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  1. Event
    until
    This collaborative workshop will explore what safety means when hospital-level care is delivered at home through Virtual Wards. The workshop will be a space to reflect on a draft version of practical safety guidance shaped by lived experience from Patient and Public Involvement contributors. You will be invited to share ideas on what resonates, what’s missing, and how to support safer, more person-centred care in Virtual Wards. It's looking for a range of perspectives - whether you work in Virtual Wards, support safety and quality improvement, represent patient voices, or research care in the community. Register
  2. News Article
    The ‘inability or unwillingness’ of some NHS and social care providers to work together has contributed to an ‘unimaginable’ deterioration in emergency care performance, according to NHS England The claim is made in the urgent care recovery plan for 2025-26, released by NHS England and the Department of Health and Social Care. The plan includes a new target to reduce 12-hour accident and emergency waits and pledges to invest £370m of capital funding in improving urgent care and mental health facilities. The plan said, “Each part of the system has responsibility for improving urgent and emergency care performance. However, blame shunting has become a feature in some poorly performing systems and can no longer be tolerated." National urgent care director Sarah-Jane Marsh told HSJ that “the duty to collaborate and work together and do the best for patients is on all trust boards, and it shouldn’t rely on some overseer to make sure that happens. It’s a fundamental part of being a leader”. Trusts will be told to ensure the proportion of patients waiting over 12 hours for admission, transfer or discharge from A&E remains less than 10%. The 45-minute “maximum” ambulance handover time will become mandatory across all trusts ahead of winter, according to the plan. Chief executive of the College of Paramedics, Tracy Nicholls, said, “The plan sets out progressive structural proposals that have the potential to enhance public safety and strengthen paramedic autonomy. However, it may underestimate key challenges, including workforce readiness, the capacity of the mental health system, and practical implications of the Right Care, Right Person model. Without urgent alignment of funding, training, and alternative care pathways, there is a real risk that paramedics could be left navigating a reform process that shifts responsibility without equipping them with the necessary tools and support. Read full story (paywalled) Source: HSJ, 5 June 2025 Related reading on the hub: How corridor care in the NHS is affecting safety culture: A blog by Claire Cox My experience of the 'Wait 45' policy - Florence in the Machine A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift
  3. Content Article
    The NHS must focus on collaboration to reap the benefits of digital solutions, writes Dr Pooven Maduramuthu, healthcare industry lead, UKI at DXC Technology. The NHS is currently facing significant challenges, including resource constraints, fragmented systems, and increasing demands for high-quality patient care. Digital enabling solutions have the potential to address these issues by improving interoperability, streamlining processes, and enhancing patient outcomes. However, to fully realise these benefits, the NHS must prioritise collaboration. By working together, NHS organisations can leverage existing investments, reduce implementation costs, and benefit from economies of scale. This collaborative approach ensures that digital solutions are not only effective but also sustainable and scalable across the healthcare system.
  4. Content Article
    To make integrated care a success, someone needs to monitor the gaps between services, and the Care Quality Commission is the best pick for it, writes Jacob Lant in this HSJ opinion piece. It may be an unpopular view, but if we are going to make a success of integrated care, then someone really needs to be watching what happens in the gaps between services. Having already developed an approach for reviewing how local systems work, the CQC is arguably best placed to pick up this function.
  5. Content Article
    On 9 May 2025, the WHO Patient Safety and Quality of Care Unit hosted a webinar on Patient Engagement for Patient Safety, as part of the WHO Global Patient Safety Webinar Series, bringing together health care leaders and patient advocates from around the world. The webinar highlighted the importance of engaging patients and families, as emphasised in Strategic Objective 4 of the Global Patient Safety Action Plan 2021–2030. Participants heard diverse global perspectives and real-world examples demonstrating how partnerships with patients and families are being operationalised to improve safety and quality of care. The panel featured speakers from Greece, Saudi Arabia, Singapore, Uganda and the United States. Discussions focused on practical strategies, implementation challenges and opportunities for action in strengthening patient and family engagement.
  6. Content Article
    The overarching vision of the NIHR Yorkshire and Humber Patient Safety Research Collaboration (PSRC) is to co-produce innovative solutions to make care safer for patients and their families. Key to this is ensuring that these solutions reflect and meet the needs of our diverse communities. This can be achieved by working with and for patients, families, and health and social care staff, grounding our research in their daily realities and the evolving system within which care is delivered. This PPIE strategy offers the mechanisms by which we can deliver on this, recognising that respectful and trusting relationships are the cornerstones to making effective change.
  7. Content Article
    The last two or three years have seen an unprecedented number of developments in the UK (England in particular) which can be loosely described as being advances or planned advances in patient and family empowerment (or “engagement” in patient safety). This editorial from Peter Walsh explores the potential and challenges of Martha's Rule, Hillsborough Law, Patient Safety Partners, the Harmed Patient Pathway and the Independent Advice and Advocacy.
