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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, emergency medicine doctor Chelcie Jewitt describes why and how she co-founded Surviving in Scrubs, a campaign that shares survivor stories of sexism, harassment and sexual assault in the healthcare workforce. She outlines the work the campaign is doing with professional regulators to set clear behavioural standards that will more effectively hold perpetrators to account. She also describes the training and support that Surviving in Scrubs offers healthcare staff and organisations on how to respond to harassment and abuse. 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

We asked the Patient Safety Group (PSG) of The Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top 10 patient safety tips for surgical trainees. See also: Safety in surgery series Top 10 tips for surgical safety: ‘Think Safety, think SEIPS’ Top 10 priorities for patient safety in surgery Listen to the patient and what matters to them; share decisions with them. Encourage the patient to be in control of their care; they only have to consider their own care and will not be lost to follow up. Trust your instincts; always speak up if you think something is not right. Never be afraid to ask for help if you need it. Look after yourself and your team; there can be no patient safety without team safety. Foster good team working; recognise and respect the value of all team members; take account of everyone’s strengths and weaknesses. Take responsibility for the safety of your patients; patient safety is everyone’s responsibility, not just that of the quality improvement team. Help design systems that make it easier for you to do the right thing. Do not make assumptions. Work as imagined is not the same as work done; make sure you always test any process in practice and confirm that what you think is the case is actually happening. Regularly audit your practice. Celebrate good practice and share your experiences. Take on board feedback and learn from it; be willing to change practice. When outcomes are not as expected, openly discuss and learn, to enable you and your team to reduce the risk of the same thing happening again.

Can you think of a campaign that has really got your attention, stuck with you and made you do something differently? Claire Kilpatrick has been involved in the World Health Organization’s (WHO) World Hand Hygiene Day campaign since its launch 17 years ago. In this blog, Claire gives her thoughts around campaigning, explains this year's World Hand Hygiene Day slogan, 'it might be gloves, it’s always hand hygiene', and shares some of WHO's campaign resources. All the outreach activities for a successful campaign take time and effort, and often considerable resources. But if it works, it can work for a long time! Do you know what campaign activities actually expect to achieve? How do you evaluate the reach and impact of any of your campaign efforts? Campaigning can ultimately help make up people’s minds with regards to what they think, how they will act and how they will continue to sell the message in the long term. Ideas exist about how you can undertake annual campaign evaluations. And even if your campaign impact expectations are not met, it doesn't mean your campaigning efforts aren’t worth it. You might still persuade people to change, in some way, at some point. You don't always dash out and buy those new running shoes immediately after you see the ad, but you might in a couple of month’s time because you remembered them… But, if people feel bombarded with information it makes it harder for them to become informed. This makes succinct campaign messaging and clarity even more important, in order to achieve the desired impact. For 17 years, since its launch, I have been involved in WHO's World Hand Hygiene Day campaign, commemorated every 5 May. Working with communications experts and colleagues in regions and countries around the world, I have learned so much about the importance of messaging and was inspired to come up with this year’s slogan: it might be gloves, it’s always hand hygiene. Why this theme? Because: Medical gloves used in healthcare—disposable gloves used during medical procedures—can get contaminated as easily as bare hands and do not protect 100%. When worn, gloves should be removed, for example, after touching a wound site/non-intact skin, and hand hygiene performed immediately. But not everyone knows or practices this. Regardless of whether gloves are worn, hand hygiene—at the right times and in the right way—is still one of the most important measures to protect patients and health workers. By 2026, hand hygiene compliance monitoring and feedback should be established as a key national indicator, at the very least in all reference hospitals. Currently 68% of countries report they are doing this. Do all countries know this is a mandate to be achieved? Excessive glove use contributes significantly to the volume of healthcare waste and does not necessarily reduce transmission of germs. An average university hospital generates 1,634 tons of healthcare waste each year and this number is increasing 2 –3% per year (especially since Covid-19); wealthier countries generate more waste. Appropriate glove use and hand hygiene can help minimise this waste. Some country efforts are evident in this regard, but more needs to be done. And there are more facts available that you can use to explain these topics to your colleagues. The great news is, WHO