Patient_Safety_Learning

Clive Flashman is Chief Digital Officer at Patient Safety Learning. In this long-read article, Clive shares his reflections on the digital patient safety landscape and how it has developed in the last year. Before he looks ahead to 2026, Clive offers his insights on several critical safety topics including: Digital incidents, alerts and early warning Electronic patient records How not to deploy an AI tool Patients at the centre of digital design Governance, culture and skills for trusted AI From Electronic Patient Records (EPRs) and wearables to generative AI at the desktop, 2025 has felt like the year digital health stopped being ‘the future’ and became an everyday patient safety issue. Across the hub, especially in Network meetings, and on social media, the same message has kept surfacing: technology is now woven into almost every part of care. Programming is now just as important as design, governance and culture when it comes to keeping patients safe. AI is everywhere – but it must be safe This year has marked a clear shift from talking about ‘AI potential’ to dealing with ‘AI in use’, and with that a sharper focus on how safely AI is being deployed. On the hub, we have highlighted the discussions from our roundtable at The Healthcare Excellence Through Technology (HETT) show discussing AI and Patient Safety. We’ve also shared how within the WHO European Region health systems are moving from pilots to scaled AI deployments, while still wrestling with readiness, regulation, and the gap between hype and reality at the bedside.[1] Several of our 2025 hub articles have tried to unpack what ‘safe AI’ actually means in practice: extending Patient Safety Incident Response Framework (PSIRF) principles to digital and AI systems[2] strengthening AI governance and making accountability for harm explicit rather than implied. In parallel, some of my articles on social media have stressed that AI is just another tool in the safety toolkit – powerful, but only as safe as the data, design and culture wrapped around it. Digital incidents, alerts and early warning Digital‑related safety alerts have been a regular drumbeat this year, underlining that software, data and algorithms can cause real harm if they are not designed or implemented well. Content shared on the hub has included warnings about IT faults in maternity systems[3] and concerns about unsafe use of AI translation apps[4], both of which show how configuration and workflow decisions can have life and death consequences. At the same time, 2025 saw the launch of a world‑first AI early warning system[5] to scan NHS data for emerging safety signals, starting with maternity. At Patient Safety Learning we have welcomed this announcement, recognising this as both a huge opportunity and a real test of public trust. Earlier detection and targeted inspections are promising, but only if data quality, transparency and clear lines of accountability are built in from day one. Electronic patient records under the safety spotlight By the end of the year, EPR systems were firmly in the patient safety spotlight again. We saw the publication of a new Health Services Safety Investigations Body (HSSIB) thematic report on EPR‑related safety issues[6] and a linked response from Patient Safety Learning. In previous years, these reports, and blogs on incidents such as the EuroKing maternity alert,[7] have shown how poor planning, rushed go‑lives and weak incident reporting can turn EPR programmes into sources of avoidable harm rather than enablers of safer care. On social media, I have continued this conversation by commenting on botched upgrades,[8] under‑tested systems[9] and opaque vendor contracts. I have argued for robust project discipline, meaningful user testing and strong quality assurance as non‑negotiables in any EPR roll‑out. Through roundtables and sessions with NHS England’s Frontline Digitisation team and vendors, the focus has increasingly shifted from blame to shared responsibility: national bodies, trusts, suppliers and patients all have a role in making ‘safety in use’ real. Copilot in the NHS: how not to deploy an AI tool Generative AI at the desktop became very real for many staff this year with the arrival of Microsoft Copilot in the NHS. In a recent blog, I described a senior patient safety manager who opened their laptop to find Copilot ‘suddenly there’. There had been limited communication, unclear governance and little practical training on how it should (or should not) be used in a safety‑critical environment. That story has resonated widely (it had already garnered over 40,000 views on Linkedin) because it illustrates a wider pattern. Powerful tools are being deployed as if they were just another productivity app, without the basics of change management, risk assessment or support. In response, I set out a more responsible approach to rolling out tools like Copilot including: national guardrails and minimum safety expectations local risk assessments aligned with existing patient safety frameworks and role‑based training that focuses on how people’s day‑to‑day work could change. Patients at the centre of digital design Alongside these technical debates, a recurring question this year has been whether digital tools actually make care safer and easier for patients and staff, or simply add friction. Articles on the hub have highlighted the importance of co‑design, patient voice and usability – from resources on putting patients at the heart of digital health[10], to reflections on how poor user experience quietly undermines safety.