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Patient Partnership Week (29 June-3rd July 2026) is a moment to focus on a simple but powerful truth: healthcare works best when patients are treated as partners.  Across the week, The Patients Association are bringing together patients, professionals, policymakers, and researchers to explore what meaningful partnership looks like in practice and why it matters, where progress is being made, and what still needs to change.  Patient Partnership Week 2026 webinars Understanding the causes of health inequalities and the role of trust in improving outcomes 29th June 2026, 3:45 - 4:45pm Book now Unlocking patient engagement with the People and Communities guidelines 30th June 2026, 9 - 10am Book now Do patients’ goals, values, and preferences really shape their care? 30th June 2026, 4 - 5pm Book now Power to the people? The 10 Year Health Plan, one year on 1st July 2026, 11am - 12pm Book now Why prioritising patient trust increases the value of using technology and data to improve research and care 2nd July 2026, 12:30 - 1:30pm Book now Equity in access: tackling barriers to treatment and care 3rd July 2026, 10 - 11am Book now Getting through: fixing how NHS communicates with patients 3rd July 2026, 2 - 3pmBook now

In this free webinar, Senior Consultants Mark Patterson and Matthew Rice will explore what systems leadership is, why it matters, and what it asks of leaders working across health and care. Drawing on their experience of supporting senior leaders through the Top Manager programme (TMP), The King’s Fund’s longest running leadership programme, they will share practical insights into leading across boundaries, working without direct authority, and staying curious in the face of complexity. This session will offer a practical introduction to systems leadership and will encourage you to reflect on your own leadership challenges and opportunities. It’s ideal for senior leaders who want to strengthen their ability to work across organisational boundaries and create change in complex environments. You will learn: what systems leadership looks like in practice in health and care why it matters when challenges span organisations, teams and services how to lead across boundaries when we you don't have direct authority why leadership in complex systems is often a collective endeavour and what that means for how you work with others. Register

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

At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. Diabetes is a condition that causes the amount of glucose in a person's blood to be too high. When you have type 1 diabetes, your body can’t make any insulin at all, whereas with type 2, you either can’t make enough insulin, or it can’t work properly. There are also other types of diabetes including gestational diabetes, which some women develop during pregnancy, maturity onset diabetes of the young (MODY) and latent autoimmune diabetes in adults (LADA). It is important that people with diabetes are supported to maintain good blood glucose control through diet, insulin and other diabetes medications, to prevent both acute and long-term complications. We’ve selected our top picks of useful resources about diabetes. Self-management is perhaps the most important aspect of treating diabetes effectively, so we've included some resources aimed at helping patients manage their diabetes too. 1 HSSIB reports The Health Services Safety Investigation Body (HSSIB) has published a series of reports considering the self-administration of insulin by people with diabetes mellitus. Each report focuses on specific groups of people who, due to their circumstances, may be at increased risk of harm because of the way they self-administer insulin. Insulin: supporting safe self-administration for patients in the community with a mental health problem Insulin: supporting safe self-administration for patients in the community with a disability Insulin: supporting patients to safe administration in inpatient settings 2 Decoding diabetes research – an innovative approach that makes scientific knowledge accessible to everyone In this blog, Jazz Sethi, Founder and Director of the Diabesties Foundation and part of the global team that developed D-Coded, discusses the need for the resource and outlines how it will help people living with diabetes to better understand and manage their condition. 3 Leading for patient safety: a conversation with Partha Kar Partha Kar, National Specialty Advisor for NHS England, has led work that has had an enormous impact for patients and for patient safety. In this video podcast, Steph O'Donohue from Patient Safety Learning talks to Partha about his leadership style and how it has helped him drive forward significant change in an often challenging context. 4 Decision support tool: making a decision about managing type 1 diabetes This leaflet from NHS England aims to help people with type 1 diabetes decide between the different technologies available to manage diabetes. It contains summaries of devices available and infographics outlining eligibility criteria for continuous glucose monitors (CGM), insulin pumps and hybrid-closed loop systems. 5 10 Year Vision: For diabetes prevention, care and treatment This report from Diabetes UK sets out a clear plan for the UK government about how it can improve health outcomes and tackle inequality for people living with diabetes by 2035. 6 D1abasics: Equipping staff to care safely for inpatients with diabetes The inpatient diabetes team at University Hospital Southampton NHS Foundation Trust recently launched D1abasics, an initiative that aims to improve inpatient care for people with diabetes. In this blog, Diabetes Consultant Mayank Patel and Inpatient Diabetes Specialist Nurse Paula Johnston outline the approach and explain how it will equip staff across all specialties with the basic knowledge to care safely for people with diabetes in hospital. 7 Improving diabetes care in inpatient mental health settings Despite the prevalence of diabetes amongst individuals with Serious Mental Illness (SMI), diabetes care is not currently audited within mental health inpatient settings as it audited in physical health settings. This project piloted an audit to assess the diabetes care within London NHS Mental Health Trusts. 8 Diabetes tech: Do national aspirations and local practice align? In this blog, a person with type 1 diabetes describes their recent experience upgrading their insulin pump, a medical device used to continuously deliver insulin instead of taking multiple daily injections. They describe how communication issues and gaps in staff knowledge led to a significant delay in accessing the pump, which caused them significant stress. They also ask whether recent announcements about increased access to diabetes technology over the next few years will match up to the reality experienced by people with diabetes accessing care at local healthcare organisations. 