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Phil Ross is the Chair of the Design in Mental Health Network, Co-Founder of Safehinge Primera, and a Trustee at the Centre for Mental Health (UK). In this blog, Phil describes a collaborative Quality Improvement project that aimed to ensure a door alarm system acted as a trusted safety aid, not a constant distraction. When it comes to service user safety in mental health settings, every second counts. That’s why Aspen Wood, Mersey Care NHS Foundation Trust’s new 40-bed low secure unit for people with learning disabilities, installed 67 full-door ligature alarm systems. The system that invisibly transforms the entire door into a weighing scale, detecting any sustained load and triggering an alert for staff to proactively intervene and save a life. However, frontline NHS teams using full-door ligature alarms and other full-edge systems shared a challenge: frequent false alarms. These alarms are disruptive, distracting, and desensitising. For staff already stretched, these alerts became a barrier to the calm, therapeutic environments we’re all working to create. Not one to shy away, we listened. Then we acted and together, co-launched a Quality Improvement (QI) initiative to solve the issue. The cost of constant alarms in mental health wards Imagine being a nurse on a mental health ward where an alarm sounds 10-20 times every day. Each alarm demands immediate attention – a possible ligature attempt – yet almost every time it turns out to be a false alert. Front-line caregivers were understandably anxious that alarm fatigue – the desensitisation to alarms due to overexposure – could undermine patient safety. The false alarms were also distracting staff from providing care. Alarm fatigue is not a trivial inconvenience; it’s a well-documented clinical risk. In healthcare settings, when clinicians face an overload of alarms, they can become desensitised, leading to slower responses or ignored alerts.[1] In the context of mental health, the stakes are especially high – an ignored alarm could mean a patient death by suicide. Recent findings in the UK have highlighted this danger: an NIHR review noted that “‘alarm fatigue’ associated with surveillance technology use can even have fatal consequences”.[2] Tragically, this was echoed by a real-world incident in Essex, where an 18-year-old patient was found unresponsive after staff failed to respond for over 52 minutes to a bathroom sensor alert. The inquest revealed that staff had grown so accustomed to frequent alerts on their digital monitoring system that “alert fatigue” had set in.[3] Aspen Wood’s alarm challenge: 600+ alerts and a team determined to help At Aspen Wood, the alarm overload soon after installation quickly became recognised as an urgent patient safety and operational issue. The Trust’s leadership moved swiftly, bringing us in to discuss the issue and creating a cross-functional working group to explore ways to resolve it. Around the table were clinicians from the wards, Estates managers, the Trust’s risk and patient safety leads, our team of experts from Safehinge Primera, who developed the full-door anti-ligature alarm, and Pinpoint, who provide the staff attack alarm system that relays door alerts to staff devices. This collective approached the problem to try and understand the issue in greater detail and explore ways to solve it. Everyone agreed on a critical point: expecting zero alarms wasn’t realistic, but we should aim to get as low as possible (there will always be some incidents or tests). The team set an initial target: roughly one ligature alarm per day across Aspen Wood – ambitious yet attainable with the right improvements. Collaborative problem-solving Several concrete solutions emerged from the discussions and subsequent development work: ● Adjusted sensitivity threshold: When the QI team discussed weight sensitivity, the Trust’s Risk team highlighted that the door alarm was much more sensitive than other safety devices within the room - the load release curtain tracks released around 20 kg. Our full door alarm was set to a 7 kg weight threshold, unnecessarily sensitive. Here, the adjustable weight threshold became a big advantage for the Trust, changing to 15 kg for this user group (with the benefit of keeping lighter weight sensitivity when used for people with eating disorders). This change sharply cut false positives without compromising safety (indeed, the team carried out a series of lab tests based on a range of different previous ligature attempts). ● Firmware enhancements and battery life: Our team also rolled out a new approach to greatly improve battery life. The new firmware also introduced smarter data logging – essentially enabling the system to be more intelligent about what triggered it, so that staff could get feedback if improper use of the door was causing alarms (like wedging the door open or hanging objects). These behind-the-scenes tweaks enhanced the system’s robustness and reduced nuisance triggers by providing helpful feedback for staff. ● Localised and silent alerting: Initially, a door ligature alarm at Aspen Wood would broadcast an alert across the entire hospital network via the staff attack alarm system. This meant a single bathroom incident could set off alerts on multiple wards, needlessly alarming staff beyond the affected area. The