[11] Wearable AI has been one of the more hopeful technological areas this year, with content[12] showing how real‑time analytics at the wrist[13] or bedside could support earlier detection of deterioration and move care closer to home. This very much aligns with the core shifts described in the new 10 Year Health Plan for England,[14] published in July 2025. But even with wearables, the same concerns return: data overload unclear liability when automated insights are missed and the need to align new tools with existing (and in many ways, outdated) safety and regulatory frameworks rather than building parallel assurance processes. Governance, culture and skills for trusted AI A strong consensus is emerging that trusted AI in healthcare rests as much on people, governance and culture as on technology. Throughout 2025, Patient Safety Learning has highlighted work on transparency and AI governance from organisations such as the Institute for Healthcare Improvement.[15] Staff and patients need clarity about data provenance, model limitations and escalation routes if they are to rely on AI‑supported decisions. Training and culture have been major themes in some of the AI-related talks and workshops I have run, including with colleagues in mental health and addiction services. The focus has been on practical skills – helping people understand when to trust AI, when to challenge it, and how to report concerns. It’s also been valuable to look at building digital safety into everyday practices. From how PSIRF investigations explicitly include digital and AI systems, through to treating cyber resilience and ‘fragile IT'[16] incidents as core patient safety and business‑continuity risks[17] rather than just technical problems. Looking ahead to 2026 Stepping back from EPRs, wearables, Copilot and early warning systems, a clear picture emerges from 2025: digital transformation is now inseparable from patient (and clinical) safety. Every new deployment – from a national AI system to a ‘simple’ productivity tool – is a patient safety decision, not just a technology decision. Looking to 2026, three priorities stand out for anyone working at the intersection of digital health innovation and patient safety: Embed safety system learning approaches into digital health change programmes so incidents involving software, data and AI are captured, investigated using models being adopted by PSIRF and shared. And are not treated as IT ‘glitches’. Test AI and digital tools against real safety outcomes (whether they actually reduce harm and make care safer for patients), not just efficiency or adoption metrics. be willing to pause or roll back and improve deployments that negatively impact patient safety. Invest in people – patients, clinicians, managers and digital teams – so they have the skills, confidence and support to question the tools they use and to shape how technology is introduced into care. Linked to this is the need to focus more on human factors as a core skill within NHS quality improvement teams. My challenge to all digital health innovators and vendors is: Treat every digital health project as a patient safety improvement project, and bring patients, staff and ecosystem partners into the conversation early. The pace of change in technology will keep moving quickly; our responsibility is to ensure that safety, learning and trust move just as fast. Related reading Electronic patient record systems: Putting patient safety at the heart of implementation (Patient Safety Learning, 31 July 2024) Patient safety and the role of AI in a cautiously optimistic future: A blog by Ian Fearnley Balancing promise and risk: AI hallucinations, confabulations and omissions in healthcare One size does not fit all. How AI and better data can help us embrace complexity in diagnosis and treatment AI in healthcare translation: balancing risk with opportunity References [1] WHO. Artificial intelligence is reshaping health systems: state of readiness across the WHO European Region. 19.11.25. [2] The Safety Guru with Eric Michrowski. Bridging the Gap: Safety Principles from Aviation to Healthcare Safety with Niall Downey. 22.08.24. [3] HSJ. Maternity units disrupted for nine months by IT fault. 3.10.2025. [4] Digital Health. NHSE warns that AI translation apps could impact patient safety. 3.06.25. [6] HSSIB. Patient safety issues associated with electronic patient record (EPR) systems – a thematic review. 27.11.25. [7] NHS England. Identified safety risks with the Euroking maternity information system. 7.12.23. [8] Flashman, C. LinkedIn Post. 2025. [9] Flashman, C. LinkedIn Post. 2025. [10] Flashman, C. Putting patients at the heart of digital health. Patient Safety Learning's the hub. 14.09.23. [11] NHS Providers. Making the most of your electronic patient record system. 19.01.23. [12] Mahajan, A., Heydari, K. & Powell, D. Wearable AI to enhance patient safety and clinical decision-making. npj Digit. Med. 8, 176. 22.03.25. [13] Ma, X., Wang, L., Meng, S. et al. A retrospective cross-sectional study showing wearable smartwatches enhance patient safety and efficiency in the intensive care unit. Commun Med 5, 341. 8.08.25. [14] Department of Health and Social Care. Fit for the Future: 10 Year Health Plan for England. 3.07.25. [15] Moran B, Weckman A, and Martinez N. Transparency and Training: Keys to Trusted AI in Health Care. Institute for Healthcare Improvement. 25.09.25. [16] HSJ. ‘Fragile’ IT blamed for critical incidents and patient harm. 20.01.25. [17] HSJ. Critical incident declared after EPR launch. 5.11.25.