9 NHS England - Language Matters: language and diabetes The language that healthcare professionals use to talk about diabetes can have a profound impact on how people living with diabetes, and those who care for them, experience their condition and feel about living with it. This guidance by NHS England sets out practical examples of language that will encourage positive interactions with people living with diabetes. When people with diabetes feel encouraged and empowered to manage their condition, it has been shown to make a difference to their health outcomes. The examples in ‘Language Matters’ are based on research and supported by a simple set of principles. 10 Key things to remember if you use injectable medication to treat your diabetes This checklist by TREND Diabetes outlines the steps patients should take to ensure they inject their insulin or other diabetes medication correctly. It explains the importance of taking steps such as moving injection sites and changing needles, and outlines how failing to do this can affect blood glucose control. 11 Improving safety for diabetic inpatients: 4 key steps In this video, Partha Kar, National Specialty Advisor for Diabetes, shares four steps to improve safety for inpatients with diabetes, based on information from the National Diabetes Inpatient Audit. He also highlights key resources to help staff improve their knowledge of diabetes and understand how to offer the safest care to people with diabetes when they are staying in hospital. 12 Diabetes technology is life-changing, but we need to be prepared when it fails In this blog, Andrew Stroud talks about his family's experiences supporting their daughter, Bia, to manage her type 1 diabetes. He describes the huge value of technology in improving diabetes management and reducing the mental burden of the condition on people with diabetes and their parents and carers. However, like all technology, medical devices for diabetes can fail, and Andrew highlights the need to be prepared for this situation to ensure the person with diabetes is safe while they cannot use the devices they rely on every day. 13 How safe are closed loop artificial pancreas systems? Closed-loop artificial pancreas systems are self-regulating systems for administering insulin to patients with type 1 diabetes. They allow for tighter blood glucose control and reduce the decision-making burden for people with diabetes. In this blog, Lotty Tizzard, Patient Safety Learning's Content and Engagement Manager, takes a look at the benefits and potential patient safety risks associated with closed-loop artificial pancreas systems (APS). People with diabetes have developed the algorithm that runs these systems and made it freely available to anyone wanting to build their own DIY artificial pancreas. This has spurred the medical tech industry to develop commercial systems, which will make the technology more widely available. But there are challenges in ensuring accessibility to all people with type 1 diabetes who would benefit from the technology, and there are questions about regulation and liability. 14 A systematic approach to insulin safety (video series by Communications PharmSocNI) This video series looks at systematic approaches to insulin safety, including: Human Factors - A Journey of Discovery; SEIPS – The Swiss Army Knife Approach; and Summary & Applying the Learning. 15 System-wide strategies for better diabetes care chapter 1: Evidence approved medicines and chapter 2: Ensuring equitable access to glucose sensing technology for type 2 insulin users Two reports from Public Policy Projects (PPP). Chapter 1 calls for changes in the use of approved medicines to improve diabetes care in the UK and chapter 2 highlights the opportunities and challenges brought by CGM technology to type 2 insulin users and other patient groups. 16 National Diabetes Foot Care Audit 2018 to 2023 Ulceration of the foot in people living with diabetes presents significant challenges, including emotional, physical and financial costs, and is associated with increased risk of both amputation and death. It affects between 1 and 2% of all people with diabetes each year and its management accounts for approximately 1% of the total NHS budget. The aim of the National Diabetes Foot Care Audit is to measure factors associated with increased risk of ulcer onset and adverse ulcer outcomes, and to share information relating to best clinical practice. 17 Diabulimia: what is it and why have so few people heard of it? Type 1 diabetes with disordered eating (T1DE), or diabulimia as some experts call it, is a serious eating disorder that people with type 1 diabetes can develop where the person reduces or stops taking their insulin as a way of managing their weight. The condition can be life-threatening. Although studies are limited, it’s estimated that eating disorders affect more than a third of patients with type 1 diabetes. This episode of the Healthcare Improvement podcast looks at diabulimia and a new toolkit published by SIGN, part of Healthcare Improvement Scotland, which sets out recommendations to raise awareness and provide guidance on how best to support people living with the diabulimia. 18 NHS England: Children and young people diabetes toolkit This toolkit is designed to support integrated care systems (ICSs) to design, plan, and deliver high-quality treatment and care for children and young adults aged 0-25 years with all types of diabetes. 19 Insulin therapy in primary care The management of insulin therapy requires knowledge of the type of diabetes it is being used for and appropriate dosing, as well as correct injection technique, to prevent complications and medication errors. Diabetes nursing specialist Debbie Hicks shares key points on the management of insulin therapy for nurses in primary care. 20 Handbook: Diabetes footcare in dark skin tones Covering essential topics such as physiology, history-taking, assessment techniques, and investigative methods, this handbook has been designed to provide essential information as well as quick tips to healthcare professionals to improve foot care for people with dark skin living with diabetes. Featuring clinical assessments and visual/audio guides, this handbook is the product of a unique collaboration across healthcare professional specialities, and with input from people living with diabetes. 21 Addressing racial inequalities in paediatric diabetes Dita Aswani and Fulya Mehta are both consultant paediatricians and NHS England national advisors for Children and Young adults’ (CYA) diabetes. In this blog, they outline racial inequalities that persist in paediatric diabetes and present five key areas for change. In summary they talk about what healthcare professionals can do to reduce inequalities through their own practice. Do you have a resource or story about diabetes to share? We’d love to hear about it - leave a comment below or join the hub to share your own post.