system was reconfigured so that door ligature alarms now alert only the local ward. This change empowers the ward staff to quickly verify and respond, and, if it is a serious incident, staff can still escalate using their Personal Infrared Transmitter (PIT) alarm. The result is fewer interruptions hospital-wide and a more scalable response protocol. The Mersey Care team had always opted for silent alarms to prevent disrupting service users with learning disabilities, an approach we’re seeing adopted nationally across all care pathways. ● Staff training refreshers: We worked with the Trust to co-create simplified support materials to ensure staff felt confident managing the alarm system. A quick-reference poster was designed (with input from Aspen Wood’s clinical team) to support new or bank staff on how to swiftly reset a door alarm after an incident. Training sessions were scheduled, including hands-on practice using our mobile training unit. This conscientious approach acknowledged that technology is only as effective as the people using it. ● Stronger interface and support: Both Safehinge Primera and Pinpoint also recognised that closer integration and joint support when complex technical issues arise would help Mersey Care’s Estates team resolve issues quickly and easily. We also worked together to create a joint troubleshooting guide for the Aspen Wood team, so any issues could be quickly pinpointed (no pun intended) and resolved. By improving the interface between the two systems and clarifying responsibility, the Trust gained confidence that “issues” would no longer fall into a void between different suppliers, but instead, a collaborative team of experts. Results: from 600 alarms to just 6 – a transformative difference The results were even better than we’d hoped for…not 30 alarms per month, but just 6 alarms. When the stakeholders reconvened at the end of April 2025, our door alarm dashboard evidenced that alarm rates had plummeted. This has restored the alarm system to its intended role: a trusted safety aid, not a constant distraction. Reliability through the system's continual monitoring (avoiding the costly daily check requirements from push-bar, door edge type alarm systems) and adjustable weight sensitivity meant the alarms were keeping staff focused on time to care, whilst ensuring service user safety too. “The current pressure on frontline teams is huge, so when the built environment adds noise instead of support, it’s a problem that Estates are asked to resolve quickly. What made this initiative work was the openness on all sides. Together, we made the Safehinge Primera full-door ligature system smarter and safer for everyone, and something that we hope will help other NHS Trusts across the country.” Chris Murphy, Assistant Director of Estates and Facilities, Mersey Care NHS Foundation Trust A model for best practice: hopeful lessons beyond Aspen Wood The journey at Aspen Wood carries hopeful lessons for mental health facilities everywhere. Alarm fatigue in an inpatient mental health setting is not an insurmountable fate; it’s a challenge that can be overcome through empathetic, curious, and determined collaboration. Mersey Care didn’t shy away from flagging the problem, and in partnership with suppliers, they created the space to carry out an analysis and co-create solutions. The outcome made our alarm smarter, more user-friendly, and tailored to the ward’s needs. In doing so, they upheld a core principle of patient safety: technology must augment, not hinder, the human care process. This story also underlines a broader point in NHS mental health services: collaboration and continuous improvement are key. Just as we strive to co-produce care with service users, here we see collaboration between clinicians, engineers, and estates teams. The result – a dramatic reduction in alarms and a safer, calmer ward – speaks to the power of being conscientious (putting service user and staff needs first) and determined (not giving up on a good idea, even when it hits bumps in the road). By staying curious (asking “Why is this happening? How can we fix it?”) and maintaining a positive mindset that a solution would be found, the Aspen Wood team exemplified the best of NHS innovation culture. Looking ahead, Mersey Care’s Aspen Wood can serve as a model of best practice that we’re actively rolling out with other mental health Trusts. References 1. HSSIB. Investigation report: The impact of staff fatigue on patient safety. 2025. (Accessed online 11.02.26). 2. Griffiths JL, Saunders KRK, Foye U et al. The use and impact of surveillance-based technology initiatives in inpatient and acute mental health settings: a systematic review (preprint). 2024. (Accessed online 11.02.26). 3. BBC News. Essex mental health patient died despite staff alarm – inquest. (Accessed online 11.02.26) Further reading Reiter-Millard B. Tackling Alarm Fatigue. Safehinge Primera. 2025. (Accessed online 11.02.26) Opinions expressed in blogs and other content are those of the author. Patient Safety Learning welcomes sharing content and opinions that promotes safer patient care and for the reduction of avoidable harm. The views expressed on the hub however do not necessarily represent Patient Safety Learning's views or values. References to a specific product or service does not imply a recommendation or endorsement.

