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When we talk about NHS administration, it often gets described as systems, processes, inefficiencies. That’s not how it feels in general practice. From where I sit as a practice manager, administration is the bit that either helps a patient get care – or quietly stops them from getting it at all, writes Kay Keane in this guest blog for The King's Fund. The recent report from The King's Fund talks about patients feeling ‘lost in the system’. What is less visible is the amount of work happening every single day to stop that from happening.  

Failure to be aware of and to follow clinical guidelines and protocols could constitute clinical negligence, but not in all cases, and much will depend on the facts of each case. John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses aspects of the law on clinical guidelines and other care management tools.

The NHS is in a state of crisis, with increasingly long delays for ambulances and emergency care. Often people believe that hospital delays and bottlenecks are caused entirely by the difficulty of discharging patients to social care. But there is another factor which is just as much of a problem, and which should be far easier to fix: the masses of unnecessary paperwork doctors and nurses have to fill out every day. Gordon Caldwell explores this issue in an article in the Spectator.

Administrative data systems are used to identify hospital-based patient safety events; few studies evaluate their accuracy. McIsaac assessed the accuracy of a new set of patient safety indicators (designed to identify in hospital complications).

Referrals to hospital are increasing as more people continue to live longer with a range of complex conditions. The Professional Records Standards Body (PRSB) recognise that good information sharing is integral to ensuring that patients can receive the ongoing care that they need. Currently there are differences between GP systems and GP practices in the clinical content of referrals, with multiple templates in use. The clinical referral information standard is designed to improve the exchange of referral information from GPs to hospital consultants and other health care professionals providing outpatient services. Working with clinicians and patients, the PRSB have published this standard along with implementation guidance for digital referrals from GPs to hospitals. Once implemented, it will ensure that clinicians have the right information they need to provide the best care for patients. The standard was produced in collaboration with the Royal College of Physicians Health Informatics Unit and input from the Royal College of General Practitioners. By using the standard professionals will have access to all relevant information in a timely manner results in safer and more consistent care for people using health and care services. The information will include data about medication, previous history, allergies and current symptoms, as well as a patient’s concerns and expectations. This standard has now been updated to version 1.1. Detailed release notes are available outlining the changes. These can be found in the supporting documents link above. The standard has been updated in-line with new PRSB digital medications information assurance. The PRSB has worked in partnership with the Health Informatics Unit at the Royal College of Physicians to produce these standards.

A great  initiative by East Sussex Healthcare NHS Trust to reinforce the importance of basic checks to keep patients from harm when administering medicines.

The Institute for Safe Medication Practices (ISMP) is the only US nonprofit organisation devoted entirely to preventing medication errors.  In this short video, produced by ISMP in partnership with the Temple University School of Pharmacy, experts discuss current medication safety concerns and offer practical error prevention recommendations. This issue (episode 3) focuses on: safe administration of concentrated insulin products errors with confusing product labelling educating patients about safe medication practices.

The relentless increase in administrative responsibilities, amplified by electronic health record (EHR) systems, has diverted clinician attention from direct patient care, fuelling burnout. In response, large language models (LLMs) are being adopted to streamline clinical and administrative tasks. Notably, Epic is currently leveraging OpenAI's ChatGPT models, including GPT-4, for electronic messaging via online portals. The volume of patient portal messaging has escalated in the past 5–10 years, and general-purpose LLMs are being deployed to manage this burden. Their use in drafting responses to patient messages is one of the earliest applications of LLMs in EHRs. Previous works have evaluated the quality of LLMs responses to biomedical and clinical knowledge questions; however, the ability of LLMs to improve efficiency and reduce cognitive burden has not been established, and the effect of LLMs on clinical decision making is unknown. To begin to bridge this knowledge gap, the authors of this study, published in the Lancet, carried out a proof-of-concept end-user study assessing the effect and safety of LLM-assisted patient messaging.