  8. Content Article
    This report from the Partnership for Change explores one of the most persistent challenges patients face: poor care co-ordination. It draws on insight from across the health charity sector to offer a clear and practical vision for improving how care is delivered and experienced in the NHS. The Partnership for Change is a collaboration of ten leading patient groups brought together and funded by Pfizer.  The report outlines a set of recommendations to help the NHS, and wider health systems, put patients at the centre of co-ordinated care. The report recommendations are to: Measure patient experience and act on the data. Make communication between healthcare, professionals and patients simpler, quicker, and more efficient. Proactively build a culture of collaboration. Take a holistic approach to care for long-term conditions. Related reading on the hub: How the Patients Association helpline can help you navigate your care Care co-ordination for people with long-term conditions: Patient Safety Learning’s response to HSSIB investigation #NavigatingHealth—Enabling every patient, every time, system-wide The challenges of navigating the healthcare system
  9. News Article
    The World Health Organization's member countries on Tuesday approved an agreement to better prevent, prepare for and respond to future pandemics in the wake of the devastation wrought by the coronavirus. Sustained applause echoed in a Geneva hall hosting the WHO’s annual assembly as the measure — debated and devised over three years — passed without opposition. The treaty guarantees that countries which share virus samples will receive tests, medicines and vaccines. Up to 20% of such products would be given to the WHO to ensure poorer countries have some access to them when the next pandemic hits. WHO Director-General Tedros Adhanom Ghebreyesus has touted the agreement as “historic” and a sign of multilateralism at a time when many countries are putting national interests ahead of shared values and cooperation. Dr. Esperance Luvindao, Namibia’s health minister and the chair of a committee that paved the way for Tuesday’s adoption, said that the COVID-19 pandemic inflicted huge costs “on lives, livelihoods and economies.” "We — as sovereign states — have resolved to join hands, as one world together, so we can protect our children, elders, frontline health workers and all others from the next pandemic," Luvindao added. "It is our duty and responsibility to humanity.” The treaty’s effectiveness will face doubts because the United States — which poured billions into speedy work by pharmaceutical companies to develop Covid-19 vaccines — is sitting out, and because countries face no penalties if they ignore it, a common issue in international law. Read full story Source: The Independent, 20 May 2025
  10. Content Article
    Leadership Futures recently published a report 'Harnessing technology for human progress: Advancing into Industry 5.0', which is driven by a bold ambition: to transform organisations worldwide through technological advancements. In this blog, Caroline Beardall looks at the implications of this for healthcare and suggests five actions that organisation's should take to ensure we achieve the benefits from technology while keeping patient safety at the forefront of an evolving landscape. The recent Leadership Futures report 'Harnessing technology for human progress: Advancing into Industry 5.0' provides a valuable framework for integrating technology with human-centered leadership, which is highly applicable to advancing patient safety in health and care. Its vision of Industry 5.0 as a collaborative human-AI partnership offers a route to reduce errors, enhance clinician capacity and improve patient outcomes. However, realising these benefits requires caution—ethical and inclusive implementation strategies that address the complexities and risks unique to health and care settings. It throws up three fundamental challenges: How can healthcare leaders ensure AI tools are safe to use and that clinical staff can trust them? Who should be responsible if an AI system makes a mistake that affects a patient? How can healthcare organisations use technology to work better without losing the importance of human interaction and the skills needed for high levels of patient satisfaction and safety? In order to answer these questions, and deepen the discussion on harnessing technology responsibly to safeguard and improve patient care, there are some actions we can take to build on the report and begin to gain evidence and experience specific to healthcare. As the landscape of healthcare shifts and evolves, we should consider applying the following five actions (with examples of how to do this) so we can achieve the maximum benefits from technology for patient safety. 1. Foster collective, collaborative leadership across boundaries Leaders should actively promote cooperation and shared responsibility across organisational and professional boundaries, focusing on the overall patient journey rather than siloed departmental goals. This aligns with the report’s emphasis on human-machine collaboration and the need for integrative leadership cultures that support safe, seamless care delivery. By working collectively, leaders can ensure technology is implemented with broad input and oversight, reducing risks and enhancing patient safety. Implement interdisciplinary collaboration practices: Organise regular team meetings involving diverse healthcare professionals to discuss patient care holistically, ensuring all voices contribute to decision making. Create shared goals and aligned metrics: Develop common objectives focused on patient safety and quality that unify departments and reduce siloed working. Lead by example: Demonstrate collaborative behaviours and openness to input, encouraging a culture of trust and teamwork. 2. Embed ethical, human-centred use of technology Leaders must champion ethical principles in technology adoption, ensuring AI and digital tools augment rather than replace human judgment and empathy. This includes rigorous validation of new technologies, transparency in AI decision-making, and ongoing monitoring to prevent harm or bias. Prioritising patient experience and human values in technology deployment safeguards safety and trust. Prioritise transparency and clinician involvement: Engage frontline staff early in AI and technology design and deployment to ensure tools meet clinical needs and ethical standards. Establish continuous monitoring and feedback loops: Use data and user feedback to identify and mitigate risks or biases in technology that could impact patient safety. Promote ethical leadership training: Equip leaders with skills to balance innovation with patient experience and accountability. 3. Develop and support workforce readiness and engagement Preparing staff to work effectively alongside new technologies is vital. Leaders should invest in training that builds digital literacy, critical thinking and resilience, while also fostering a positive work climate where staff feel valued and supported. Engaged and confident clinicians are better able to use technology safely and maintain high standards of care. Invest in targeted training and digital upskilling: Provide contextual, in-app guidance and interactive training to help staff adopt new technologies confidently and efficiently. Foster a culture of psychological safety and empowerment: Encourage open discussion, honest feedback and staff involvement in decision making to build trust and resilience. Practice empathetic leadership: Focus on emotional and professional needs of staff to reduce burnout and improve engagement. 4. Set clear, aligned objectives focused on quality and safety Leadership should establish clear, challenging and aligned goals at every level that prioritise patient safety and quality improvement over mere efficiency or target-driven metrics. This clarity helps reduce staff stress and confusion, enabling teams to focus on delivering compassionate, safe care supported by technology. Communicate clear expectations and priorities: Use consistent, transparent communication to align teams around patient safety goals and reduce ambiguity. Implement continuous feedback and learning systems: Regularly review performance data and patient feedback to refine objectives and improve care quality. Balance efficiency with human factors: Ensure operational goals do not compromise critical human skills or patient-centred care. 5. Champion diversity, inclusion and accountability in leadership Inclusive leadership practices that promote equality and diversity are essential to fostering innovation and ethical decision-making in healthcare technology adoption. Leaders must also clarify accountability frameworks for technology-related decisions and errors, ensuring responsibility is shared and transparent to maintain patient safety. Promote inclusive leadership practices: Value diverse perspectives and foster equity to enhance innovation and ethical decision-making Clarify accountability frameworks: Define roles and responsibilities clearly, especially concerning technology-related decisions and errors, to maintain trust and safety Model human-centred leadership traits: Practice self-awareness, compassion and mindfulness to create cultures of excellence, trust, and caring. By integrating these strategies, human-centric leaders can effectively translate the insights from the Leadership Futures report into practical actions that improve patient safety, staff satisfaction and overall health system resilience. This approach embraces complexity and change as opportunities, not obstacles, which then enables sustainable progress in better health and care delivery. Further reading Amelia N. 6 Effective Leadership Strategies for Healthcare in 2025. Edstellar, 31 December 2024. West M, et al. Leadership in Healthcare: a Summary of the Evidence Base. Kings Fund; Faculty of Medical Leadership and Management; Center for Creative Leadership, 2015. LeClerc L, Kennedy K, Campis S. Human-Centered Leadership in Health Care: An Idea That's Time Has Come. Nursing Administration Quarterly 2020; 44(2):p 117-26.