Elizabeth Wood is an Editor at EIDO Healthcare, who manages the production of their Easy Reads. In this blog, she explains what an Easy Read is, and why accessible, written information is critical to fighting inequality. Elizabeth offers advice on where to find Easy Reads, and who can support you to create them.  “The noblest pleasure is the joy of understanding.” Leonardo da Vinci [1] Imagine this; your doctor has just told you that you need an operation. You’re told this operation has complications, and potential consequences for the rest of your life. You’re overwhelmed but feel reassured when the doctor hands you a leaflet, saying it will help you understand what’s going to happen. Except, you don’t understand it. There’s too much text, words you don’t recognise and pictures of people who look nothing like you. Now, you’re not just overwhelmed. You’re confused and scared. No patient should feel like this. Everyone deserves information they can comprehend that helps them make an informed decision about their health and care. That’s where Easy Reads come in. What is an Easy Read? An Easy Read is a way of making written information clearer for people with learning disabilities, and people who struggle with reading, writing, or remembering things. They’re also useful for patients who don’t speak English as their first language. The key difference between an Easy Read and other patient advice is in the level of detail. The language is simpler, shorter and easier to follow. Unless it’s essential, medical jargon is left out of an Easy Read. If it has to be included, it’s always explained in simple terms. There are often pictures next to each statement, making the leaflet more accessible and engaging. Websites like Photosymbols are a great resource, because they use models who have learning disabilities themselves. This is important to help patients relate to what they’ve read and feel reassured. Written information remains important Written information isn’t a substitute for a meaningful conversation between a doctor and their patient. However, studies show that patients can forget a staggering 40-80% of what they’re told during a consultation.[1] It’s vital they have something they can refer back to and process in their own time. In the UK, 1.5 million people are living with a learning disability.[2] That’s a lot of people left severely disadvantaged if they don’t understand what they’ve been told. Presenting patients with learning disabilities with information they can really process isn’t just a tick box – as laid out in the Equality Act 2010, it’s the law.[3] Easy Reads should always be available. There’s some great stuff already out there but there can always be more. Online information can lead to exclusion The government’s drive to progress much of our healthcare from analogue to digital means the NHS is becoming increasingly digitally led; with fewer paper forms being printed, more online consultations and an increase in investment in digital health.[4] Assuming that patients can use health services online relies on several factors, including: the patient having access to the internet the patient wanting to access the information online, and websites and apps catering to their needs; written in a way they can understand, with features like screen reader and alt text enabled where necessary. If we’re not careful, the move to digital could lead to widespread areas of exclusion. This is especially a concern for individuals with learning disabilities. “[n]early half of people with complex disabilities face exclusion as they struggle to access and engage with services online.”[5] Finding and creating Easy Reads In a world that’s so fast-paced it can feel impossible to make sure no one gets left behind. But fear not! It’s easier than you think to make information accessible. Creating an Easy Read isn’t just about tweaking existing information – in most cases a full rewrite is needed. This is where accessible information organisations like Making it Clear, or the learning disability charity Mencap are great to work with when creating the resource from scratch. We also have a range of procedure-specific Easy Reads at EIDO Healthcare, which I am responsible for. The NHS has a number of free Easy Reads, as well as various articles on how best to support those with learning disabilities and impairments, as laid out in the ‘Accessible Information Standard’. When writing, it’s crucial you remember who you’re writing for. This is when user testing and focus groups come in handy.[1] Patients can tell you about their specific needs, what issues they may have with the content and how to ensure the leaflet is truly a resource that helps them when they need it most. Easy Reads help the patient and those who support them, like friends, family, or care workers, understand the proposed procedure and make decisions together. This is how we work in partnership with patients. This is how we fight inequality and ensure their trust and safety. References [1] Kessels RP. Patients' memory for medical information. J R Soc Med. 2003 May;96(5). [2] Mencap. How common is learning disability in the UK? Accessed online 1/12/2025. [3] Mencap. How common is learning disability in the UK? Accessed online 1/12/2025. [4] Department of Health and Social Care. 10 Year Health Plan for England: fit for the future. 3/7/25. [5] Sense. Potential and Possibility 2024. Accessed online 1/12/25. [6] The Information Access Group. The benefits of user research in Easy Read. Accessed online 1/12/25.

