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Content ArticleIn Northern California and beyond, healthcare systems are rapidly integrating artificial intelligence (AI) and digital tools to transform how pain is recognised, measured, and managed. From algorithm-guided assessments to wearable sensors and predictive analytics, these tools promise to augment clinical decision-making and improve patient outcomes. Yet significant controversies remain, including concerns over algorithmic accuracy, bias, data privacy, and the extent to which technology should complement or potentially displace human clinical judgment.
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Event
Seating Masterclass (Northeast Scotland)
Patient Safety Learning posted an event in Community Calendar
Seating Matters’ in-person Seating Masterclasses are the ideal chance to refresh and enhance your knowledge of effective sitting, pressure care management, and the seating assessment process. Stay up to date with the latest innovations in seating and gain practical insights from leading experts. Our resident OT, Kirsty Ryan, will share her expertise on conducting thorough seating assessments, managing pressure, and supporting posture. Whether you’re an occupational therapist, healthcare professional, caregiver, or simply passionate about seating solutions, this masterclass offers a valuable opportunity to connect with peers and explore new approaches to practice. Don’t miss out—register today using the promo code PATIENTSAFETYLEARNING to secure your free place! Register -
Event
Seating Masterclass (Dublin)
Patient Safety Learning posted an event in Community Calendar
Seating Matters’ in-person Seating Masterclasses are the ideal chance to refresh and enhance your knowledge of effective sitting, pressure care management, and the seating assessment process. Stay up to date with the latest innovations in seating and gain practical insights from leading experts. Our resident OT, Kirsty Ryan, will share her expertise on conducting thorough seating assessments, managing pressure, and supporting posture. Whether you’re an occupational therapist, healthcare professional, caregiver, or simply passionate about seating solutions, this masterclass offers a valuable opportunity to connect with peers and explore new approaches to practice. Don’t miss out—register today using the promo code PATIENTSAFETYLEARNING to secure your free place! Register -
Event
Seating Masterclass (Bristol)
Patient Safety Learning posted an event in Community Calendar
Seating Matters’ in-person Seating Masterclasses are the ideal chance to refresh and enhance your knowledge of effective sitting, pressure care management, and the seating assessment process. Stay up to date with the latest innovations in seating and gain practical insights from leading experts. Our resident OT, Kirsty Ryan, will share her expertise on conducting thorough seating assessments, managing pressure, and supporting posture. Whether you’re an occupational therapist, healthcare professional, caregiver, or simply passionate about seating solutions, this masterclass offers a valuable opportunity to connect with peers and explore new approaches to practice. Don’t miss out—register today using the promo code PATIENTSAFETYLEARNING to secure your free place! Register -
Event
Seating Masterclass (London)
Patient Safety Learning posted an event in Community Calendar
Seating Matters’ in-person Seating Masterclasses are the ideal chance to refresh and enhance your knowledge of effective sitting, pressure care management, and the seating assessment process. Stay up to date with the latest innovations in seating and gain practical insights from leading experts. Our resident OT, Kirsty Ryan, will share her expertise on conducting thorough seating assessments, managing pressure, and supporting posture. Whether you’re an occupational therapist, healthcare professional, caregiver, or simply passionate about seating solutions, this masterclass offers a valuable opportunity to connect with peers and explore new approaches to practice. Don’t miss out—register today using the promo code PATIENTSAFETYLEARNING to secure your free place! Register -
Content ArticleECRI's Top 10 Health Technology Hazards for 2026 is now available. This annual report helps hospitals, health systems, ambulatory surgery centres, aging care organisations, and manufacturers identify potential risks and take steps to promote safer health technology use. An Executive Brief of the report is now available for complimentary download. This year's report features first-time topics and timely concerns that address high-priority challenges, including: The misuse of AI chatbots In healthcare. Unpreparedness for a “digital darkness” Event The growing challenge of combating substandard and falsified medical products.