provides a range of resources to help meet the World Hand Hygiene Day campaign goal—to bring people together and to maintain the profile of life saving infection prevention action. By providing these, WHO helps to cut down on the time, effort and materials that countries and healthcare facilities have to find to maintain their own campaign efforts. Essentially the campaign is nothing without local action, without you. So, for 5 May 2025, and for long term impact, here are some of things you could do: A campaign badge Use it in your email signature, in your socials, or you can even print it and make real badges/pins – show that you are always part of the campaign community. An advocacy slide Drop it in to your presentations. Posters Your own ready to use poster maker. Place these in your work areas. Aim to reach different target audiences. Personalise the posters and remember to change them over time to continue to get attention. Two-minute educational video Embed this new short video into your training sessions. In this eye-opening short story, follow two nurses—one who always practices hand hygiene at the right moments and another who relies on gloves. Spoiler: Gloves aren’t the hero here. Video background Use this as your backdrop for virtual meetings to maintain the campaign profile. Social media messages Use the WHO FAQs to create messages. Repost WHO’s social media messages around 5 May. Remember to use #handhygiene so we can have a socials takeover and have maximum reach. Idea for an engagement activity Start discussions in an informal way, for example, in wards or clinics when you visit, or advertise more formal sessions, maybe including treats! Use the WHO FAQs and then ensure that conversations are informed by actual staff experiences of glove use and hand hygiene. Consider how you will share copies of FAQs for ongoing reference. Improvement documents and tools To show impact over time, use the Hand Hygiene Self Assessment Framework alongside other infection prevention assessment tools. The results guide you to available improvement tools. One of the most popular resources on the WHO YouTube channel remains the 5 Moments for Hand Hygiene training video. Some of the most visited WHO web pages remain the how to handrub, how to handwash and 5 Moments for Hand Hygiene posters. Implementation is also key A guide to implementation for hand hygiene explains the necessary on-going commitment. WHO has a number of guides to implementation for different infection prevention topics, and I have just co-led on a new guide for implementing an infection prevention national action plan – to be launched by WHO in June. Global IPC community of practice Chat with people from around the globe to share and learn more on IPC. As the world of global health evolves, we will need to get even more creative, in both what we say and how we disseminate our messages. Partnerships might help this going forward. In a 2021 paper by Storr et al, they highlighted some considerations for the future around environmental cleaning and infection prevention, including combining advocacy efforts. They noted that “the current melee of global campaigns that countries are called on to be involved in may be resulting in competition and dilution of messages, rather than being complementary.” There is still a lot of buzz around hand hygiene, but I am grateful to be issuing this blog with Patient Safety Learning because the campaign is more than just hand hygiene and to continue to get attention we can do more together. But now that it’s 5 May, as my colleagues in the Global Handwashing Partnership say – all the best for clean hands! Further reading on the hub: Top picks: Nine resources about hand hygiene

In the ever-evolving landscape of healthcare, patient safety and quality care remain the cornerstones of effective medical practice. Every day, healthcare professionals strive to provide treatments that not only heal but also protect patients from harm. As a passionate advocate for patient-centred care, Ssuuna Mujib, a volunteer at the Uganda Alliance of Patients' Organisations, believes that prioritising safety is not just a responsibility—it’s a moral imperative that shapes trust, outcomes and the future of healthcare. The importance of patient safety Patient safety refers to the prevention of errors and adverse effects associated with healthcare delivery. According to the World Health Organization (WHO), millions of patients worldwide suffer from preventable harm due to unsafe care each year. These incidents can range from medication errors to hospital-acquired infections, surgical complications or misdiagnoses. The consequences are profound, affecting patients’ lives, increasing healthcare costs and eroding trust in medical systems. Ensuring patient safety requires a multifaceted approach that involves healthcare providers, administrators, policymakers and patients themselves. By fostering a culture of safety, we can minimise risks and create an environment where quality care thrives. Key strategies for improving patient safety and care To deliver exceptional care while safeguarding patients, healthcare systems must adopt evidence-based practices and innovative solutions. Here are some critical strategies to enhance patient safety: 1. Effective communication Clear and open communication among healthcare teams is vital. Miscommunication can lead to errors, such as administering the wrong medication or misinterpreting a patient’s condition. Standardised tools like SBAR (Situation, Background, Assessment, Recommendation) can improve handoffs and ensure critical information is shared accurately. 