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.

On the 20 January 2026, a selection of Patient Safety Partners who are also members of the Patient Safety Partners Network, wrote to a number of key stakeholders outlining their concerns around healthcare worker fatigue and calling for action.  The letter was sent to: Wes Streeting MP, Secretary of State for Health and Social Care Baroness Merron, Parliamentary Under-Secretary of State (with portfolio responsibility for patient safety) Dr Aiden Fowler, National Director of Patient Safety and NHS England Professor Henrieta Hughes, Patient Safety Commissioner for England Layla Moran MP, Chair of the Health and Social Care Select Committee Jeremy Hunt MP, Chair of the All-Party Parliamentary Group on Patient Safety Danny Mortimer, Chief Executive of NHS Employers The content of the letter can be viewed below. 20 January 2026 Dear [RECIPIENT] We are writing to you on the issue of healthcare worker fatigue and its impact on patient safety. The signatories of this letter are all members of the Patient Safety Partners Network. The Network is composed of Patient Safety Partners, in both paid and voluntary positions within NHS organisations, whose role is to improve patient safety. It is hosted on the hub by the charity Patient Safety Learning, who provide a monthly drop-in session, sometimes with guests, to talk through topical and relevant issues. This facilitates information sharing, peer support and safe space for discussion. Fatigue poses serious risks to both the wellbeing of staff and safety of patients. Healthcare workloads are often heavy, stressful and involve complex decision making – however we lack robust fatigue risk management systems that exist in other safety-critical industries. At a recent Network session focusing on fatigue, we were joined by Dr Laura Pickup, Head of Human Factors at University Hospitals Bristol and Weston NHS Foundation Trust and a member of the organising committee for the Healthcare Fatigue Forum. The discussion highlighted several key issues: Fatigue in healthcare has become normalised, with staff continuing to work while exhausted, unlike in other safety-critical industries where controls are in place to prevent fatigue-related risks. Fatigue is a systemic issue, not an individual failing. It must be recognised through existing governance and risk management processes. Addressing fatigue requires leadership, organisational commitment, and system-level change, not simply individual resilience. Fatigue can be a contributor to avoidable harm and must be formally recognised as such within safety investigations. Staff should be empowered to speak up when they are too fatigued to work safely. Our Call to Action We are asking that every healthcare organisation formally adds fatigue to its organisational risk register. By doing so, each organisation would be required to: Risk assess the impact of fatigue on both staff and patient safety. Identify mitigation and management actions to reduce fatigue-related risks. Monitor progress and outcomes through established governance systems. Recognising fatigue in this way is not merely a procedural step—it is an essential act of leadership and accountability. It acknowledges that fatigue is a significant, system-level patient safety risk and ensures that it is managed with the same rigour as other high-impact safety concerns. We would also welcome the following complementary actions: Inclusion of fatigue as a contributing factor in investigations under the Patient Safety Incident Response Framework (PSIRF), where relevant. Endorsement and amplification by the Department of Health and Social Care, NHS England, and individual NHS organisations of the work being done by the Healthcare Fatigue Forum and the #FightingFatigue campaign to raise awareness and share best practice. We would welcome your response and support for our call to action. I look forward to your response in due course. Yours sincerely, 12 signatories were included (Members of the Patient Safety Partners Network).

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.