Craig Russo outlines the Core Needs School Pilot, a needs-led, school-based early intervention model for young people with neurodevelopmental needs. He describes how embedding clinicians in schools enables rapid, functional assessment and support without waiting for diagnosis, improving outcomes while significantly reducing costs and demand on specialist services. It demonstrates impact and support expansion, highlighting strong value for money, improved access and alignment with national SEND reform principles. The Core Needs provides a clear, practical example of how a needs‑led model can be operationalised at scale within mainstream education, moving beyond theory into delivery. It demonstrates how embedding clinical expertise directly into schools transforms access, shifting support closer to children and young people and enabling real-time assessment, observation and intervention in their everyday environment. This approach not only improves timeliness but strengthens relationships between health, education and families, creating a more joined-up system that is easier to navigate. A key learning point is the power of intervening early with functional, strengths-based support rather than relying on diagnostic thresholds. The model shows that many young people can be effectively supported through a single, well-structured intervention, supported by a period of watchful waiting and clear step-up pathways when required. This has important implications for demand management, demonstrating a credible route to reducing pressure on specialist services while maintaining safe and appropriate escalation. The pilot also highlights the importance of building capability within schools. By working alongside SENCOs and staff, clinicians are not only supporting individual children but leaving a lasting legacy of increased confidence, skills and consistency within the wider workforce. This creates a multiplier effect, where impact extends beyond the initial intervention and contributes to longer-term system resilience. From an operational perspective, the pilot identifies critical enablers of success, including strong multi-agency partnership working, clear referral processes, dedicated workforce capacity and a structured delivery model. It also makes clear the risks of not investing, particularly around increasing demand, widening inequity of access and continued reliance on costly statutory pathways. For decision-makers, the key action is to consider how this model can be embedded as part of the core local offer, rather than as a time-limited pilot. The evidence presented supports scaling through a phased approach, ensuring quality and consistency are maintained while expanding reach. It also prompts a wider reflection on how services can redesign pathways to prioritise early intervention, improve flow and ensure that resources are directed where they have the greatest impact. Overall, this pilot offers a compelling, evidence-informed case for system change, showing not just what should be done differently, but how it can be delivered in practice in a way that is sustainable, equitable and centred on the needs of children and young people. More blogs on the hub from Craig Russo: Partnership working between A&E, the police and custody healthcare

The rapid development and use of artificial intelligence (AI) in health and social care raises professional, ethical and legal questions. In February, the Professional Standards Authority for Health and Social Care hosted a participatory workshop in collaboration with academics from the University of Bristol, Dr Helen Smith and Professor Jonathan Ives to explore how we can guide and regulate health and care professionals who use AI. The workshop brought together professional regulators and Accredited Registers, as well as patients, service users and members of the public. Through group discussions and a series of real-world scenarios, participants explored themes such as AI safety, bias, transparency and accountability. In this blog, Patrick Murphy, Policy Advisor, reflects on the messages that came out of the workshop. The value of lived experience The workshop reinforced a key message, that the future of AI in health and care cannot be shaped by technical expertise alone. Creating spaces where patients and service users work alongside regulators and Accredited Registers supports safer innovation. Lived experience brings vital insight into how systems work in practice, where risks can emerge, what the public want and need from regulation, and how to build trust. It also helps support the safe and reliable integration of AI. The workshop was designed with participation in mind. Patients and service users took part alongside regulators and accredited registers on an equal footing. In a space that can sometimes feel highly technical, the workshop showed that meaningful public involvement is both possible and necessary. Participants with lived experience engaged confidently with topics such as assurance, transparency and accountability. Discussions also covered how regulation, standards and guidance are experienced by the people they are meant to serve. A consistent message throughout the day was that patients and service users are not just observers of AI policy and regulation, they are essential partners in getting it right. Their contributions raised practical questions and real-world examples, and kept the focus on how AI-enabled decisions can affect people’s lives, access to services and confidence in care. Equity, transparency and trust Patients, service users and members of the public highlighted several issues that deserve particular attention as AI becomes more common across health and care. If engagement only reaches the most confident, connected or well-resourced groups, AI tools and the rules around them risk being shaped by a narrow range of experience. True inclusion means actively involving people who are often overlooked, so innovation serves everyone and not just those who are easiest to reach. To support safe and fair innovation, tackling inequality needs to be built into every stage, from development, to procurement and service design, to long-term monitoring after deployment. Fairness and equity must be central, not an afterthought. Avoiding harm requires more than technical fixes. It also needs careful scrutiny of the data that feeds AI systems. That includes the data used to train models and the data used in designing health and care services. It is also essential to be clear about which outcomes are being measured and how success is defined. Trust depends on clarity, and it is important to give consideration to how AI is integrated in health and social care. Patients and service users should not feel like they are interacting with a 'black box'. It should be clear when AI is being used, what role it is playing in someone’s care and what options are available if something feels wrong. Empowering people helps them remain partners in their own health and care journey. The workshop highlighted challenges but also the opportunities for health and social care improvement presented by AI. As we navigate this technological transformation, patients and service users should remain empowered through co-production, helping to shape the standards, guidance and regulation that govern how AI is designed, deployed and monitored in practice. To find out more about the workshop and read the report, visit: Artificial intelligence - how to guide and regulate for health and social care professionals using AI