2. Robust training and education Continuous professional development ensures that healthcare workers stay updated on best practices and emerging technologies. Training programmes should emphasise error prevention, infection control and patient engagement. Empowering staff with knowledge builds confidence and competence in delivering safe care. 3. Leveraging technology Technology plays a transformative role in patient safety. Electronic Health Records (EHRs) reduce documentation errors, while barcode medication administration systems help verify medications before they reach patients. Additionally, artificial intelligence tools can predict risks, such as sepsis, enabling early interventions. 4. Patient empowerment Patients are active partners in their care. Encouraging them to ask questions, understand their treatment plans and report concerns fosters shared decision making. Educating patients about their medications and procedures can prevent errors and enhance adherence. 5. Creating a culture of safety A blame-free environment encourages healthcare workers to report errors or near-misses without fear of retribution. Root Cause Analysis (RCA) and Failure Modes and Effects Analysis (FMEA) can identify systemic issues and drive improvements. Leadership must champion safety as a core value, setting the tone for the entire organisation. The role of compassion in patient care While systems and protocols are essential, the human element of care cannot be overlooked. Compassionate care builds trust and promotes healing. Listening to patients, respecting their dignity and addressing their fears create a therapeutic environment. When patients feel valued, they are more likely to engage in their treatment plans and communicate openly, reducing the risk of errors. Challenges and the path forward Despite progress, challenges like understaffing, resource constraints and burnout continue to threaten patient safety across the world. Addressing these requires investment in workforce development, equitable resource allocation and mental health support for healthcare workers. Collaboration between governments, healthcare institutions and communities is crucial to overcoming these barriers. Looking ahead, the integration of data analytics, telemedicine, and patient-reported outcomes will further revolutionise safety and care. By embracing innovation while staying grounded in empathy, we can build a healthcare system that is both safe and compassionate. A call to action Patient safety and care are shared responsibilities. As healthcare professionals, we must commit to continuous improvement, learning from mistakes and advocating for our patients. As patients, we should actively participate in our care and hold systems accountable. Together, we can create a future where every patient receives safe, high-quality care. Let’s work hand in hand to make patient safety not just a goal, but a reality.

This conference brings together leading experts at the forefront of ensuring adherence to Martha’s Rule and offers a comprehensive and practical guide for clinical staff to seamlessly integrate Martha’s Rule into their daily practice. The conference delves into the caregiver’s perspective, principles and implications of Martha’s Rule, legal and patient safety considerations, effective communication strategies, and the use of technology in the adoption of Martha’s Rule. The conference will also discuss the new approach to managing acute physical deterioration through the prevention, identification, escalation, response – PIER approach which is currently being implemented Throughout the day, there will be interactive sessions, small breakout groups, and collaborative exercises, fostering a dynamic learning experience. Register Reduced rate places can be booked online with code HCUK195MRSO

This conference brings together leading experts at the forefront of ensuring adherence to Martha’s Rule and offers a comprehensive and practical guide for clinical staff to seamlessly integrate Martha’s Rule into their daily practice. The conference delves into the caregiver’s perspective, principles and implications of Martha’s Rule, legal and patient safety considerations, effective communication strategies, and the use of technology in the adoption of Martha’s Rule. The conference will also discuss the new approach to managing acute physical deterioration through the prevention, identification, escalation, response – PIER approach which is currently being implemented Throughout the day, there will be interactive sessions, small breakout groups, and collaborative exercises, fostering a dynamic learning experience. Register Reduced rate places can be booked online with code HCUK195MRSO