Last month, Public Policy Projects hosted their annual Patient Safety Forum in partnership with Patient Safety Learning. Held at the Royal College of Surgeons of England in London, it was attended by senior healthcare leaders, patient safety experts, representatives from the HealthTech industry, frontline healthcare professionals and patients. In this article, Patient Safety Learning reflects on the recurrent theme of safe systems and safe cultures.  Safe systems and cultures formed an integral theme throughout the Forum. Across the discussions, one message stood out clearly—safety cannot be something we focus on only when inspections are approaching or when things go wrong. It has to be built into everyday practice. One speaker framed this idea simply—every day should be a CQC (Care Quality Commission) day. Not because staff fear inspection, but because the systems around them consistently support safe care. When systems work well, healthcare professionals can deliver the care they want to give without constantly battling the structures and culture around them. Yet the conversations during the day also highlighted how far many parts of the system still have to go… Fatigue—“I’ll sleep when I’m dead” A significant discussion focused on staff fatigue and the culture that has developed around it in healthcare. Rather than being treated as an exceptional risk, fatigue is something that is just expected. In some cases it has become a misplaced badge of honour—evidence of dedication to the job. The example phrase of “I’ll sleep when I’m dead” resonated with many. A response no doubt born from a sense of utter powerlessness and lack of evidence that things will change. But normalising exhaustion creates unsafe systems for both staff and patients. Senior Nurse, Maggie Pacheco, shared an example from her own experience. After working six consecutive night shifts she was asked to take on a seventh. It did not feel safe, and during that shift a near miss occurred. Her story reflected a wider reality—systems that rely on exhausted staff are systems that increase risk. Sue Strudwick, Patient Safety Partner, highlighted that fatigue also shapes how care is delivered. When staff are constantly depleted, the system pushes them into reactive responses rather than preventative thinking. Creativity, reflection and improvement require energy and time, both of which fatigue removes. If healthcare is serious about safe systems, then fatigue cannot remain normalised. Staff support must be prioritised and built into the design of rotas, policies and expectations. Structural change is required, not symbolic gestures. Staff safety as a foundation of safe systems The forum also highlighted the importance of ensuring that staff themselves feel safe at work. Healthcare workers continue to face violence, harassment, racism and sexual abuse in some workplaces. These experiences damage morale, wellbeing and the ability to focus on patient care. A safe healthcare system cannot exist if the people delivering care do not feel physically and psychologically safe themselves. Protecting staff is therefore not separate from patient safety—it is part of it. When silence signals risk Another strong theme was the importance of psychological safety, particularly when it comes to speaking up and raising safety concerns. Silence in an organisation is sometimes interpreted as stability. In reality, it can indicate the opposite. Panellists described the presence of “shut up signals” within teams and organisations—signals that speaking up is unwelcome or risky. These signals may appear through dismissive responses, defensive leadership or negative consequences after raising concerns. Once staff recognise them, they quickly learn that raising issues carries a personal cost. The impact on patient safety is significant. When staff do not feel able to speak openly about risks or mistakes, organisations lose their early warning systems. Problems remain hidden until they escalate into serious harm. Language and responses after incidents play an important role here. Punitive reactions can discourage openness and suppress learning. Safe cultures, by contrast, make it easier for staff to raise concerns and share information when something goes wrong. Many of the guests in our Speaking up for patient safety interview series highlight the same issues surrounding psychologically unsafe cultures, and the devastating impact this can have on patients and staff. From blame to systems thinking Closely linked to speaking up is the way organisations respond when incidents occur. Healthcare is a complex system where harm rarely results from a single individual’s actions. During the forum, Ted Baker, Chair of the Health Services Safety Investigations Body (HSSIB), highlighted the importance of shifting the question from “who is to blame?” to “how did the system allow this to happen?” Frontline staff frequently create workarounds to protect patients when systems or policies do not function well in practice. These adaptations often keep services running safely despite structural weaknesses. If organisations focus only on individual blame, they risk overlooking the system conditions that allowed harm to occur in the first place. A systems approach enables learning and improvement rather than fear and defensiveness. Leadership and culture change Underlying many of these issues is the need for a different style of leadership. Creating safe systems requires leaders who listen, collaborate and engage with those delivering and receiving care. Solutions are more likely to be sustainable when they are developed with frontline staff and patients rather than imposed from above. Working with patients, the public and Patient Safety Partners were repeatedly highlighted as an important part of cultural change. A healthcare system that values patient experience alongside operational metrics is more likely to identify risks early and respond effectively. What organisations measure also shapes their culture. When success is defined solely through activity and productivity, the human experience of care can easily be overlooked. Balanced measures that include safety and experience are essential for creating systems that truly support quality care. Culture is the system The conversations at the Patient Safety Forum made clear that safety cannot be separated from culture. Policies and processes matter, but the everyday behaviours, expectations and norms within organisations matter just as much. Safe systems are created when staff are supported rather than exhausted, when concerns can be raised without fear, and when organisations seek to understand system failures rather than simply assign blame. Changing culture is never quick or easy. But if healthcare systems want to improve patient safety, they must be willing to challenge the norms that have become embedded in everyday practice and redesign systems that allow safe care to happen consistently. Share your insights Have you seen patient safety affected either positively or negatively by culture and systems? Share your thoughts on this article and the issues raised by commenting below (sign up first for free). Or you can email our editorial team at [email protected].