Stefan Peil summarises a pilot study he has done to see whether a structured systems model can support the preparation of a morbidity and mortality (M&M) conference discussion. The example used is a coronary angiography risk scenario to explore whether a model-based representation of patient safety knowledge could serve as a reliable basis for an artificial intelligence (AI)-assisted decision template. The work was produced to address a practical problem in patient safety: relevant information for M&M preparation is often spread across diagrams, reports and team knowledge, which can slow and make shared understanding less consistent. The pilot study, therefore, examined whether systems modelling could help organise, make transparent and reuse safety relevant information in a more structured way. The full study is attached at the end of this page. The challenge The identified challenge was the lack of a structured, reusable approach to preparing patient safety discussions for M&M conferences. The aim was not to automate clinical judgement, but to test whether a model-based risk analysis derived from team knowledge could serve as a structured input for drafting an M&M decision template. M&M preparation often relies on fragmented information and informal interpretation. In complex clinical environments, such as coronary angiography, risks do not arise from a single isolated factor. They emerge from the interaction between tasks, people, technology, information flow and organisational conditions. In this specific pilot example, the safety concern was a risk scenario in coronary angiography in which cognitive overload during real-time decision-making and escalation could contribute to complications not being detected in time. This formed the basis for testing whether a structured model could provide a clearer and more traceable starting point for discussion. Method and measures To explore this, a systems model based on Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 was created in Systems Modeling Language (SysML) using SPARX Enterprise Architect. The objective was to represent the work system, the contributory task factor, the resulting risk and the proposed measures in a traceable form. The model focused on one coronary angiography scenario. The critical task factor was described as cognitive density in real-time decision-making and potential escalation. In the model, this contributed to the risk that complications would not be detected in time. The text states an impact on quality of care, an occurrence rating described as relevant and an overall risk class of moderate. The proposed measures were: pre-procedure briefing risk-adapted staffing standardised laboratory layout regular simulation drills. The intended achievement was a more structured, transparent and reusable basis for M&M preparation and discussion. Outcomes and lessons learned The pilot showed that a structured model can be a useful way to organise safety-relevant knowledge. Because the model linked work system elements, risks and measures in a traceable way, it provided a clearer starting point for discussion than unstructured text alone. The practical process tested in this pilot was: defining a relevant patient safety scenario in coronary angiography modelling the work system and the contributory task factor linking this to a patient safety risk documenting possible mitigating measures using the model as the basis for an AI-assisted one-page decision template. One important observation was that the AI-generated output reflected the underlying model's content. This suggests that a structured model can support more consistent synthesis than relying only on memory or informal interpretation. The text does not describe multiple alternative technical approaches in detail, so it cannot be stated from the source whether other options were formally compared or ruled out. It also does not state direct patient involvement. Staff involvement is referenced indirectly by using team knowledge as an input to the model. The text does not report formal measurement tools, outcome metrics, time savings, patient safety indicators or model costs. Therefore, no validated impact measurement can be claimed from the source. A key lesson learnt was that AI can assist with drafting and synthesis, but cannot replace clinical judgement, governance or safety review. Any output generated from the model still needs to be checked against the source material and reviewed by responsible clinical and patient safety leads. Impact This work is only a prototype, not as a formal effectiveness study. As a result, the impact that can be claimed is limited. The main result was that the structured model appeared to support: clearer organisation of safety-relevant knowledge better traceability between work system factors, risks and proposed measures a more consistent starting point for multidisciplinary discussion reuse of modelled information for drafting a one-page M&M decision template. At the same time, the the study is explicit about what was not demonstrated. The pilot did not test whether the approach: improved patient outcomes reduced harm shortened preparation time in routine practice improved care delivery in a measurable way. A further limitation was that only a single, limited example was used, and some information was withheld for data protection reasons. This means the results were narrower than would be needed for broader implementation decisions. What worked was the structured linkage between the work system, contributory factors, risks and measures. What remains uncertain is whether this translates into measurable operational benefit in routine clinical governance. A likely barrier to improvement is the need for continued expert review, because AI-generated output cannot be used without clinical validation and governance oversight. If repeated, the next stage would need a clearer evaluation design, including defined measures of clarity, consistency, usability and possibly preparation time. Next steps The next step is a practical pilot in real clinical governance settings. A suitable next-stage comparison would be conventional M&M preparation versus model-supported preparation in a small, clearly defined pilot. The proposed questions for the next phase are: Does the approach improve clarity and shared understanding? Does it help teams identify contributory factors more systematically? Does it support consistency and traceability of measures related to patient safety? The study does not provide evidence of long-term organisational change, staff reaction, patient impact statistics or system-wide implementation results. Therefore, those elements cannot yet be stated as outcomes. However, based on insights from the pilot study, the anticipated longer-term value would be to make patient safety knowledge: more structured more reusable easier to discuss across professional groups more clearly linked to the wider work system rather than to isolated errors. A sensible next step would, therefore, be a controlled local test with defined governance, clinical review and evaluation criteria before any broader adoption.

