an autistic boy say a new immersive room in their local hospital's children's A&E will "change so many lives". Robert and Gemma Cummings spent the past year fundraising to open the room, which is the first of its kind in Wales, at the paediatric department of Prince Charles Hospital in their hometown of Merthyr Tydfil. The project was inspired by their own "distressing" experiences with their six-year-old son Ellis, who struggles with "sensory overload". They hope the room, officially opened on Thursday, will allow children to receive emergency care without parents reaching a "crossroads" in deciding whether or not hospital visits are worth the potential of trauma. Read full story Source: BBC News, 7 December 2025
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