Research undertaken by digital health platform, CAREFUL shows that handover in hospitals is the cause of frequent and severe harm to patients. Handover in hospitals is the cause of frequent and severe harm to patients, according to new research* by digital health platform, CAREFUL. Many patients are suffering because handover is poorly controlled and under-recognised as a source of clinical risk. Handover is the transfer of responsibility and crucial patient information between practitioners and teams. Handover takes place when shifts change and when patients are transferred between departments or outside of the hospital into another care setting. This is a time when staff are under pressure and when mistakes can happen – as the research shows. “We undertook this research because little is known about how practitioners see the risks of handover and the impact of handover on patient safety,” says CAREFUL CEO, Dr DJ Hamblin-Brown. “We anticipated that doctors and nurses would report some errors, but the frequency with which harm is reported across the world is disturbing.” Patient safety in operating theatres has been a recognised problem for many years – ever since the publication of the original checklist article in the New England Journal of Medicine. By contrast, handover, despite being possibly the most common clinical process across healthcare, has not been studied so widely. CAREFUL’s research investigated clinicians’ experience of handover, receiving 432 completed responses from clinicians in 26 countries via an open, anonymous and confidential online questionnaire. Published in February 2022, the findings revealed that errors in handover occur weekly or daily, according to 12% of respondents. Nearly 10% had witnessed severe harm – either death or otherwise life changing – because of handover error. “Handover takes place about 4,000 times each day in a typical teaching hospital”, explains Dr Hamblin-Brown. “It is a procedure prone to a multitude of errors due to reliance on paper that’s easily lost or verbal discussion that’s easily forgotten.” One of the most worrying findings in the research is that most handover takes place using a many different support systems; 35% are still using handwritten notes; 21% are using office documents such as Word and Excel; 10% write on whiteboards and a full 15% are using unofficial messaging apps like WhatsApp. Healthcare leaders reflect the same concerns as staff, but they specifically also want more access to patient information and better electronic systems. Digital platforms may be the only real solution to the challenges surrounding handover, with the ability to provide safe and secure access to handover information at the swipe of a screen that is neither lost nor forgotten. “We work in an industry that is failing to take seriously the dangers of handover. It is arguably the most common, and one of the most important, processes. We harm both staff and patients if we fail to address the dangers of handover,” concludes Dr Hamblin-Brown. *This paper is in pre-print and has not yet been peer-reviewed.

In this blog for Patient Safety Movement, Pranjal Bora, Head of Product Management at Digital Authority Partners, looks at the ways in which digital technologies improve outcomes and safety in healthcare. The blog examines areas in which digital technologies are currently being used, and looks at the potential future uses of AI and other digital technologies.