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NHS Resolution Safety and Learning team will be hosting the next quarterly National Mental Health Networking forum, a national event designed to support networking, collaboration and the sharing of best practice. This is the second in a three-part series exploring mental health care across the system starting with crisis and emergency departments, followed by inpatient safer care and concluding with community support and recovery. This quarterly event will bring together voices from across the system to drive national collaboration, sharing learning and continous improvement in mental health care. This session will spotlight inpatient care and services, with a focus on: Trauma Informed Care Reducing restrictive interventions Workplace Violence and aggression Updates to the Mental Health Act You will hear from NHS England Quality Transformation Team, South London and Maudsley NHS Foundation Trust, Greater Manchester Mental Health NHS Foundation Trust, NHS Resolution Safety and Learning Team, legal experts, and a lived experience ambassador. Register

Working across frontline emergency care, patient safety and digital patient safety over the course of my 22-year career in the NHS has given me a unique perspective on how digital systems shape real clinical practice. As a paramedic now working as a Clinical Safety Officer within NHS Wales, I’ve seen first‑hand how digital tools can support safer care—but also how they can contribute to patient harm when things don’t work as intended. In this blog, I reflect on the challenges of identifying issues and, more importantly, assessing patient harm in a digital context. These thoughts aren’t theoretical, they come from day‑to‑day reality: the calls, the investigations, the conversations and the moments where something in the digital healthcare system doesn’t work the way it should—and a patient feels the impact. I’m sharing these thoughts to stimulate conversation, hopefully build shared understanding and help strengthen our collective approach to digital patient safety across the UK. The growing complexity of digital healthcare Digital healthcare has evolved rapidly, and with that evolution comes complexity. Electronic health records, diagnostic platforms, telehealth solutions, national and local systems—all interacting with each other in ways that aren’t always obvious. When something goes wrong, pinpointing where the issue originated can be incredibly challenging. Was it a configuration setting? A workflow design flaw? A user misunderstanding? A vendor update? A mismatch between national and local versions of the same system? Add to that, the fact that some third‑party suppliers are unable or unwilling to share detailed technical information (I assume due to concerns that competitors may gain access to it) makes it even harder to determine how the incident occurred or how to prevent it from happening again. Interconnected systems, shared responsibilities Because digital care rarely sits within a single organisation, the responsibilities for harm often cross boundaries too. Different organisations use systems differently. Local configurations vary. Some teams rely on national services; others are still using legacy versions. All of this makes investigation slower, more complicated and highly dependent on strong cross‑organisational collaboration. No single organisation can fully assess digital‑related harm in isolation, but still we try! The challenge for non-patient‑facing Health Bodies For organisations like mine, there is an added complexity: we don’t have direct clinical access to patients. This means our ability to assess harm depends on the engagement of colleagues across health boards and trusts—many of whom are experiencing significant operational pressures. Data security and privacy Sharing information about harm while protecting patient data is essential, but not always simple. We must balance transparency with strict confidentiality requirements. Digital errors, diagnostic risks and human interpretation Not all harm is caused directly by digital systems. Sometimes the system works correctly, but the presentation of the data creates an issue, or the clinician/user interaction or interpretation of the data is the issue. Other times, issues stem from algorithmic limitations, technical malfunctions or messaging fabric (infrastructure that connects the system components and allows them to communicate) problems. Determining whether harm originated with the tool, the user or the interaction between them is rarely straightforward, and tools like Systems Engineering Initiative for Patient Safety (SEIPS) are vital in breaking this complexity down. Training, local workarounds and the gaps no one talks about Training remains a significant challenge. National bodies like mine are not responsible for delivering frontline training, and local approaches vary widely. This leads to several risks: Depth and quality of training varies. Important system features may be misunderstood or overlooked. Safety considerations are not always emphasised during training. Local 'shortcuts'—never designed, tested or approved—become normal practice. Once these shortcuts become embedded in everyday workflows, they can be incredibly difficult to unwind. Yet they often play a significant role in digital‑related incidents. The existing DCB0129 and DCB0160 standards provide a useful foundation, but they offer limited guidance on how to investigate and learn from digital incidents. They were designed at a time when digital healthcare was far less complex than it is today. Suppliers don’t like to highlight their products weaknesses or errors