  11. Content Article
    In this blog, Siân Slade shares how, through her research interest into the difficulties of navigating the healthcare system in Australia, she created a policy and advocacy project: #NavigatingHealth. The aims of the project are to streamline the silos and address the fragmentation of healthcare by bringing together all those who are developing solutions to enable patients and carers to better navigate healthcare journeys.  Background About 10 years ago, I listened to a friend’s experience navigating cancer and puzzled over the challenges encountered. These made me question my prior assumption of 'patient-centricity' across healthcare. In 2015, the Organisation for Economic Co-operation and Development (OECD) released a report highlighting the complexities of the Australian healthcare system. This led me to realise that while we do have patient-centred care, it is often provider dependent, not system-wide, and relies on the patient (or carer) to navigate the system; a time when individuals are at their most vulnerable. Given 'the standard you accept is the standard you walk past”, I decided to do 'my bit' to address this. I enrolled in a Master of Public Health, researching healthcare navigation in Australia. I found there was a fragmented approach to try and address an already fragmented problem. This led me to embark on a PhD as well as develop a policy and advocacy platform: #NavigatingHealth. Setting up a national network and community of practice My focus has always been on a practical approach that solves problems for individuals but also seeks to understand how to scale these at a systems level to sustain change in the long-term. If this was a known problem, why was nothing being done to address it? Surely this was something government were addressing... or there must be an app? I spoke to lots of people—patients, carers, speakers at conferences, those who had written books of their healthcare experience and, yes, those developing apps. Everyone agreed it was a problem, but nothing was addressing the totality of the problem. The problem was not just in navigating healthcare, but also the challenges navigating related systems, such as those for people with disabilities, or for aged care, as well as social services and education. #NavigatingHealth started life as two, 60-minute webinars held in mid and late September 2021, supported by the Australian Disease Management Association. The inaugural webinar speakers provided vignettes across a life journey—from childhood through to getting older—based on their own lived-experiences as patients, carers or professionals (not-for-profit, health services and government). The positive reception of the webinars led to setting up a bimonthly national network and community of practice in Australia that ran until the end of 2024. The meetings were deliberately not recorded to build a safe space for people to share ideas, build tacit (word of mouth) knowledge and a like-minded solutions focused community. Summaries of all the events and speakers are available on the #NavigatingHealth project page. In health, information and projects evolve. Building an online community was low-cost and accessible to everyone. The success of the Australian approach led to a series of global webinars using the same format of expertise provision from individuals in research, policy, and advocacy and health services. The first global webinar was held in 2022 attracting over 20 countries. Connecting and collaborating The 'glocal' community continues to grow. Projects are constantly evolving, elevating and expanding as well as exiting often impacted by funding constraints. In the spirit of a complex adaptive learning health system, core to our success is the community knowledge built through relationships, trust, like-values and non-linear interactions. Taking an approach that is resourceful versus one requiring constant resourcing (we use accessible tools such as LinkedIn and more recently Bluesky) to provide an effective, free platform to keep individuals in touch with one another. Our dedicated #NavigatingHealth project page on the Nossal Institute for Global Health website at the University of Melbourne acts as a central hub for events and resources. The genesis during the pandemic and expansion virtually through Teams and Zoom, as well as in-person post-pandemic, has enabled different ways to expand the national community, the global network and we welcome all-comers. The project is voluntary and our success is based on linking people, developing relationships, sharing expertise, maintaining momentum and the opportunity we all have to impact into #NavigatingHealth. The annual forums, 2024 #NavigatingHealth Simplifying Complexity and 2025 #NavigatingHealth Enabling Patients, System-Wide, focused on bringing together colleagues nationally in Australia. The in-person workshops created the opportunity to build community, share ideas, leverage learnings and also provide educational content. These collaborations have allowed development of materials for curriculum and teaching, and an evolving conversation about the importance of systems-thinking. We developed a short global project collecting stories from individuals who are happy to be involved. Our video, NavigatingHealth - why this matters, provides a glimpse of our approach. Looking forward The Future of Health Report published in 2018 highlights that our health systems, locally and globally, will change from 'one size fits all' to one that is personalised. The challenge is how? Future of Health Report, CSIRO 2018. The 'secret sauce' is that by working collaboratively we can all be part of evolving and effecting systems change. The work is underpinned by equity and a focus on enabling early access to care, addressing barriers, such as financial or cultural constraints, and helping to make visible information asymmetries and power imbalances to ensure effective collaboration and co-production. Building on the success of our past forums, planning for 2026 is underway. Block out 1 April 2026 in your calendar for the inaugural #NavigatingHealth Day! Our collective expertise is our power—let’s do this! Want to know more? Please get in touch with Siân at [email protected] or via LinkedIn. Further reading on the hub: The challenges of navigating the healthcare system How the Patients Association helpline can help you navigate your care Lost in the system? NHS referrals
  12. News Article
    A “blueprint” for integrated care board cost-cuts says “headcount should be reduced at board level”. The “model ICB blueprint” issued by NHS England says the organisations should “look to streamline boards to deliver [their] core role”. HSJ understands the biggest reductions in board members are expected to come from ”greater collaboration” such as shared roles, and “clustering” of integrated care board leadership in many regions – expected to involve sharing of chairs and CEOs. Discussions about consolidation are already well underway in several regions, although NHSE understands formal mergers are likely to be delayed until at least next year. The blueprint document indicates ICBs must also remove some board posts which are linked to functions being axed or transferred. These functions include performance management, workforce, and “digital leadership and transformation”. The guidance says ICBs should “streamline” boards “with the right roles and profiles to deliver core Model ICB functions”. Read full story (paywalled) Source: HSJ, 6 May 2025