Aimed at Clinicians and Managers, this national virtual conference will provide a practical guide to human factors in healthcare, and how a human factors approach can improve patient care, quality, process, and safety. The conference delves into integrating human factors into healthcare systems and processes, clinical decision making, healthcare system design, quality of patient experience, medication safety, and workload, fatigue, and stress management. Throughout the day there will be interactive sessions, small breakout groups, and collaborative exercises, fostering a dynamic learning experience. This conference will enable you to: Network with colleagues who are working to embed a human factors approach. Learn from outstanding practice in using human factors and ergonomics to improve patient safety and quality. Reflect on national developments and learning including the patient safety syllabus and the role of human factors within the new Patient Safety Incident Response Framework (PSIRF). Understand the tools and methodology. Develop your skills in training and educating frontline staff in human factors. Understand how you can improve patient safety incident investigation by using a human factors approach. Learn from case studies demonstrating the practical application of human factors to improve patient care and safety. Understand the role of human factors in improving culture and delivering psychological safety. Self assess and reflect on your own practice. 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. Register We are pleased to offer hub members a free place using the code HCUK00HFPSL

Patient Safety Partners (PSPs) are being recruited by NHS organisations across England as part of NHS England’s Framework for involving patients in patient safety.  This page explains:  What a Patient Safety Partner is. What the Patient Safety Partners Network is. How to join the Network. How members are benefiting. What is a Patient Safety Partner? Patient Safety Partners can be patients, relatives, carers or other members of the public who want to support and contribute to a healthcare organisation’s governance and management processes for patient safety. What is the Patient Safety Partners Network (PSPN)? The Patient Safety Partners Network is for Patient Safety Partners, in both paid and voluntary positions within NHS organisations, whose role is to improve patient safety. It is hosted on the hub by the charity Patient Safety Learning, who provide a monthly drop-in session, sometimes with guests, to talk through topical and relevant issues. This facilitates information sharing, peer support and safe space for discussion. The Network has over 200 members. How can I join the Network? Membership is open to people who are: UK hub members (it’s free) in a health or care service provider organisation in a Patient Safety Partner role. Membership is open to PSPs from Integrated Care Boards, mental health, ambulance, acute and community trusts, as well those from NHS England, independent providers and the third sector. You can join by signing up to the hub today. When putting in your details, please tick the Patient Safety Partners Network (PSPN) option in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected]. I am a Patient Safety Partner – how will I benefit from joining the Network? We asked some of the Patient Safety Partners who are members of the Network to share their thoughts… “The PSP network has given me the confidence to challenge some things at my Trust and reassured me in terms of what I can be doing and how I can be positively involved in patient safety.” Sue Strudwick, Patient Safety Partner at Kingston and Richmond NHS Foundation Trust. “I have learned so much in my time as a network member and the generous advice and support I have received from colleagues is worth its weight in gold, I really recommend you give it a go- give it a try and I guarantee you won’t be disappointed.” Marion Endicott, Patient Safety Partner at South West London Integrated Care Board. “The PSPN is valuable and important to me as a sounding board & shared experience forum, providing support with a shared goal in promoting patient safety.” Joanne Foley, Patient Safety Partner at NHS Essex Integrated Care Board. Related resources Patient Safety Partners: a toolkit of resources Letter from Patient Safety Partners calls for fatigue to be added to organisational risk registers (20 January 2026)

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].