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News Article
Trust’s missing training contributed to death
Patient Safety Learning posted a news article in News
A coroner has warned a trust over communication failures, leadership and a “lack of professional curiosity” in relation to a patient’s death, which appear to echo previous cases at the provider. Hampshire and Isle of Wight Healthcare Foundation Trust was criticised by area coroner Nicholas Walker after the death of 34-year-old Abigail Jelley, who took her own life last year while suffering from post-natal depression. Mr Walker said he was concerned “structural issues with the leadership of [the trust]” could result in harm done to future patients. He referred to an internal investigation report that he said described a “lack of professional curiosity, lack of escalations of deteriorating patients, non-patient centred decision making and a linear approach to risk assessment and formulation”. The coroner described how Ms Jelley, who began to struggle with her mental health after the birth of her second child in 2024, was seen by different mental health professionals “whose job it was to react to that crisis and attempt to assist her through it”. Ms Jelley had been living with her parents before she died, who could have provided valuable information, but they were not spoken to by medical professionals, the coroner said. He noted: “It was accepted [by the trust] that there was a lack of professional curiosity shown by professionals both in Abigail’s case and generally.” It was also found that community mental health teams do not receive mandatory training on perinatal “red flags”, and despite requesting it longer than a year ago, the team had yet to receive it. Read full story Source: HSJ, 5 November 2025 -
Content Article
Top picks: Venous thromboembolism
Patient Safety Learning posted an article in High risk areas
Blood clots, particularly deep vein thrombosis (DVT) and pulmonary embolism (PE), together venous thromboembolism (VTE), pose a significant health threat to patients. These potentially life-threatening conditions can manifest silently and without warning, making vigilance and knowledge crucial. In this Top picks, we’ve pulled together resources, blogs and reports from the hub for patients and healthcare professionals, which focus on how to recognise venous thromboembolism and how to improve patient safety. 1. Deep vein thrombosis: understanding and managing your risk In this blog, Jo Jerrome, CEO of Thrombosis UK, explains the dangers of DVT and why it is important for patients and staff to be aware of the risk factors. Jo offers advice on how we can all manage our risk of DVT. 2. HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments This investigation by the Healthcare Safety Investigation Branch (HSIB) explores the timely recognition and treatment of suspected pulmonary embolism in emergency departments. 3. Jenny, and why we must learn from her misdiagnosis of pulmonary embolism Jenny Edwards died in February 2022 from pulmonary embolism, following misdiagnosis. In this blog, her son Tim introduces us to Jenny, illustrating the deep loss felt following her premature passing. He talks about the care she received and argues that there were multiple points at which pulmonary embolism should have been suspected. 4. Venous thromboembolism (VTE): deep vein thrombosis and pulmonary embolism VTE is a significant cause of mortality, long-term disability and long-lasting ill-health problems – many of which are avoidable. 1 in 20 people will have a VTE at some time in their life and the risk increases with age. This NHS Resolution guide provides more information about the risks of VTE and how to spot the common signs and symptoms. 5. HSIB - The assessment of venous thromboembolism risks associated with pregnancy and the postnatal period final report This investigation by the HSIB explores the issues associated with the assessment of risk factors for venous thrombosis in pregnancy and the first six weeks after birth. 6. NHS Resolution: Working to prevent avoidable venous thromboembolism VTE is an international patient safety issue and a clinical priority for the NHS. Around half of all cases of VTE are associated with hospitalisation, with many events occurring up to 90 days after admission. It is a leading and preventable cause of death in an estimated 25,000 of hospitalised patients each year. This information leaflet highlights the cost of VTE claims and what you can do in your organisation to prevent VTE. 7. Pulmonary embolism misdiagnosis – a systemic problem Tim Edwards is a risk management expert and son of Jenny, who passed away in February 2022 from pulmonary embolism, following a misdiagnosis. Frustrated by the quality of the initial investigation that followed her death and the lack of assurance that learning would take place, Tim conducted an independent review. In this opinion piece, Tim draws on his research to highlight the key patient safety issues, and to encourage further dialogue around the topic. 8. Let's Talk Clots! Help reduce your risk of DVT and PE in hospital with this simple app Download the free Let’s Talk Clots patient information app from Thrombosis UK, and help reduce your risk of DVT and pulmonary embolism in hospital. 9. Patient Safety Spotlight Interview with Beverley Hunt, Professor of Thrombosis and Haemostasis and founder of Thrombosis UK In this interview, Beverley Hunt talks about setting up Thrombosis UK and how it has grown to have a national impact on patient safety in hospitals. She also describes the value of combining policy work with seeing patients face-to-face, and explores the need to find new ways of working to deal with the pressures facing the healthcare system. 10. Risk assessment models for venous thromboembolism in medical inpatients This cohort study in JAMA Network Open aimed to determine the prognostic performance of the simplified Geneva score and other validated risk assessment models (RAMs) to predict VTE in medical inpatients. The study provided a head-to-head comparison of validated RAMs among 1352 medical inpatients. It found that sensitivity of RAMs to predict 90-day VTE ranged from 39.3% to 82.1% and specificity of RAMs ranged from 34.3% to 70.4%. The authors concluded that the clinical usefulness of existing RAMs is questionable, highlighting the need for more accurate VTE prediction strategies. 11. HSIB: Investigation into management of venous thromboembolism risk in patients following thrombolysis for an acute stroke This HSIB investigation focused on the management of VTE risk in inpatients following thrombolysis for an acute stroke detection of medical problems (that impact on VTE risk) occurring in inpatients following thrombolysis for an acute stroke. Do you have a resource or story to share? We’d love to hear about it - leave a comment below or join the hub to share your own post. -