  13. Content Article
    Although there have been significant advancements over the past decades, substantial gaps in safety and quality remain in healthcare delivery, especially in low- and middle-income countries (LMICs) and the public sector. Even within the same country, there are notable geographical disparities in equitable access to safe care. Healthcare organizations (HCOs) and countries worldwide face numerous challenges and have competing priorities for focused interventions, often struggling to invest adequately in safety and quality. In alignment with the Global Patient Safety Action Plan 2021-2030 and JCI’s vision, JCI introduces Patient Safety Pathways. This pioneering initiative aims to develop, strengthen, sustain, and enhance patient safety initiatives with actionable plans, especially for organisations in the early stages of establishing their patient safety and quality infrastructure. JCI is working in collaboration with countries and organizations to advance safer patient care. The Patient Safety Pathways initiative focuses on the needs of HCOs starting their journey towards eliminating avoidable patient harm by creating pathways for incremental improvements and transformative changes. This collaboration includes working with Ministries of Health (MOHs), national and international HCOs, and patient advocacy organizations at various stages of development to enhance the quality of healthcare and patient safety. The Pathways Initiative components: Patient Safety Grand Rounds A series of online discussions to engage thought leaders in patient safety at policy, systems, and healthcare delivery levels through open dialogue, collaborative learning, problem-solving, and sharing of best practices and success stories. JCI Training of Trainers Develop a cadre of trainers as “Patient Safety Champions.” These champions will be equipped with the necessary knowledge and tools who in turn can help develop skills and competencies for healthcare professionals, fostering a culture of safety at the national and organizational level. Needs assessment and technical support Tailored technical support to selected HCOs from LMICs, based on their identified needs and gaps.
  14. News Article
    Members of the World Health Organization (WHO) have agreed the text of a legally binding treaty designed to better tackle future pandemics. The pact is meant to avoid the disorganisation and competition for resources seen during the Covid-19 outbreak. Key elements include the rapid sharing of data about new diseases, to ensure scientists and pharmaceutical companies can work more quickly to develop treatments and vaccines. For the first time, the WHO itself will also have an overview of global supply chains for masks, medical gowns and other personal protective equipment (PPE). WHO director general Dr Tedros Adhanom Ghebreyesus described the deal as "a significant milestone in our shared journey towards a safer world". "[Member states] have also demonstrated that multilateralism is alive and well, and that in our divided world, nations can still work together to find common ground, and a shared response to shared threats," he said. It is only the second time in the WHO's 75-year history that an international agreement of this type has been reached – the first being a tobacco control deal in 2003. It still needs to be formally adopted by members when they meet for the World Health Assembly next month. US negotiators were not part of the final discussions after President Donald Trump announced his decision to withdraw from the global health agency, and the US will not be bound by the pact when it leaves in 2026. Read full story Source: BBC News, 16 April 2025
  15. Content Article
    For decades, the Agency for Healthcare Research and Quality (AHRQ)’s Patient Safety Network (PSNet) has been a guiding light for healthcare professionals, researchers and policymakers committed to improving patient safety. Launched in the early 2000s, PSNet provided a rich repository of evidence, case studies and expert analysis, shaping safety initiatives across the US and beyond. Its sudden closure under the Trump administration is not only a devastating loss but also a shockingly rapid dismantling of a crucial resource. This blog from Clive Flashman, Patient Safety Learning's Chief Digital Officer, reflects on PSNet’s history, its impact and what its absence means for the patient safety community. Few initiatives have left as profound a mark on the global patient safety movement as AHRQ's PSNet. For nearly two decades, it was more than just a website—it was a living, breathing community of professionals, researchers and policymakers dedicated to improving the safety of patients worldwide. Its closure is more than a bureaucratic decision; it is the erasure of a collective body of knowledge that shaped and guided countless patient safety initiatives. A vision for a safer healthcare system PSNet was launched in the early 2000s as part of the broader push to improve patient safety following the landmark 1999 Institute of Medicine report To Err Is Human. Recognising the urgent need for a central hub where healthcare professionals could access the latest research, policy developments and real-world case studies, AHRQ established PSNet as an online resource to bridge the gap between research and practice. From its inception, PSNet was driven by a team of leading figures in patient safety, including pioneers such as Dr Kaveh Shojania and Dr Robert Wachter. Their vision was clear: to create a curated space where the latest evidence, commentary and real-world learning could be disseminated widely, ensuring that healthcare professionals at every level had access to the best possible insights to enhance patient care. A hub of knowledge and collaboration over the years PSNet evolved into the world’s premier patient safety repository. It featured: Case studies and real-world analyses of safety incidents, helping clinicians and policymakers understand systemic issues. Expert perspectives and interviews with leading safety scientists and practitioners, offering in-depth insights into evolving best practices. Curated research and literature reviews, providing a continuously updated digest of the latest evidence on safety interventions. Toolkits and guidance, to support frontline healthcare providers in implementing best practices. It became an essential resource not just in the US, but internationally, serving as a touchstone for policymakers and clinicians striving to reduce preventable harm in healthcare systems worldwide. Milestone contributions Several landmark contributions defined PSNet’s legacy. These included its ground breaking work on: Diagnostic errors, spotlighting how cognitive biases and system failures contribute to missed and delayed diagnoses. Medication safety, offering evidence-based strategies to reduce adverse drug events. Patient engagement in safety, emphasising the critical role of patients and families in preventing harm. Health IT and patient safety, providing critical insights into both the promise and perils of digital transformation in healthcare. Articles and reports from PSNet didn’t just inform debate, they shaped policy, guided clinical practice and influenced training programmes worldwide. A sudden and jarring end despite its immense value PSNet has been abruptly and systematically dismantled under the Trump administration’s policies. The closure was not just a budgetary decision; it was an ideological move that ignored the overwhelming consensus on the importance of maintaining accessible, evidence-based patient safety resources. What is perhaps most shocking is the speed with which the decision has been executed. The removal of content has been swift, with little time for the patient safety community to archive or transition critical materials. Researchers, clinicians and institutions that have long relied on PSNet have been left scrambling to retrieve invaluable resources before they disappear forever. The human cost of the closure The loss of PSNet extends far beyond the US. The global patient safety community has long depended on its insights, guidance and leadership. From hospital administrators to frontline nurses, from policymakers crafting national safety strategies to medical educators training the next generation of clinicians, PSNet was a touchstone—a place where those committed to patient safety could find the best available evidence and real-world learning. Now, that light has been extinguished. A tribute and a commitment To those who built PSNet, who curated its content, who shared their expertise and insights over the years: your work mattered. Your contributions saved lives, informed policies and built a global movement dedicated to reducing preventable harm. While PSNet itself may be gone, its legacy lives on in the work of those who continue the fight to improve patient safety. The challenge now is to ensure that its loss does not set back the progress of the last two decades. Those of us who remain in this field must honour its impact by preserving its lessons, continuing its conversations, and finding new ways to collaborate and share knowledge. Patient Safety Learning has captured some of the most important content and tools on the hub so that the global patient safety community can continue to refer to them and use them. With sadness, but also with immense gratitude, we bid farewell to PSNet. Its absence will be deeply felt, but its influence will not be forgotten. Continue to share your knowledge and patient safety resources the hub is Patient Safety Learning's online platform for patient safety. Designed with input from patient safety professionals, clinicians and patients, we created the hub after identifying shared learning as one of the six evidence-based foundations of safer care. It offers a powerful combination of tools, resources, stories, case studies and good practice to anyone who wants to make care safer for patients. Its communities of interest give people a place to discuss patient safety concerns and how to address them. Membership is free – you can register here and you can then start to share content on the hub.
  16. Content Article
    Patient and family voices play a critical role in understanding patient safety issues, learning from incidents and managing risk. In this Top picks, we’ve pulled together resources from the hub that highlight the value in involving patients and the public in patient safety.  1. The role of simulation-based education, co-design and co-delivery in improving patient safety Dr Kirsten Howson, Specialist Education Lead at SimComm Academy, discusses the role Simulation-Based Education (SBE) can have in patient safety. Kirsten highlights some of the techniques used in SBE, the benefits for staff and patients, and the importance of involving people with lived experience in the design and delivery of SBE. 2. Working with bereaved parents for safer and more equitable care Julia Clark and Mehali Patel from the Sands Saving Babies’ Lives research team, draw on their recent Listening Project to illustrate the value of working with bereaved parents. Julia and Mehali argue that hearing and amplifying these unique insights is vital to developing safer, more equitable neonatal and maternity care. 3. Integrating patient and public involvement into co-design of healthcare improvement: a case study in maternity care (March 2025) Despite recognition of the importance of patient and public involvement (PPI) in healthcare improvement, compelling examples of “what good looks like” for PPI in co-design of improvement efforts, how it might be done, and formalisation of methods and reporting are lacking. The authors of this study sought to address these gaps through a case study. 4. Patient safety and lived experience Anthony O'Connor works primarily in the areas of lived experience and in co-production and strives to have both of these concepts better understood, and more effectively utilised wherever possible. In this blog he focuses on lived experience, its definition, its usage, and its impact. 5. Patient safety and co-production Anthony O’Connor talks about the benefits of co-production and why it is essential to patient safety. Anthony gives examples of how co-production can be used more in healthcare and encourages everyone to develop their knowledge of co-production and start embedding it into their work. 6. Providing patient-safe care begins with asking and listening... really listening! Dan Cohen talks about how patient-safe care is all about collaborating and listening to your patients to find out what really matters to them. He illustrates this in a case study of his own personal experience whilst working as a clinician in the USA. 7. Catching cancer early: what more can we do as GPs? GP, Amelia Randle sets out a number of ways clinicians can develop their daily practice to improve cancer diagnosis at an early stage. Amelia talks about involving patients in questioning symptoms, deep listening and learning from patients and families. 8. “Listening to a patient’s history for longer can help doctors make the right diagnosis” Mary Dahm and Carmel Crock tell us more about their research to explore the relationship between communication and diagnostic accuracy. The findings highlight how critical it is to spend time listening to the patient, and for doctors to communicate uncertainties well. Share your insights Have you been involved in safety improvements as a patient? Or perhaps you’re a healthcare professional who has made safety improvements that were informed by the patient voice? Could you share your insights on the value of the patient voice in patient safety? You can comment below (sign up first for free) or email our editorial team at [email protected].