made; therefore, there is vast variation in the quality of investigation reports shared post incident. Rather than worrying about reputational damage, I wish the focus was on candour and opportunities for learning and development. The timeliness problem: when harm takes time to surface Digital harm isn’t always immediate. It may be a misfiled result, a confusing display or a workflow that gradually introduces delay. Additional challenges include: Variation in national policy timescales (in Wales six differing policies provide timescale guidance). The need for clinical review to confirm harm. Limited capacity among clinicians supporting digital investigations. This can make it difficult to meet regulatory expectations for timely disclosure—even when everyone involved is committed to doing the right thing. Freedom to Speak Up: a critical enabler of early detection Speaking up plays a vital role in identifying digital‑related safety issues early. Many concerns emerge informally at first—“this doesn’t look right” or “this field always causes confusion.” If staff feel unsure about raising these concerns, they can remain hidden until harm occurs. Strengthening a Freedom to Speak Up culture is essential. It provides all staff a protected route to escalate concerns, even when they feel uncertain or worry that a system issue might be dismissed as user error or a training gap. I firmly believe that a strong speaking up culture means digital risks are more likely to be surfaced early, before they become incidents. A rapidly changing safety landscape Wales has seen significant changes in digital governance and health policy in recent years, from the transition from NHS Wales Informatics Service (NWIS) to Digital Health & Care Wales (DHCW) to updates in national structures (NHS Executive now NHS Performance & Improvement) and regulatory expectations. As I type, the National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011 (often referred to as 'Putting Things Right') are undergoing review and update. These shifts can create uncertainty about roles, responsibilities and reporting pathways. When something goes wrong, it’s not always clear who is responsible for what—and this ambiguity can complicate harm assessment. Where digital meets traditional healthcare Digital systems are embedded into clinical workflows, communication pathways and multi‑team processes. Every interface, integration point and manual interaction/data entry represents a potential source of risk. Reviewing these interconnected pathways is rarely quick or straightforward, but it is essential for understanding how digital harm occurs and how it can be prevented. Conclusion and call to action: building a safer digital future together The reflections in this paper highlight the complexity of digital patient safety work. Digital systems bring enormous potential for improving care, but they also introduce new risks that we are still learning how to manage. To address these challenges, we need a coordinated national approach that brings together healthcare organisations, digital suppliers, clinical safety experts, policymakers and frontline staff. This means: Updating and strengthening digital safety standards. Improving consistency in both incident investigation and harm assessment. Enhancing training and digital literacy. Supporting timely, transparent reporting. Facilitating availability of clinicians to undertaken harm reviews. Encouraging openness and speaking up. Improved incident data triangulation. Thematic analysis of incidents and nationally shared learning. Building stronger cross‑organisational collaboration. Most importantly, we need a culture where digital concerns are raised early and acted upon quickly. The opportunity ahead is significant, as are some of the challenges… But I truly believe that by working together, we can shape a safer digital health landscape—one that protects patients, supports professionals and ensures that innovation enhances care rather than complicating it. Further reading on the hub: How do we harness technology responsibly to safeguard and improve patient care? NHS England warns electronic patient record could pose ‘serious risks to patient safety’: what can we learn? The foundations for a safe digital service delivery in health—A blog by Rob Ludman Applying a robust approach to digital clinical safety in diagnosis b

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.  Using patient stories to create significant impact and improve cancer patient experience The Cheshire and Merseyside Cancer Alliance (CMCA) were finalists in the 'Partnership Working to Improve the Experience' category at the Patient Experience Network 2025 Awards. In this blog, CMCA explain how patient stories are deliberately integrated into their governance, learning and pathway redesign, and how this approach transforms storytelling from passive listening into active improvement. Why the patient voice matters when things go wrong Risa Mallory is a retired psychotherapist from Canada. After a serious cardiovascular event in 2018 she became a patient advocate, collaborating with organisations across the globe. In this blog, Risa describes why patient involvement is critical when things go wrong in healthcare 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. 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. 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. 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. 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. 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. 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. “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].