This Health Services Safety Investigations Body (HSSIB) investigation explored the patient safety risks associated with the communication of critical clinical information when patients are discharged from acute hospital inpatient settings, and the follow-up of ongoing actions for patients by primary and community care. Discharge from hospital represents a transition of care from one provider (the hospital) to others (such as general practice, pharmacy and/or community care). To support patient safety, critical clinical information about the patient needs to flow between providers to ensure care after discharge is timely and appropriate. The main method for communicating information on discharge from hospitals is the electronic discharge summary. This provides an overview of why the patient was in hospital, what happened during the admission, and plans for their ongoing care. This investigation considered communication processes between providers on discharge of patients from hospital, and how the use of electronic correspondence impacts on these processes. If critical clinical information is not communicated effectively at transitions of care, patients may come to harm by missing or receiving incorrect care. Patients and healthcare staff described multiple incidents of harm following discharge because of problems with the communication of information. Findings Patients are coming to harm where follow-up actions are needed after discharge from hospital and discharge planning has not accounted for constraints and challenges in the local health and care system (referred to here as ‘the local system’). This means actions are not always undertaken or completed within expected timeframes. A lack of integration – as evidenced by limited collaboration between primary, community and secondary care providers – contributes to discharge planning and communications that do not always ensure patients receive continuity in their care. Risks to patient safety associated with the quality and timeliness of discharge correspondence, most notably the discharge summary, have been “normalised”. There is unclear accountability for the safety of patients early after discharge. The current regulatory approach for inspection of care quality does not lend itself to effective scrutiny of cross-provider pathways, such as transitions of care between providers. Oversight mechanisms in providers and integrated care boards do not always exist or function to ensure that end-to-end discharge communication is achieved through the creation, sending, receipt and actioning of correspondence. A lack of interoperability between IT systems within and across providers means information does not pass seamlessly, increasing the risk of information being lost, delayed or missed. The design/configuration of the parts of electronic patient record for correspondence, including discharge summaries, can introduce the potential for errors and does not always support staff to create, send and process correspondence. Discharge correspondence may not be accurate in scenarios where patients continue to receive care in hospital after discharge correspondence has been sent. Discharge summaries are not actively sent to, or accessible to, all the providers of ongoing care who need to know the clinical information they contain. The content of discharge correspondence, including discharge summaries, does not always meet the information needs of recipients to ensure safety-critical actions for a patient’s ongoing care are handed over, understood and achieved. Medical staff writing discharge summaries recalled no specific education on the writing of user-centred and safe discharge correspondence during undergraduate and postgraduate education. The availability of discharge correspondence in different systems, for example shared care records, varies across the country with limited opportunities for primary and community care staff to access it via other routes if correspondence has not arrived. Patients do not always receive a copy of their discharge summary which removes this ‘backup’ option for providers to access information. It also means patients do not have information to support their own understanding of their care needs. HSSIB makes the following safety recommendations Safety recommendation R/2025/065: HSSIB recommends that the NHS England/Department of Health and Social Care, in collaboration with relevant national bodies including the Professional Record Standards Body, adopts user-centred design principles to develop and validate new discharge correspondence templates for primary and community care settings. This is to provide standards for discharge correspondence that support recipients’ access to high-quality safety-critical clinical information, and that can be contextualised to local system needs. Safety recommendation R/2025/066: HSSIB recommends that the Department of Health and Social Care, through its future strategic and policy programmes, sets specific expectations for NHS healthcare providers to ensure that: high-quality safety-critical information about patients is accessible after discharge, and processes exist to complete safety-critical actions for ongoing patient care within required timeframes. This is to enable providers to deliver continuity in patient care after discharge from hospital. HSSIB makes the following safety observation Safety observation O/2025/074: Primary, community and secondary healthcare providers can improve patient safety by working collaboratively to recognise and mitigate local system challenges and constraints that prevent the: communication of high-quality safety-critical information about patients completion of actions for ongoing patient care within required timeframes. HSSIB suggests safety learning for Integrated Care Boards HSSIB suggests that integrated care boards support collaboration between primary, community and secondary care providers across their local systems to: jointly validate the quality of discharge correspondence plan for the constraints and challenges faced by different parts of their local systems assure themselves that risks to patient safety on discharge from hospital are mitigated as far as is practicable. Local-level learning prompts HSSIB investigations include local-level learning where this may help providers/organisations and staff to identify and think about how to respond to specific patient safety concerns at the local level. HSSIB has identified learning to help consider and mitigate risks around creating, sending and processing discharge correspondence. For providers creating and sending discharge correspondence How does your organisation ensure staff recognise discharge correspondence as safety-critical information for the clinical handover of care? Do your staff know who are the recipients of and users of your discharge correspondence, particularly discharge summaries? How does your organisation know that its correspondence meets the needs of those receiving and acting on the information? How does your organisation ensure important information about medication changes are reliably and accurately described in discharge correspondence? How does your organisation support staff to ensure the contents of discharge correspondence meets the needs of all likely recipients and is of high quality? How does your organisation know that all required discharge correspondence is reliably produced, sent and received by all necessary recipients, not just GPs? How does your organisation ensure patients and their families/carers (if appropriate) are given an accessible copy of any discharge correspondence? How does your organisation ensure discharge correspondence is updated if a patient has further clinical input after the correspondence was written? Do your staff recognise that capacity and resource issues in primary and community care mean time-critical actions after discharge may be delayed or unable to be actioned? How does your organisation support staff to communicate time-critical actions to providers of ongoing care so they are undertaken within the required time? Does your organisation have pathways for primary and community care to troubleshoot incomplete or ambiguous information in discharge correspondence? How does your organisation involve staff in the development and testing of EPR templates to ensure they are easy to use and do not contribute to incidents? Does your organisation include digital and clinical input in the training of staff to write discharge correspondence to help them understand what ‘good’ looks like? For providers receiving and processing discharge correspondence Does your organisation have processes for identifying and prioritising safety and time-critical actions requested by secondary care? How does your organisation manage seemingly ‘duplicate’ correspondence to ensure it is not an updated version with further information or actions? Does your organisation have processes for effectively feeding back concerns and incidents to secondary care when discharge communications do not meet your needs? How does your organisation involve staff in the development and testing of software and processes to ensure they are easy to use and do not contribute to incidents? How does your organisation assure your internal processes for the administration of correspondence to ensure thoroughness of review while looking to be efficient?