  17. Content Article
    The need for fast-paced innovation in healthcare is widely acknowledged. And ensuring that healthcare innovation is shaped by the people it serves remains a pressing priority – one made all the more evident by the growing emphasis on health equity in the 10 Year Health Plan. Patient voices are often cited as central to healthcare innovation, yet in practice, those voices can be overlooked or engaged too late in the process. On 26 February, the Health Innovation Network invited patient representatives to join them at HETT North in Manchester. They visited innovators exhibiting with the Health Innovation Network, and were encouraged to share experiences and reflections on Patient and Public Involvement and Engagement, common challenges and best practices. In partnership with The Patients Association, a roundtable discussion was convened to explore how Patient and Public Involvement and Engagement can deliver more inclusive, sustainable healthcare innovation.  What emerged from the roundtable discussion is a comprehensive set of recommendations that outline how sustained, well-structured patient engagement can enable more equitable, impactful and inclusive healthcare innovations. Forging a more equitable future through Patient and Public Involvement and Engagement sets out these recommendations, exploring how patient voices can be embedded in the development of digital technology, the need to move beyond conventional pathways, and how to build trust through local communities. A consistent theme was the emphasis on meeting people where they are. Addressing health inequalities requires acknowledging how social, economic, and cultural contexts shape individuals’ access to—and perceptions of—care. Explore the full report to discover real-world case studies, expert insights and actionable recommendations that can shape the future of patient involvement in healthcare innovation.
  18. Content Article
    Public Involvement Front Door is an online resource developed by the NIHR North West London Patient Safety Research Collaboration (PSRC) to help researchers navigate, improve, and embrace public involvement. The Public Involvement Front Door combines a values-based approach with practical tips and resources to open up the world of public involvement and empower researchers of all disciplines and experience levels to meaningfully involve public members in their work. This project is funded by NIHR SafetyNet, and throughout the site you will find guidance specific to the challenges faced in patient safety research, and well as case studies of projects where patients and public members have been safely and meaningfully involved in patient safety research. The Public Involvement Front Door is designed to support you throughout your public involvement journey. The site is split into five stages, allowing you to easily jump to the content most relevant to you at any given moment: Understanding public involvement: Learn about what public involvement is, why it matters, and how it can help your research. Planning your involvement: Plan the who, what, when, where, and how of your public involvement – plus consider how much time and money you’ll need and how you’ll track impact throughout the project. Reaching public members: Explore how to engage with communities and form reciprocal relationships with community organisations to reach public members and involve diverse groups in your work. Involving public members: Understand how to support public members leading up to, during, and after an activity, including tips on how to safeguard public members and yourself. Disseminating your findings: Consider how you will share your findings with the public members you involved and how they can help you share those findings with the wider public. Throughout the site, you’ll find general guidance, graphics and illustrations, tips from public members, and frequently asked questions.
  19. Content Article
    Increasingly, healthcare staff are working in teams with many different professionals across different settings, but they may not have been trained to do this. What does research tell us about what makes such teams work well or better? What kind of challenges are presented in shared or integrated care? What is the glue that holds teams together and why is it so important? How can we improve the process of patient referrals from one part of the system to another? What did we learn from pandemic about new ways of working together, within and across services? Host Tara Lamont and guests Jenelle Clarke, Sarah Yardley and Justin Waring share their experience and insights on building relationships across interdisciplinary teams.
  20. Content Article
    The Leadership Academy has commissioned a project to explore how it can maximise the potential of ‘people power’ through its work, ensuring that participants in its programmes are equipped to work in co-production, across boundaries, and focus on health creation and community capacity, not just how to lead services or organisations. This short primer sets out the theory and context around community development and co-production and what this means for NHS leaders and leadership development. Recommendations from the project will build on what’s already working well across the country and highlight opportunities for change, in order to build an even stronger Academy offer into the future.
  21. Content Article
    In this podcast interview series, NHS whistleblower Peter Duffy and Patient Safety Learning’s Chief Executive Helen Hughes explore how the healthcare system responds when its staff raise concerns about patient safety. In each episode, Helen and Peter interview someone who has spoken up about patient safety issues in healthcare organisations, or who works to help staff raise concerns where they see unsafe care. In this episode, Peter and Helen speak to Bernie Rochford MBE, who spoke up while working as a clinical commissioner at a primary care trust. Bernie found serious issues and inaccuracies in records that posed a risk to patient safety—vital information about Continuing Healthcare patients (patients with significant ongoing care needs in the community) was missing from the system, and there were financial anomalies and serious governance issues. After raising her concerns and getting no response from her managers, Bernie found herself classed as a whistleblower and was isolated at work, eventually losing her job and going to employment tribunal. Bernie describes the serious impact this had on her health and talks about how she is now using her own traumatic experience to work for positive change for others who speak up. She discusses the complexities of regulating managers with Peter and Helen, and argues that we need to look at how people relate, rather than looking to technology, to provide a safer future for healthcare. Now a Principal Freedom to Speak Up Guardian, Bernie currently has a Churchill Fellowship award and is researching different global approaches to speaking up. Subscribe to our YouTube podcast to keep up to date with the latest episodes. View a transcript of this interview Read a blog from Peter and Helen about the interview series Can you help? As part of Bernie’s Churchill Fellowship award she will be looking at speaking up and whistleblowing good practice and alternative approaches from around the world. She will be particularly focusing on approaches in Japan, South Korea, the USA and the Philippines. While her research is predominantly patient safety and healthcare focused, Bernie's interest in learning and sharing best practice goes beyond these areas, as we can learn from other industries and cultures as well. If you have any suggestions, ideas, best practice or experience that you can share with her, from anywhere in the world, please email Bernie. She will be very grateful to hear from you! How whistleblowers are passed around the system In the interview, Bernie talks about how she was passed from one person and organisation to another as she tried to raise her concerns. This diagram, which was included in the report of the Freedom to Speak Up review carried out in 2015 by Sir Robert Francis QC, shows the 54 people, teams and organisations Bernie approached to speak up about the patient safety issues she saw.