Content Article
Understanding your HSE culture (2018)
Patient Safety Learning posted an article in Culture
Understanding your HSE culture is one of the world's most widely used tool for measuring HSE culture. The tool measures organisational HSE culture against the Hearts and Minds/Hudson and Parker safety culture ladder. Understanding your HSE culture helps organisations explore their culture by providing descriptions of how companies behave at the 5 different levels of culture: Pathological: people don’t really care about HSE and are only driven by regulatory compliance and/or not getting caught. Reactive: safety is taken seriously, but only after things have gone wrong. Managers feel frustrated about how the workforce won’t do what they are told. Calculative: focus on systems and numbers. Lots of data is collected and analysed, lots of audits are performed and people begin to feel they know "how it works". The effectiveness of the gathered data is not always proven though. Proactive: moving away from managing HSE based on what has happened in the past to preventing what might go wrong in the future. The workforce start to be involved in practice and the Line begins to take over the HSE function, while HSE personnel reduce in numbers and provide advice rather than execution. Generative: organisations set very high standards and attempt to exceed them. They use failure to improve, not to blame. Management knows what is really going on, because the workforce tells them. People are trying to be as informed as possible, because it prepares them for the unexpected. This state of "chronic unease" reflects a belief that despite all efforts, errors will occur and that even minor problems can quickly escalate into system-threatening failures. -
Content Article
Using the Hudson Ladder in the context of health culture
Patient Safety Learning posted an article in Culture
Is the Hudson Framework suitable for health culture? David Day, Head of SHE at nuclear specialist Nuvia UK, talks about why he has selected a particular cultural model as the basis to develop a health culture assessment tool. -
News Article
NHSE vows to end ‘bombardment’ of trusts
Patient Safety Learning posted a news article in News
NHS England has vowed to “reduce duplication and prevent providers from being bombarded with conflicting instructions”, including by removing integrated care boards’ performance management role. A new draft NHS Performance Assessment Framework, published today, promises to “streamline oversight” by “providing consistent and co-ordinated oversight to reduce duplication and prevent providers from being bombarded with conflicting instructions”. The document attempts to set out how integrated care boards and trusts will be regulated by NHS England, starting from July. It confirms that NHSE, not ICBs, will be responsible for provider performance management – a move announced late last year but met with anger from many ICBs. The new paper says: “Discussions about performance will be led by colleagues at NHS England, who are experienced in addressing delivery challenges.” The proposal that NHSE performance management will be carried out “with and through” ICBs — included in earlier versions of the framework — has gone. In addition, trusts’ performance “segments” will no longer take into account wider system performance, nor a proposed judgement of their “capability”, as they will “solely [be] linked to delivery metrics”. ICBs will still have to “hold their partners to account using the system levers that bind them together, such as their joint system plans, partnership agreements, joint committees and collaboratives”, however. The framework is subject to consultation, and new NHSE CEO Sir Jim Mackey told its board today it was likely to be changed. There will “absolutely be some things we need to change and adjust”, he said. “This isn’t something that can be perfect at the first go.” Read full story (paywalled) Source: HSJ, 27 March 2025 -
EventuntilThe Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. In this webinar we will explore MNSI’s Health Equity Warning Score (HEWS) and the Health Equity Assessment and Resource Toolkit (HEART). MNSI's health equity, diversity and inclusion leads developed this assessment tool to systematically identify, acknowledge, investigate and analyse factors affecting health equity which impact care and perinatal outcomes. Join this webinar to find out how you can put this tool into practice in your trust. Register for the webinar
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Content Article
Eating disorders training for health and care staff
Patient-Safety-Learning posted an article in Eating disorders
This series of training programmes was collaboratively developed by eating disorder charity Beat, Health Education England and NHSE. It was developed in response to the 2017 PHSO investigation into avoidable deaths from eating disorders, as outlined in recommendations from the report Ignoring the Alarms: How NHS Eating Disorder Services Are Failing Patients. It is designed to ensure that healthcare staff are trained to understand, identify and respond appropriately when faced with a patient with a possible eating disorder. It includes sessions relevant for different healthcare professionals and includes: Medical students and foundation doctors programme Nursing workforce sessions GP and Primary care workforce sessions Medical Monitoring in eating disorders Understanding Eating Disorders Webinar resource for dietitians, oral health teams and community pharmacy teams -
Content ArticleAn estimated 90,000 people are living with dementia in Scotland, with that number expected to increase to 164,000 by 2036. These national clinical guidelines from Health Improvement Scotland, the first to be published in nearly 20 years, provide recommendations on the assessment, treatment and support of adults living with dementia. It calls for greater awareness of pre-death grief for people with dementia, their carers and their loved ones, as they fear the loss of the person they know. To accompany the guidelines, a podcast has been produced by Health Improvement Scotland speaking to professionals, including Dr Adam Daly, Chair of Healthcare Improvement Scotland’s Guideline Development Group and a Consultant in old age psychiatry, and Jacqueline Thompson, a nurse consultant and the lead on pre-grief death for the guideline. We also hear from Marion Ritchie, a carer who experienced pre-death grief while caring for her husband.