In this blog, Claire Cox, Associate Director at Patient Safety learning and chair of the Patient Safety Management Network (PSMN), describes how the PSMN is transforming from a community of interest to an emerging movement in patient safety. One where people are empowered to build openness, trust, and courage together. Four and a half years ago, the Patient Safety Management Network (PSMN) began in the simplest of ways: just four people on a Teams call. The new Patient Safety Incident Response Framework (PSIRF) was emerging, and each of us were trying to make sense of what it meant in practice. We weren’t looking for anything grand - just a space to connect, to share a little peer support, and to avoid feeling quite so alone in the work we do. Nervous beginnings Looking back now, it’s almost comical that we chose to hold our first meetings on a Friday afternoon. In retrospect, it sounds ridiculous - how was that sustainable? Why would anyone willingly show up at the end of the week, when energy is lowest and inboxes are fullest? And yet, people did. Perhaps it was the timing, coming at the moment when we were finally exhaling from the week. Perhaps it was the relief of finding others who were facing the same uncertainties. Whatever the reason, those early Friday sessions became the unlikely seedbed of what the PSMN would become. At first, even sharing the smallest thing - like a template - made us nervous. Did we even have permission from our organisations to share this? Every exchange carried a sense of caution. Some people were unsure if they were ‘allowed’ to join the meeting without permission. The network was transactional, useful, but tentative. From transactions to connections In those earliest meetings, the structure was simple. The majority of the time was spent with one person “teaching” the group something, it may have been about the role of the Academic Health Science Network or an update on the Patient Safety Incident Framework. It was mostly passive - people listened, a few had cameras on, but there wasn’t much interaction. And that was okay. The purpose back then wasn’t to force participation. It was to listen, share, and simply be present. If “being present” meant sitting quietly with your camera off, that was absolutely fine. People didn’t have to be there. The fact that they showed up - on a Friday afternoon no less - was the first sign that this network mattered. Presence became the foundation. Even in silence, people began to sense that they were not alone in their work, their questions, or their uncertainties. Over time, that quiet presence grew into participation. People began asking questions, adding their experiences, and opening up. The dynamic shifted from one-way teaching to two-way learning, and eventually into rich, many-to-many conversations where every perspective mattered. That was the turning point: the realisation that the PSMN wasn’t just about transmitting knowledge - it was about creating it together. Building psychological safety This deeper sharing required something crucial: psychological safety. Trust that questions wouldn’t be dismissed. Trust that missteps could be talked about without fear. Trust that every voice mattered, regardless of experience or role. Over time, members began modelling openness and vulnerability - admitting when they didn’t know the answer, sharing stories of what hadn’t worked, and inviting others to join them in learning. Bit by bit, the culture evolved into one where curiosity was celebrated, not questioned. A platform for shared learning Today, the PSMN is unrecognisable from those early Friday calls. It has become a psychologically safe learning platform where insights are not just exchanged but created together. What makes it truly special is the breadth of the community. The network brings together voices from every corner of the healthcare system - frontline staff from all sectors, Patient Safety Partners, carers, academics, commissioners, regulators, and more. You name it, the expertise is represented within our network. And that mix of perspectives is powerful. Because here, learning isn’t confined by organisational walls, geographical borders, or professional silos. Instead, knowledge flows freely across them. Each conversation is enriched by the fact that people are willing to step outside of their own context and learn from others. Now, the PSMN is moving into something we could only have dreamed of in those early days: sharing our Patient Safety Incident Investigations. To begin with, this means exploring how we are approaching them and what the learning has been. It’s an incredibly exciting step - because this is the first time in patient safety history that this kind of open sharing has been done. It is a sign of just how far the network has come: from tentative, nervous beginnings to breaking new ground in the way patient safety is learned and shared. Looking back, looking ahead When we reflect on this journey - from four people on a Friday afternoon call, hesitant to even share a template, to a thriving community that spans the entire UK healthcare system - it’s hard not to feel anything other than inspired. What started small, simple, and a little uncertain has grown into something transformational. The PSMN has become a beacon of what is possible when people come together with openness, trust, and courage. It is no longer just a community of interest, it’s an emerging movement Want to join us? Does your work involve Patient Safety? Are you based in the UK? Would you like to be part of this journey - learning, sharing, and shaping the future of patient safety together? Join the PSMN via the Patient Safety Learning hub The more voices we bring together, the stronger our collective learning becomes.