This conference focuses on recognising & responding to the deteriorating patient and ensuring best practice in the use of NEWS2. The conference will include National Developments including recommendations on NEWS2, the national PIER approach to the effective management of acute physical deterioration in health and care, the forthcoming 2025 NICE Sepsis Guidance and implementation of Martha’s Rule. The conference will also include reflections on implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. We are pleased to offer a 20% discount with code hcuk20PSL Find our more and to book your place

This conference focuses on recognising and responding to deterioration in mental health settings, and looks ahead to the implementation of Martha’s Rule in mental health which is now established in the acute sector and currently being piloted in mental health. This conference brings together leading experts at the forefront of recognising and responding to deterioration in mental health, and learning from implementation of Martha’s Rule. Throughout the day, there will be interactive sessions, small breakout groups, and collaborative exercises, providing a dynamic learning experience. The conference will explore implementation of Martha's Rule across mental health wards and in the community and reflect on the recognition of both physical deterioration in people with mental health conditions, and deteriorating mental health including the role of early intervention and averting crisis. A legal update will also be provided. We are pleased to offer a 20% discount with code hcuk20PSL Find out more and book your place

This course is aimed at those who wish to lead and conduct thematic reviews and those who are part of an themed review team. Through national updates and practical case studies, the conference will explore how thematic reviews can identify recurring safety issues and drive meaningful improvements in patient care. Sessions will provide insights into conducting system-based reviews, analysing qualitative data, and developing actionable safety recommendations. The conference will also focus on building confidence and competence in thematic review processes to support a proactive, learning-centred approach to patient safety. hub members can receive a 20% discount with code hcuk20PSL. If you are a member of the Patient Safety Management Network or Patient Safety Education Network you can book for only £195 +vat with code HCUK195psl. Register here.

This National Virtual Summit focuses on supporting staff to deliver good complaint handling and implementing and monitoring adherence to the PHSO National NHS Complaint Standards which are now being used and embedded across the NHS. Through national updates, practical case studies and in depth expert sessions the conference aims to improve the effectiveness of complaints handling within your service, and ensure that complaints are welcomed and lead to change and improvements in patient care. The conference will identify how you can improve response times to complaints in line with the government ambition to “reform the complaints process and improve response times to patient safety incidents and complaints” (10 yr plan for health 2025) through expanding on the Complaint Standards as outlined in the Dash review. The conference will also reflect involving people and their families in complaints and integrating the process with the new Patient Safety Incident Response Framework (PSIRF) to ensure patient safety actions and learning. The use of AI and technology in the management of complaints data and responses will also be discussed. This conference will enable you to: Network with colleagues who are working to improve complaints handling Update your knowledge on the NHS Complaint Standards and how implementation can improve complaints handling Reflect on the implications of the 10 year plan and Dash patient safety review Improve response times to patient safety incidents and complaints Understand how to manage complaints alongside the Patient Safety Incident Response Framework (PSIRF) Reflect on the perspective of a complainant who has been through the system to understand what person centred really means in Practice Understand how AI and technology can improve your analysis and response to complaints Learn how to bring kindness and compassion into complaints management, investigation, responses and learning Understand what PHSO and the CQC look for in a good complaint response Self assess your service against the NHS Complaint Standards Improve the way complaints and investigations involving serious incidents are handled Develop your skills in complex complaints handling including disputes, vexatious complainants and complaints across organisations Understand how you can improve frontline resolution of complaints in real time Develop your skills in de-escalation and conflict and dispute resolution Support staff through the complaints process including inquests Identify key strategies for ensuring change occurs as a result of complaints Ensure you are up to date with the latest legal issues including ensuring adherence to the duty of candour Self assess, reflect and expand your skills in complaints handling Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes We are pleased to offer a 20% discount with code hcuk20PSL Find our more and register here

The London Branch of SaRS is delighted to announce a joint collaboration webinar between SaRS and the International Ergonomics Association (IEA) Maritime & Ergonomics Technical Committee examining the fatigue risks in healthcare and the maritime industry. Fatigue is an insidious risk in all industries, one that is often misunderstood, undiagnosed and unregulated and is arguably the biggest performance shaping factor that affects safety and reliability in most industries, particularly those with time and commercial pressures allied to constraints on team resources. In this webinar the risks of fatigue will be explained, the challenges of managing these risks in healthcare and maritime and potential mitigating strategies will be unpacked. Healthcare and maritime, despite challenging work patterns, are often neglected sectors when talking about fatigue risks and share some common issues in the underpinning contribution of fatigue to safety. This webinar will support safety professionals to understand fatigue risk in more depth, providing more information on the systemic and practical contributors, and provide insight into how fatigue risks can be pragmatically managed. It will also draw from the experience of other industries, specifically rail, who have systematically embedded fatigue management over the last 3 decades. The webinar will be applicable to a wide range of safety professionals including, managers, operators, members of safety departments, analysts, auditors, investigators, etc. To register for the webinar please click here.