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Content ArticleThe Greater Manchester Major Trauma Network recognise that many older patients self-present to emergency departments and the ‘Meet Harry’ infographic was produced as an aide memoire to triage nurses and clinicians to assist in assessment. You can view the ‘Meet Harry’ infographic by clicking on the image or download it from the attachment below.
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Content ArticleHealthcare Organisational Culture (OC) is a major contributing factor in serious failings in healthcare delivery. Despite an increased awareness of the impact that OC is having on patient care, there is no universally accepted way to measure culture in practice. This study from Simpson et al. was undertaken to provide a snapshot as to how the NHS is currently measuring culture. Although the study is based in England, the findings have potential to influence the measurement of healthcare OC internationally. An online survey was sent to 234 NHS hospital trusts, with a response rate of 35%. Respondents who completed the online survey, on behalf of their representative organisations, were senior clinical governance leaders. The findings demonstrate that the majority of organisations, that responded, were actively measuring culture. Significantly, a wide variety of tools were in use, with variable levels of satisfaction and success. The majority of tools had a focus on patient safety, not on understanding the determining factors which impact upon healthcare OC. This paper reports the tools currently used by the respondents. It highlights that there are deficits in these tools that need to be addressed, so that organisations can interpret their own culture in a standardised, evidence-based way.
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Content Article
Patient-led assessments of the care environment (PLACE)
Patient Safety Learning posted an article in Environmental
PLACE assessments will provide motivation for improvement by providing a clear message, directly from patients, about how the environment or services might be enhanced. The 2023 programme is planned for launch in early September 2023. Good environments matter. Every NHS patient should be cared for with compassion and dignity in a clean, safe environment. Where standards fall short, they should be able to draw it to the attention of managers and hold the service to account. PLACE assessments will provide motivation for improvement by providing a clear message, directly from patients, about how the environment or services might be enhanced. The assessments involve local people (known as patient assessors) going into hospitals as part of teams to assess how the environment supports the provision of clinical care, assessing such things as privacy and dignity, food, cleanliness and general building maintenance and, more recently, the extent to which the environment is able to support the care of those with dementia or with a disability. Recruitment and training of patient assessors is the responsibility of those organisations undertaking assessments. The assessments take place every year, and results are published to help drive improvements in the care environment. The results show how hospitals are performing both nationally and in relation to other hospitals providing similar services. -
Content ArticleThe Acute Frailty Network (AFN) was a scheme run in England by NHS Elect, using an approach called Quality Improvement Collaboratives (QICs), to help trusts implement principles of Comprehensive Geriatric Assessment (CGA) as part of their acute pathway. In July 2023, Street et al published a paper in BMJ Quality and Safety analysing the impact of the AFN which concluded that there was no difference in length of hospital stay, in-hospital mortality, institutionalisation and hospital readmission between organisations that took part in AFN and those that did not. This article outlines the position of the British Geriatrics Society (BGS) on the paper, addressing why it thinks that focusing on older people’s healthcare is more important than ever. It highlights the importance of ensuring that the paper's findings are not used as a reason to abandon efforts to improve acute frailty care. Rather, they should be seen as a call to redouble efforts to identify and overcome the barriers to delivering CGA in acute settings.