The Safety 360° Summit is a curated, high-level event that for the first time brings together senior European leaders from diverse risk domains in a cross-industry dialogue on the central safety challenges of our time. Cyberattacks, AI-driven disinformation, rising geopolitical tensions, and societal polarisation simultaneously shape today’s landscape of safety and risk – yet they are still largely addressed in isolation within industry-specific silos. The Safety 360° Summit transforms this fragmentation into a shared strategic dialogue, laying the foundation for more effective responses to the central safety challenges of our time. Register

the hub is home to a growing number of networks for people involved in patient safety. These communities of interest provide forums to share knowledge and good practice. Members include people who work in patient safety such as patient safety specialists, patient safety partners, clinicians, organisational leaders with responsibility for patient safety,  governance or risk. In this blog Claire Cox, Associate Director at Patient Safety Learning, reflects on key highlights and achievements from the networks throughout 2025. It has been another uplifting year of growth and development for the networks we host on the hub — our shared space for learning and improving patient safety. These networks are owned and driven by their members, whose energy, knowledge, and experience shape everything they do. Patient Safety Learning is proud to support them, helping create welcoming communities where ideas can be shared, challenges explored, and collaboration can thrive. Together, these networks continue to offer rich and valuable insights from those working on the patient-safety frontline, guiding us all towards safer care. Patient Safety Management Network (PSMN) Celebrating is fourth birthday this year, the PSMN continues to go from strength to strength, having grown to now include more than 2000 members. Key highlights from this year include: Working with experts from the Care Quality Commission (CQC) and NHS Resolution to create a new Frequently Asked Questions (FAQs) resource on Duty of Candour. Providing evidence which informed the Health Services Safety Investigations Body’s report looking at how staff fatigue impacts on patient safety. Embarking on the creation of the Network’s second book, following on from the successful publication last year of Patient Safety: Emerging Applications of Safety Science. Experts from within and outside the network sharing their expertise and wisdom at the weekly meetings, inspiring discussions for the better understanding of safety risk, and sharing good practice for wide dissemination and improvement. At the beginning of 2026 we are planning to embark on a new series of meetings inviting Network members to share their examples of investigations with each other. We all investigate differently and bring our own approaches to problem-solving. This is a chance to share not only the approach individual network members take, but also the recommendations made and the lessons they learnt along the way. This is an example of how this network has become a trusted space for sharing and discussing often complex and challenging issues. Patient Safety Education Network (PSEN) The PSEN is a network for those who teach any element of patient safety or provide learning from patient safety incidents. This year the Network has featured a number of engaging discussions on topics including: The use of Post Transformative Simulation Briefing to design and test systems and processes, drawing on resources shared by the Association of Simulated Practice in Healthcare. Discussing with a presenter from NHS England the Safe Learning Environment Charter and what it means for those working in patient safety education roles. Discussing a new training resource, now available for free on the hub, intended to help people facilitate an interactive workshop, bringing SEIPS (Systems Engineering Initiative for Patient Safety) to life. This was developed at a joint PSMN and PSEN symposium held last year. Patient Safety Partners Network (PSPLN) The PSPN includes Patient Safety Partners, in both paid and voluntary roles within NHS organisations, whose role is to improve patient safety. Key highlights from this year include: Hosting a session with the Patient Safety Commissioner for England discussing her work and how to build on, and increase, the impact of the work of Patient Safety Partners. Contributing to the development of new guidance that offers a clear, structured approach to patient and family involvement in After Action Reviews (AARs), a learning tool used with the Patient Safety Incident Response Framework in the NHS. A lively debate on the topic of staff fatigue and its impact on patient safety, summarised in a blog by Network member Sue Strudwick. Regular discussions between individual PSPs as to how their roles are developed, the work they’re engaging in and the impact that they’re having. The launch of an Advisory Group to provide strategic, collaborative, and representative input into the development, delivery, and future direction of the PSPN, ensuring it is shaped by those with lived experience and diverse perspectives. This network provides a valuable space for PSPs, some of whom are still establishing themselves in role and are benefitting from the vibrancy of Trusts who have embraced PSPs and the insights they bring. Patient Safety Paediatric Leaders Network (PSPLN) This is an invited network for anyone who is a strategic-level decision maker in a specialist children’s hospital or unit with a leadership responsibility for patient safety and/or quality. Co-hosted with Great Ormond Street Hospital (GOSH), this is a space for leaders to reflect on challenges, seek advice, share perspectives and examples of good practice. The group varies its approach to its monthly meetings, alternating between general discussions and specific topics, often informed by an invited speaker. In response to a ‘what three things keep you awake at night, the Network members agreed to move into a ‘Community of Practice’ model and created a multi-disciplinary and multi-organisational project focused on reducing the risk of avoidable harm associated with parenteral nutrition for babies and children. This project has embedded a SEIPs (Systems Engineering Initiative for Patient Safety) based approach to risk assess current arrangements across all the network members’ Trusts. Jointly project managed by GOSH and Patient Safety Learning, it is bringing together the expertise and experience of parenteral nurses, neonatologists, pharmacists, patient safety experts and many more to develop solutions to often challenging issues and create the opportunity to standardise good practice. Keep an eye out for more information about this on the hub in the new year. Safer Surgery and Invasive Procedures Network (SSIPN) This is a group for healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. It was recently re-launched following a merger of the NatSSIPs Network with another voluntary network focused on improving patient safety in surgery. In 2026, this Network will meet every two months, with practical sessions focused on improving patient safety in surgery and implementing the National Safety Standards for Invasive Procedures 2 (NatSSIPs). Its next session on 4th February will be focused on approaches to implementing checklists for the purpose of standardising procedures and communication in surgical settings. Join a network You can apply to join any of our networks by signing up to the hub today. When you complete the registration form you’ll see a section called ‘Join a private group’, please tick the box by the relevant Network. If you are already a member of the hub, please email [email protected]. New networks We are always exploring and developing new networks. Our plans for 2026 include new networks for safety leaders and primary care, If you have an idea for a network and want to get involved in developing and supporting one, please let us know by email at [email protected].