On the 10 April 2025, the Health Services Safety Investigations Body (HSSIB) published a report looking at how care is co-ordinated for people with long-term conditions. In particular, the investigation considered the role of ‘care co-ordinator’ to understand how care is co-ordinated within the existing workforce. In this blog, Patient Safety Learning sets out its reflections on the findings and recommendations in this report. HSSIB investigates patient safety concerns across the NHS in England and in independent healthcare settings where safety learning could also help to improve NHS care. Their latest report looks at primary and community care co-ordination for people with long-term conditions, specifically considering the role of ‘care coordinator’ in this context.[1] While language around the care coordination is varied, the role of care co-ordinated is defined by NHS England as follows: “Care co-ordinators help to co-ordinate and navigate care across the health and care system, helping people make the right connections, with the right teams at the right time. They can support people to become more active in their own health and care and are skilled in assessing people’s changing needs. Care co-ordinators are effective in bringing together multidisciplinary teams to support people’s complex health and care needs.”[2] In this blog we set out our reflections on the findings and recommendations in this HSSIB investigation. Challenges navigating the healthcare system Navigating the healthcare system in the UK can be complex and frustrating for patients, families and carers. At Patient Safety Learning we hear time and time again about the lack of joined up care and communication within and across organisations. Failing to share the right information at the right time can create significant patient safety risks. Poor communications, both with patients and between healthcare professionals, can result in misunderstandings and mistakes resulting in poor outcomes and potentially patient harm. In a recent series of blogs published on the hub, patients and their relatives shared with us the challenges and barriers they have faced when trying to navigate the healthcare system.[3] The concerns and issues raised in this HSSIB investigation echo many of the key themes we identified in our new blog series. Confusing communications HSSIB’s report refers to the case of a child prescribed anti-epileptic medication by a specialist hospital to reduce the number and severity of their seizures. It then details the difficulties the parents subsequently found in getting this medication through their GP or consultant. The parents highlighted concerns about the lack of communication between the separate services, with the report noting: “The parents told the investigation that they were ‘exhausted’ because of the effort they had had to put in over the years to connect services together, having to tell the same story over and over again, while having to provide care for their child.” Delays to treatment The investigation report also highlights the case of a middle-aged professional working man who suffered a stroke. He received hospital care to treat and manage his healthcare needs; however, once discharged he encountered significant difficulties when seeking appropriate support for his additional healthcare needs. HSSIB highlighted how he had told them it required significant effort from him directly to ensure the right level of care was maintained for his needs. Recounting his experience, the report states: “He said that these multiple agencies ‘all operate in their own silos’ and not as a team, and that ‘there was nobody to create that team [a cross-system team aware of all his health and care concerns]’. The way that he and his wife cope with this situation is that they ‘manage the team’ to connect the individual parts of the system and get the care he needs.” Impact on mental health HSSIB also spoke to a man in his late seventies who is the main carer for his wife. She has multiple long-term conditions that require primary, secondary and community care. Reflecting on the impact that coordinating her care had on their lives, the report noted: “The husband explained that his role of care co-ordinator had placed a considerable burden on him, which led him to ‘feel overwhelmed’. He said that because he needing to act as her ‘co-ordinator’ he was unable to spend time with his wife as her husband. He also described having to administer medication and dress his wife’s wound which caused her considerable pain.” HSSIB’s investigation also highlights broader areas of concern relating to the coordination of care in the healthcare system, again mirroring themes raised we heard from patients in our recent blog series. Difficulties sharing information The investigation highlights a recurring concern around problems sharing patient information and the negative impact of this on coordinating a patient’s care. It highlights both issues of digital systems in different organisations not being compatible with one another and other barriers, stating: “Healthcare professionals described the challenges in information sharing. Digital patient records could not be viewed across primary, community, secondary and tertiary care because information technology systems are unable to ‘talk to each other’. They also said that sometimes they were unsure whether patient information could be shared as it was ‘protected information’. This was a particular problem when trying to share information between health and social care.” A complex and confusing system The report also reflects more broadly on how accessing and navigating health and care services can be difficult and complex, and potentially overwhelming for patients. This was highlighted by examples such as this from the investigation: “A GP practice told the investigation that it had tried to put together an easy-to-read document explaining the care pathway for patients with dementia, including contact numbers and ways to access services. The GP practice went on to say that the system was so complex that it was unable to bring together all the information. It stated: ‘We are healthcare professionals and we can’t do this, so how can patients