Risa Mallory is a retired psychotherapist from Canada and a hub Topic leader. After a serious cardiovascular event in 2018 she became a patient advocate, collaborating with organisations across the globe.  In this blog, Risa contends that patient-centred care provides a good foundation but should not be the end goal. She calls on healthcare systems to evolve towards patient-led care, suggesting that this is key to ensuring that patients are treated as partners rather than participants.  When you live with heart disease, healthcare stops being abstract very quickly. It becomes personal, constant, and at times overwhelming. Appointments, medications, test results, lifestyle changes—these are not theoretical concepts, they shape how you live each day. Over time, I have learned that how care is delivered matters just as much as what care is delivered. That is where the distinction between patient-centred and patient-led healthcare becomes meaningful. Patient-centred care Patient-centred care is a term I hear often. Clinicians use it to describe care that considers my needs, values, and preferences. On the surface, this sounds exactly right. As a cardiac patient, I want to be treated as a whole person, not just a heart condition. I want my concerns listened to, my fears acknowledged, and my circumstances taken into account. When patient-centred care is done well, it feels respectful. My cardiologist explains options, my nurse checks in on how I’m managing, and decisions are made with me, not just about me. But as someone who lives with this condition every day—not just during clinic visits—I have come to realise that patient-centred care still often keeps control firmly within the healthcare system. The care may be tailored to me, but it is usually still designed, paced, and directed by professionals. I am invited to the table, but I do not always get to set the agenda. That is where patient-led healthcare differs. Patient-led care Patient-led care recognises something fundamental: I am the one living inside this body. I am the one who feels the side effects, manages the fatigue, navigates fear after a hospital admission, and tries to balance medical advice with real life. In a patient-led model, my lived experience is not just considered—it is treated as expertise. As a cardiac patient, being patient-led does not mean I reject clinical knowledge or expect to make decisions alone. I still rely deeply on my healthcare team’s training and experience. What changes is the balance of power. Instead of being asked, “What matters to you?” after decisions are mostly formed, patient-led care asks that question at the beginning—and allows the answer to shape the pathway forward. For example, when discussing treatment options, patient-centred care might present several evidence-based choices and ask which one I prefer. Patient-led care goes further. It asks how those options will affect my daily life, my mental health, my ability to work or care for family, and whether the recommended plan is realistic for me to sustain. It allows me to say, “This may be clinically ideal, but it doesn’t fit my life,” without fear of being labelled non-compliant. From participants to partners The difference becomes especially clear after a cardiac event. In hospital, patient-centred care might ensure good communication, compassionate interactions, and shared decision-making. Once discharged, however, the burden of care shifts heavily onto the patient. Medications, monitoring symptoms, lifestyle changes—suddenly, I am expected to lead my own care without always being given the tools, confidence, or ongoing support to do so. Patient-led healthcare recognises this gap and works to close it. Patient-led care values partnership beyond appointments. It supports education that empowers rather than overwhelms. It acknowledges emotional recovery as part of cardiac recovery. It invites patients into service design, research priorities, and policy decisions—not as a token gesture, but as equal contributors. After all, systems built without patient input often fail to meet patient needs. From my perspective, patient-centred care is an important foundation, but it is not the end goal. It still positions patients as recipients of care, even when that care is compassionate and individualised. Patient-led healthcare moves us from being participants to being partners. It trusts that patients, when supported appropriately, can help guide better, safer, and more humane care. Living with heart disease has taught me that my voice matters—not just in my own treatment, but in shaping the systems meant to support people like me. True progress in healthcare will come when patient-centred care evolves into patient-led care, where lived experience is not an afterthought, but a driving force. More blogs by Risa Compassion is medicine: a patient safety perspective The power of being heard in healthcare When lived experience is embedded at every stage of research Women’s heart health - a patient safety priority Why the patient voice matters when things go wrong