  22. Content Article
    Overloaded with duplicative recommendations, the healthcare system must prioritise impactful actions, improve collaboration, and ensure meaningful implementation to enhance patient safety and restore public trust, writes Rosie Benneyworth, chief executive officer of the Health Services Safety Investigations Body (HSSIB).
  23. Event
    As healthcare evolves at an unprecedented pace, patient safety continues to be a top priority. The year 2025 marks 25 years since the Institute of Medicine’s landmark report, To Err Is Human, and we are now facing new, complex challenges in patient safety. From artificial intelligence in clinical settings to the growing threats of cyberattacks and medical misinformation, the landscape of healthcare has drastically changed. Additionally, rising awareness of health disparities and issues like “medical gaslighting” highlight the importance of patient-provider relationships. During this webinar, we will: Describe how ECRI and the ISMP PSO use a learning system approach to create and disseminate the list of Top 10 Patient Safety Concerns. Discuss why dismissing patient, family, and caregiver concerns should be a major area of concern for the healthcare community. Discuss how elements of a total systems approach to safety and recommendations for improvement can be used to address these concerns. Register
  24. Content Article
    Dr Kirsten Howson, Specialist Education Lead at SimComm Academy, discusses the role Simulation-Based Education (SBE) can have in patient safety. Kirsten highlights some of the techniques used in SBE, the benefits for staff and patients, and the importance of involving people with lived experience in the design and delivery of SBE. Background Initially used within the aviation industry, Simulation-Based Education (SBE) has now been adopted within healthcare education and training.[1] Clinical SBE began several decades ago[2] and has continued to successfully grow, providing learners with the opportunity to put their knowledge and skills into practice within a psychologically safe environment. Effective SBE includes a debrief following on from the simulated exercises. Research outlines that the debrief has been identified as a key component of impactful SBE, with the simulated scenarios acting as a catalyst for further reflection, conversation and sharing of experiences and ideas.[3] There are a range of techniques used within SBE: Forum theatre: Participants observe a complete simulated scenario played out in front of them, followed by a group reflection. The scenario is then run again, giving participants the opportunity to pause the scenario at multiple points and change the behaviours and language of one of the simulated characters in an attempt to improve the outcome of the interaction. Fishbowl simulation: Participants are given a scenario and task and interact with simulated characters while their peers observe the interaction and completion of the task. This is followed by a facilitated debrief in which participants are able to explore alternative methods, obtain feedback, discuss learning objectives, and reflect and share ideas. Observational simulation: Participants observe a simulated scenario which is then followed by a facilitated debrief in which participants are able to explore alternative methods, discuss learning objectives, and reflect and share ideas. Monologues: Participants observe while a simulated character delivers a monologue, which may include the character’s reflections, experiences or feelings. This is then followed by a facilitated debrief in which participants are able to explore alternative methods, discuss learning objectives, and reflect and share ideas. How simulation-based education impacts on patient safety SBE has been shown to have a wide range of benefits, many of which impact on patient safety, including: Participant skills and knowledge: SBE enhances participant skills[4] through practice, reflection and feedback, and can span not only technical skills, such as performing procedures and examinations, but also non-technical skills, such as leadership, communication skills, teamwork or prioritisation.[5] Enhancement of the skills and knowledge of clinical staff will likely result in an increase in patient safety. Participant confidence: Simulation training can increase the participant's confidence by providing participants with the opportunity to practise a new skill in a simulated setting in which there will be no safety implications; participants can build their confidence to the point at which they feel safe to use the skills in a non-simulated environment.[6] Participant teamwork: Teamwork skills are often a key focus and improve through the use of simulation training.[7] Dependent on the participant group, this can be on both an intraprofessional and interprofessional basis. Although these skills can be practised within the simulation scenarios, the debrief period also provides the opportunity to share differing points of view within the team, which can enhance teamwork, and again will likely result in an increase in patient safety. Participant mental health, burnout and sick leave: Medical and allied healthcare staff face high levels of mental health concerns and burnout, with the recent General Medical Council (GMC) report, 'The State of Medical Education and Practice in the UK Workplace Experience 2024' stating, “a third of doctors are struggling and feel unable to cope.”[8] Staff burnout impacts negatively on patient safety.[9] Simulation training has been found to have beneficial effects on anxiety, stress and burnout among some staff groups[10] and could also act as a protective factor against sick leave.[11] The importance of co-design and co-production in simulation-based education In 'Learning from Experience', The Royal College of Psychiatrists states, “The involvement of people with lived experience of mental illness either as a patient or carer in educational programmes can provide unique and relevant learning opportunities and teaching experience for doctors and psychiatrists in training.”[12] The GMC have also outlined the patient role within education in 'Patient and Public Involvement in Undergraduate Medical Education.[13] We believe that this concept should be extended across healthcare education. We endeavour to include the perspectives of a range of people with lived experience in the design and delivery of our courses, such as members of staff, parents, relatives, carers and patients where possible and appropriate. Not only does this enrich the quality of the education, bringing a broader perspective, but it also carries benefits to the patients involved, including a sense of fulfilment.