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News Article
Met wins battle with NHS over not attending mental health calls
Patient Safety Learning posted a news article in News
The Metropolitan police has won its battle to stop attending most of the mental health calls it receives after a tense behind-the-scenes row with the health service, the Guardian has learned. From 31 October the Met will start implementing a scheme that aims to stop officers being diverted from crime fighting to do work health staff are better trained for. In May, the Guardian revealed that the Met commissioner, Sir Mark Rowley, had written to health and social care leaders setting a deadline of 31 August – leading to furious reaction from health chiefs who wrote to the commissioner protesting that it would put vulnerable people at risk. The agreement means Rowley will push his deadline for the start of the changes back by two months, before a phased introduction. Health services will not publicly criticise the police decision, and will race to put measures in place to pick up the work. The scheme is called Right Care Right Person (RCRP), and has been agreed nationally by government departments and national police and health bodies. The letter sent on Thursday says: “In practice, this means that police call handlers will receive a new prompt relating to welfare checks or when a patient goes absent from health partner inpatient care. The prompt will ask call handlers to check that a police response is required or whether the person’s needs may be better met by a health or care professional.” Read full story Source: The Guardian, 17 August 2023 -
Content ArticleThe Dermatitis Family Impact (DFI) questionnaire is a disease‐specific measure to assess the impact of atopic eczema on the quality of life (QoL) of the parents and family members of affected children. The authors set out to review the published literature and to collate data on the clinical and psychometric aspects of the DFI questionnaire from its development in 1998–2012, in order to create a single source of reference for users of the DFI.
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Content ArticleRecording of a recent Care Quality Commission (CQC) webinar. Hear from Mandy Williams, Interim Director of integration, inequalities and improvement as she updates on CQC's approach to assessing integrated care systems. During the Q&A session, Mandy is also joined by Helen Rawlings, Deputy Director of Integration, Inequalities and Improvement, Matt Tait, Head of Acute Policy and Dominique Black, Strategy Manager who answers attendees questions from the live chat.
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Content ArticleThis guidance outlines the Care Quality Commission's (CQC's) approach to assessing integrated care systems (ICSs). It includes information on how these assessments will be carried out. The guidance focuses on: Themes and quality statements Evidence categories How we will assess integrated care systems Reporting and sharing information Intervention and escalation
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News Article
Thousands of children unsure of gender identity ‘let down by NHS’, report finds
Patient Safety Learning posted a news article in News
Thousands of vulnerable children questioning their gender identity have been let down by the NHS providing unproven treatments and by the “toxicity” of the trans debate, a landmark report has found. The UK’s only NHS gender identity development service used puberty blockers and cross-sex hormones, which masculinise or feminise people’s appearances, despite “remarkably weak evidence” that they improve the wellbeing of young people and concern they may harm health, Dr Hilary Cass said. Cass, a leading consultant paediatrician, stressed that her findings were not intended to undermine the validity of trans identities or challenge people’s right to transition, but rather to improve the care of the fast-growing number of children and young people with gender-related distress. But she said this care was made even more difficult to provide by the polarised public debate, and the way in which opposing sides had “pointed to research to justify a position, regardless of the quality of the studies”. “There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop.” Read full story Source: The Guardian, 10 April 2024 -
News Article
NHS faces ‘avalanche’ of demand for autism and ADHD services, thinktank warns
Patient Safety Learning posted a news article in News
The NHS is experiencing an “avalanche of need” over autism and attention deficit hyperactivity disorder (ADHD), but the system in place to cope with surging demand for assessments and treatments is “obsolete”, a health thinktank has warned. There must be a “radical rethink” of how people with the conditions are cared for in England if the health service is to meet the rapidly expanding need for services, according to the Nuffield Trust. The thinktank is calling for a “whole-system approach” across education, society and the NHS, amid changing social attitudes and better awareness of the conditions. It comes days after the NHS announced a major review of ADHD services. Thea Stein, the chief executive of the Nuffield Trust, said: “The extraordinary, unpredicted and unprecedented rise in demand for autism assessments and ADHD treatments have completely overtaken the NHS’s capacity to meet them. It is frankly impossible to imagine how the system can grow fast enough to fulfil this demand. “We shouldn’t underestimate what this means for children in particular: many schools expect an assessment and formal diagnosis to access support – and children and their families suffer while they wait.” Read full story Source: The Guardian, 4 April 2024