Risa Mallory is a retired psychotherapist from Canada and a hub Topic leader. After a serious cardiovascular event in 2018 she became a patient advocate, collaborating with organisations across the globe.  In this blog, Risa draws on personal experience, research, and her advocacy knowledge, to explain why compassion is critical to patient safety. When we talk about patient safety, the first things that often come to mind are checklists, protocols, and technologies designed to prevent errors. But there’s another equally powerful, yet often underestimated, element of safety: compassion. In healthcare, compassion isn’t a soft skill or an optional extra. It’s medicine in its own right. Human connection Compassion fosters connection. When clinicians approach care with empathy and genuine concern, patients feel safe to speak up—about their symptoms, their fears, and even when something doesn’t feel right. I know first-hand that open communication is a cornerstone of safety. There were substantial keystroke errors in my medical record that could have adversely affected my treatment, and only I was qualified to rectify them. Fortunately, the nurse was not only receptive of my lived experience knowledge, but welcomed it. Many medical errors are caught not by systems or alarms, but by a patient’s voice—when that voice is welcomed and heard. From a patient’s perspective, the presence or absence of compassion can completely change an experience. A rushed conversation or a dismissive tone can discourage questions, leading to misunderstandings or missed information that could prevent harm. Conversely, when a healthcare professional takes the time to listen, validate, and explain, it builds trust and trust saves lives. During my inpatient cardiologist’s rounds, he consistently had one ‘foot out the door’. After a few days of feeling dismissed and not feeling heard, I invited him to sit down to answer questions I had prepared for him. Initially hesitant, he eventually complied and sat down every visit thereafter. The power of compassion… for patients and staff Research has shown that compassion in healthcare improves patient adherence to treatment, lowers anxiety and pain and reduces readmissions.[1,2] It also increases medical staff’s feelings of competence.[3,4] But its role in safety is just as important: compassion encourages partnership. When care teams and patients see each other as allies, safety becomes a shared responsibility rather than a top-down directive. Compassion also protects healthcare workers. The culture of safety extends to the wellbeing of providers, too. Burnout, moral distress, and fatigue all erode safety. When healthcare systems prioritise compassion—not just toward patients, but within teams—they create environments where people feel valued, supported, and capable of delivering their best care. Compassion, in this sense, is both preventive and restorative medicine. Small gestures can ground us in what truly matters Embedding compassion into patient safety practices doesn’t require grand gestures. It can begin with small, human acts: making eye contact, calling patients by name, pausing to ask if they understand, or acknowledging their emotions before diving into data. These are simple actions that restore dignity, reduce fear, and open the door to safer care. Patients, too, can be advocates for compassionate care. Speaking up, offering feedback, and reminding systems that safety is not only about precision but also about connection helps drive the culture change we need. Compassion invites partnership; partnership builds safety. In a healthcare landscape increasingly defined by technology and efficiency metrics, compassion grounds us in what truly matters—the human relationship at the centre of healing. It bridges the gap between clinical excellence and emotional intelligence. It transforms care from a transaction into a collaboration. And, most importantly, it keeps us safe! References 1. Watts E, Patel H, Kostov A, et al. The Role of Compassionate Care in Medicine: Toward Improving Patients' Quality of Care and Satisfaction. 2023. J Surg Res. 2023 Sep:289:1-7. 2. The Transformative Role of Nursing in Improving Clinical Outcomes and Patient Satisfaction: A Systematic Review. Vascular and Endovascular Review, 2025:8(3s), 101-109. 3. Ahmed Z, Ellahham S, Soomro M, et al. Exploring the impact of compassion and leadership on patient safety and quality in healthcare systems: A narrative review. 2024. BMJ Open Quality, 13, e002651. 4. Tehranineshat B, Rakhshan M, Torabizadeh C et al. Compassionate Care in Healthcare Systems: A Systematic Review Journal of the National Medical Association. Journal of the National Medical Association. 2019:Volume 111, Issue 5, Pages 546-554. More blogs by Risa The power of being heard in healthcare When lived experience is embedded at every stage of research Women’s heart health - a patient safety priority Why the patient voice matters when things go wrong

When repeated harm occurs in healthcare, public debate often centres on identifying an individual responsible. Although accountability is essential, patient safety may be better served by asking another question first: Were there earlier signals that something was going wrong? This blog reflects the perspective of Aditi Desai, a surgeon with nearly three decades of clinical experience and an interest in patient safety systems, surgical quality monitoring and organisational learning. Recent high‑profile cases, such as the case of surgeon Yasser Jabbar at Great Ormond Street Hospital,[1] have prompted difficult reflection across the profession about how systems detect repeated patient harm. These situations understandably lead to questions about individual responsibility, but they also highlight the importance of recognising warning signals earlier. After nearly three decades in surgical practice, I have seen how outcomes can fluctuate. A surgeon may perform many procedures safely, then experience several complications in close succession. Some of this represents natural variation. But sometimes patterns emerge that should prompt earlier concern. Modern healthcare systems collect large amounts of clinical data, yet we rarely use it systematically to detect deteriorating performance early.