cope?’” Safety recommendations A theme that runs throughout HSSIB’s investigation is that there is a clear need and support for the role of care co-ordination. It highlights that while patients and carers can, and often do, themselves act in this role, when they are unwell or unable to do so a patient’s care can be significantly impacted. The report states that the availability of care co-ordination varies widely across the system. This is a particular issue for those living with multiple long-term conditions as there is no single centralised care co-ordination function to span across primary, secondary and tertiary care. Concluding its investigation, HSSIB recommends that: NHS England/Department of Health and Social Care, working with other relevant organisations, reviews and evaluates the implementation of the care co-ordinator role. This is to ensure that all patients with long-term conditions have their care co-ordinated and that they have a single point of contact 24 hours a day, 7 days a week, to help them with any queries or concerns that they may have. The Department of Health and Social Care works with NHS England and other stakeholders to develop a strategy that ensures that all diseases are given parity and that all people with a long-term condition in primary, secondary, tertiary and community or social care have their care effectively co-ordinated across multiple agencies. This is to ensure that people with long-term health conditions have co-ordinated care plans with effective communication between services and a single point of contact for concerns or questions. Patient Safety Learning agrees that there needs to be greater time and investment into care coordination. On the first recommendation, we would note that seeking to ensure all patients with long-term conditions have a single point of contact 24 hours of day, 7 days a week, would be a significant shift from the status quo. This would require a clear commitment of both financial and workforce resources from NHS England and the Department of Health and Social Care to deliver. In considering how this might be approached, it would also be important to consider: How this can be flexible depending on the long-term condition in question. Different conditions will require different levels and types of coordination. Systemic barriers that result in many of the difficulties navigating the care system would not be addressed by implementing this recommendation. For example: – We would continue to have various digital systems in primary, secondary and tertiary care that lack interoperability (the ability of computer systems or software to exchange and make use of information). – Non-digital communication barriers that prevent cross-organisational sharing of information in the NHS, ranging from data sharing restrictions to cultural attitudes within organisations, would also remain. On the second recommendation we agree with the principle of this, that there needs to be parity for people with a long-term condition and an expectation that their care is effectively co-ordinated across multiple agencies. Poorly coordinated care is not only confusing and frustrating for patients but also creates safety risks that can result in serious avoidable harm. Concluding comments The challenges of navigating the healthcare system discussed in this report are not a new issue, but a long-standing set of problems that do not have a simple solution. Their impact on patient experiences and outcomes is exacerbated in the current environment, when our healthcare system that is under increasing pressure and in a “critical condition”.[4] Patient Safety Learning believes that care co-ordination should form an important area of focus for the UK Government’s forthcoming 10 Year Health Plan. If it is to achieve its strategic ‘shift’ of moving the future of the NHS from "hospital to community" this will require a healthcare system where patients aren’t simply left to "join the dots for patient safety".[5] This will require organisational and leadership commitment to take forward the issues raised in this HSSIB investigation. The needs of patients should be central to improving health and care services, actively listening and acting on their experiences and insights when things go wrong for safety improvement. References HSSIB. Workforce and patient safety: primary and community care co-ordination for people with long-term conditions, 10 April 2025. NHS England. Care co-ordinators, Last accessed 10 April 2025. Patient Safety Learning. The challenges of navigating the healthcare system, 24 February 2025. UK Parliament. NHS: Independent Investigation, Hansard, Volume 753, 12 September 2024. Department of Health and Social Care, Independent report: Review into the operational effectiveness of the Care Quality Commission, 15 October 2024. Related reading Digital-only prescription requests: An elderly woman sent round the houses How the Patients Association helpline can help you navigate your care Lost in the system? NHS referrals Navigating the healthcare system as a university student: My personal experience The challenges of navigating the healthcare system: David's story The challenges of navigating the healthcare system: Sue's story Share your story What has been your experience of navigating the healthcare system? What is and isn’t working? How does it feel as a patient or carer when you hit barriers? Has your health been affected? Share your story in our community forum or contact our editorial team at [email protected].