[14][15] Some examples of the methods of co-design, co-delivery and stakeholder involvement we have used in our training, include The involvement of one of our Equity and Inclusivity Advisors, who is also a member of the transgender and gender diverse community, in co-design and co-delivery of courses aimed at exploring and outlining the challenges and assumptions that LGBTQIA+ individuals face. The incorporation of staff reflections and experiences into scenarios when designing courses on the following topics:: - cultural allyship - fostering workplace belonging - Band 5 and 6 leadership - managing disability - supporting internationally educated nurses. The incorporation of patient and carer feedback and experiences when designing our course, 'What Matters to Me'. The incorporation of parent experience when designing filmed training scenarios surrounding communication with parents during neonatal resuscitation. You can read more about one of our co-design projects in 'Involving patients and relatives by translating their experiences into simulation-based education'.[16] Conclusions SBE is now widely used across healthcare training to a variety of multi-disciplinary professionals, within a range of specialities, covering both technical and non-technical skills, which demonstrates the degree of versatility of SBE. It is important to incorporate the voice and perspective of people with lived experience where possible to ensure authenticity. This is an extremely exciting time for SBE as new innovative methods, uses and programmes are developed with the ultimate aim of continuing to enhance patient safety. References Oman S P, Magdi Y, Simon L V. Past Present and Future of Simulation in Internal Medicine. In StatPearls. StatPearls Publishing, 2023. Nehring WM, Lashley FR. Nursing Simulation: A Review of the Past 40 Years. Simulation & Gaming, 2009; 40(4): 528-2. Jaye P, Thomas L, Reedy G. 'The Diamond': a structure for simulation debrief. The Clinical Teacher 2015; 12(3): 171–5. Issenberg SB, et al. Simulation technology for health care professional skills training and assessment. JAMA 1999; 282(9): 861–6. Pearson E. McLafferty I. The use of simulation as a learning approach to non-technical skills awareness in final year student nurses. Nurse Education in Practice 2011; 11(6):399–405. Alrashidi N, et al. Effects of simulation in improving the self-confidence of student nurses in clinical practice: a systematic review. BMC Medical Education 2023; 23(1); 815. Gilfoyle E, et al. & Teams4Kids Investigators and the Canadian Critical Care Trials Group. Improved Clinical Performance and Teamwork of Pediatric Interprofessional Resuscitation Teams With a Simulation-Based Educational Intervention. Pediatric Critical Care Medicine 2017; 18(2): e62–9. General Medical Council. The State of Medical Education and Practice in the UK Workplace experience, 2024. Garcia CL, et al. Influence of Burnout on Patient Safety: Systematic Review and Meta-Analysis. Medicina (Kaunas, Lithuania) 2019; 55(9): 553. Couarraze S, et al. Short term effects of simulation training on stress, anxiety and burnout in critical care health professionals: before and after study. Clinical Simulation in Nursing 2023; 75: 25–32. Schram A, et al. Exploring the relationship between simulation-based team training and sick leave among healthcare professionals: a cohort study across multiple hospital sites. BMJ Open 2023; 13(10): e076163. The Royal College of Psychiatrists. Learning From Experience. Working In Collaboration With People With Lived Experience To Deliver Psychiatric Education, May 2021.   General Medical Council. Patient and Public Involvement in Undergraduate Medical Education, February 2011. Dijk SW, Duijzer EJ,  Wienold M. Role of active patient involvement in undergraduate medical education: a systematic review. BMJ Open, 2020;10(7): e037217. Gutteridge R, Dobbins K. Service user and carer involvement in learning and teaching: a faculty of health staff perspective. Nurse Education Today, 2010; 30(6): 509–14. Hamilton CJ, et al. Involving patients and relatives by translating their experiences into simulation-based education. A31. Abstract from Association for Simulated Practice in Healthcare Annual Conference 2018, Southport, United Kingdom.
  25. Content Article
    The Wales Ergonomics and Safer Patients Alliance (WESPA) was formed in response to supporting the NHS during the COVID-19 pandemic. WESPA comprises early career and senior researchers from across Cardiff University (Business, Engineering, Mathematics, Medicine) with expertise in operations management, human factors and resilience engineering. We work closely with NHS professionals (clinicians, managers and executives) to model how the design of health services impact on staff and patient outcomes. WESPA's primary aim is to carry out applied research driven by clinical need by drawing upon research expertise from across Cardiff University to enable innovation and implementation of practices to improve patient safety in the NHS, by: Partnering with NHS organisations, and working directly with NHS staff, to identify improvement priorities, it will: - embed researchers-in-residence to analyse patient safety data and observe in clinical settings; - build capability to develop data infrastructures that promote timely organisational learning to inform service design, planning and management; - evaluate models of service delivery to identify where and how the service can be designed / redesigned to improve staff and patient outcomes. Leading engagement activities with key stakeholders – healthcare professionals, managers, executives, patients, services users and the public – to gain timely feedback on our research findings. Facilitating co-production activities in the NHS to maximise understanding of human factors influencing staff and patient outcomes. Engaging with the third sector and other organisations with the purpose of influencing policy and achieving impact in the NHS. Research Development and testing of methodological approaches to apply human factors theory, principles and tools in the NHS to understand and learn from complex socio-technical systems; Identification of opportunities for health systems improvement from analysis of routine patient safety data; and, Understanding complex systems by modelling and quantifying variability using the Functional Resonance Analysis Method (FRAM).
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