[2] Risk‑adjusted monitoring of outcomes over time, combined with supportive mentoring and fair accountability, could help organisations intervene sooner, protecting both patients and clinicians. Improving patient safety requires moving beyond a simple choice between blaming individuals or fixing systems. Safer care depends on recognising both the human realities of clinical practice and the need for strong organisational oversight. Recognising the early warning signs of unsafe surgical practice Having practised surgery for more than 28 years, I have learned that clinical outcomes are rarely perfectly predictable. A surgeon may perform a hundred operations without complication. Then, within a short period, several adverse outcomes may occur—like unexpected bleeding, infection or an unintended injury during surgery. When this happens, patients suffer first and most. For clinicians, complications also carry a heavy emotional weight. Many doctors recognise the sleepless nights and intense self‑reflection that follow when a patient is harmed. In recent years, public discussions around cases of repeated patient harm have raised difficult questions about how healthcare systems detect unsafe practice. The case of Yasser Jabbar at Great Ormond Street Hospital, widely reported in the UK, has prompted reflection not only about accountability but also about whether earlier signals of unsafe care might have been detectable. The instinctive response is often to ask: “Who is the rogue clinician?” But from a patient safety perspective, an equally important question may be: “Where was the signal that care was becoming unsafe?” Distinguishing variation from unsafe care All clinical practice carries risk. Even highly skilled surgeons experience complications. Medicine is complex, and outcomes vary according to patient condition, procedural difficulty and chance. The real challenge is distinguishing between: Expected complication rates and natural variation, and Patterns that may indicate deteriorating performance or unsafe practice. This distinction is rarely straightforward. It requires careful interpretation of clinical outcomes and trends over time. The human side of surgical practice Medicine often expects clinicians to perform at a consistently high level throughout long careers. Yet surgeons, like everyone else, experience illness, fatigue, personal stress and periods of reduced resilience. Most clinicians continue working through these pressures because the culture of medicine places great value on strength, reliability and professionalism. Recognising this human reality does not diminish professional responsibility. Instead, it highlights the importance of systems that can identify when a clinician may be struggling and offer support or review before patient harm accumulates. The missing safety infrastructure Healthcare organisations collect vast amounts of data about procedures and outcomes. Yet in many systems, we still lack robust mechanisms that can: Risk‑adjust outcomes for patient complexity. Monitor outcome trends over time. Identify negative outliers early. Trigger timely peer review or mentoring. Such systems are not primarily about punishment. Their purpose is to protect patients while supporting clinicians to maintain safe practice. Moving beyond 'individual versus system' Patient safety discussions often frame harm as either the fault of an individual clinician or the result of system failure. In reality, safety depends on both. Strong systems should be able to detect emerging risks early, while still ensuring fair accountability when unsafe practice becomes clear. This approach aligns with the principles of a just culture, where organisations seek to understand and respond to risks rather than relying solely on retrospective blame.[3] A role for data, mentorship and oversight In other high‑performance fields, such as aviation and elite sport, continuous monitoring and coaching are routine. Medicine has traditionally been slower to adopt this approach. Yet supportive oversight and mentoring could help clinicians identify and address problems earlier in their careers or during periods of difficulty. Clinicians may benefit from ongoing coaching and feedback, not only during training but throughout their professional lives.[4] Surgeon and writer Atul Gawande, the WHO checklist pioneer, highlighted this idea in his TED Talk “Want to get great at something? Get a coach”, where he describes how even experienced surgeons can improve performance and safety through structured coaching and peer observation.[5] Looking forward Cases where repeated harm occurs inevitably raise questions about accountability. Where clear incompetence or unsafe practice exists, fair accountability is essential. But patient safety improves most when healthcare systems are able to recognise warning signs early, before serious harm accumulates. By combining risk‑adjusted data, supportive oversight and a culture of learning, healthcare organisations can better protect patients while supporting clinicians to maintain safe practice. Ultimately, safer care depends not only on responding to failure, but on building systems capable of recognising risk sooner. References Triggle N. Great Ormond Street doctor who botched surgery harmed nearly 100 children. BBC News, 29 January 2026. Royal College of Surgeons of England. Surgical outcomes data and transparency. Outcomes FAQ. NHS England. Being fair tool: supporting staff following a patient safety incident. 9 May 2025. Pradarelli JC, Yule S, Panda N, et al. Optimising the implementation of surgical coaching through feedback from practicing surgeons. JAMA Surgery, 2021; 56;(1): 42-49. doi:10.1001/jamasurg.2020.4581. Gawande A. Want to get great at something? Get a coach. TED Talk, April 2017.

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].