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Systems-based healthcare safety investigation is an important initiative to improve patient safety worldwide. It requires the use of credible methods and approaches by competent investigators. There is currently no empirically developed competency framework for the healthcare safety investigator role. The authors of this study sought to develop a competency framework for healthcare safety investigators using an empirical research approach. In approaching this task the authors used a two-round modified Delphi technique electronically. Two web-based surveys were sent to a panel of experts in healthcare safety investigations in England. The panel rated the relevance of a proposed set of competencies and provided qualitative comments. Strength of agreement was assessed using the interquartile range (IQR), the median and percentage agreement. Participants’ comments were reviewed, with reference to the contemporary healthcare safety literature and practice. A total of 28 participants completed the round-one survey. In round two, 24 of the 28 participants completed the survey. At the end of the round-two survey, 38 competencies and 82 corresponding descriptors were agreed as relevant with high agreement levels (IQR ≤ 1.25, median ≥ 4, percentage agreement ≥ 70%). These were organised in four domains: 1. Personal qualities, 2. Investigation knowledge and skill application, 3. Effective and compassionate engagement, and 4. Manages investigation lifecycle. The authors of this study state that this is the first empirically derived competency framework specifically focused on the healthcare safety investigator role. The high levels of agreement among participants give credibility to the findings. This competency framework provides an evidence base to inform the scope and requirements of the healthcare safety investigator workforce.

The overall goal for the Quality and Safety Education for Nurses (QSEN) project is to meet the challenge of preparing future nurses who will have the knowledge, skills and attitudes necessary to continuously improve the quality and safety of the healthcare systems they work in. This webpage outlines the competencies in the QSEN competency framework: Patient-Centered Care Teamwork and Collaboration Evidence-based Practice (EBP) Quality Improvement (QI) Safety Informatics

The Patient Association's response to the PHSO: Complaint Standards Framework. Summary of core expectations for NHS organisations and staff. See also Patient Safety Learning's response to the framework.

Resilient Health Care (RHC) is predicated on the idea that health care systems constantly adjust to changing circumstances. RHC has become increasingly popular as a new way to improve patient safety, but to date there is no agreed way of using RHC as the basis for teaching patient safety. A key resource for patient safety educators is the World Health Organisation (WHO) patient safety curriculum, released ten years ago. However, it is well established that patient safety thinking in healthcare has been driven largely by Safety-I principles, and this is reflected in the WHO curriculum. The aim of this paper is by Sujan et al., published in Safety Science, was to review and to provide a critique of the WHO patient safety curriculum from a Safety-II perspective, in order to assess to what extent RHC principles are already incorporated, and to identify areas where RHC might make contributions to the WHO curriculum. Based on this analysis, we argue that RHC thinking could be added in modular fashion to the WHO curriculum, but that in the future a broader curriculum should be developed that integrates RHC thinking throughout.

The NHS has recently conducted a consultation on its updated Standard Contract for use in 2020/21. Once finalised this contract is published by NHS England and used by commissioners to contract for all healthcare services other than primary care services. The contract is regularly updated to reflect changes in legislation, policies and technical improvements. In this year’s consultation there have been several changes proposed that specifically relate to patient safety and in this blog we outline the main patient safety changes proposed and detail Patient Safety Learning’s formal consultation response. Medical Examiners of Deaths Proposed Change: We propose to include a new requirement for acute providers (NHS Trusts and Foundation Trusts only) to establish a Medical Examiner’s Office, in accordance with guidance published by the National Medical Examiner. The Office will, initially, review those deaths occurring on the Trust’s premises and not referred to the coroner, ensuring that the certification of death is accurate and scrutinising the care received by the patient before death. Patient Safety Learning supports this proposal. We welcome the decision to make the establishment of a Medical Examiner’s Office a requirement for acute providers. This proposal was first recommended following the Shipman Inquiry (2002-2005) and recent media coverage has revealed that a significant number of NHS trusts have still yet have appoint a Medical Examiner. Medical Examiners can play a key role in improving patient safety in cases where the patient’s death was the result of avoidable harm. They can provide vital insights into these cases and help to identify effective remedial actions to prevent their recurrence, as well as sharing this information for wider learning beyond their specific trusts. Patient Safety Incident Response Framework Proposed Change: The NHS Patient Safety Strategy indicates that the current NHS Serious Incident Framework and Never Events Policy Framework will be replaced, over the next two years, by a new single Patient Safety Incident Response Framework. To accommodate and signpost this planned change, we propose adding a specific reference to “successor frameworks” to the existing requirements relating to the current Frameworks. Patient Safety Learning supports the proposal to update requirements. We welcome the review of these frameworks and the development of a new Patient Safety Incident Response Framework (PSIRF). However, we have concerns about the delay in its release, which was initially expected towards the end of 2019 and now instead subject to a limited release this year with pilot organisations, rather than being shared more widely. We are also concerned about the lack of stakeholder engagement in this process, particularly for patients and families. Despite providing a valuable source of information when incidents occur, they are often not included in investigation processes. The failure to include and listen to patients and families in investigations can often result in more harm and increasing the likelihood of complaints and litigation. In updating these processes therefore it is vital their views are taken into account. National Patient Safety Alerts Proposed Change: The National Patient Safety Alerting Committee is establishing new, co-ordinated and accredited arrangements for the issuing of National Patient Safety Alerts to providers. We propose to include a new requirement for providers to ensure that they can receive each relevant National Patient Safety Alert, identify appropriate staff to coordinate and implement actions required within the timescale the Alert prescribes, and confirm and record when those actions have been completed. Patient Safety Learning supports this proposal. We welcome steps to ensure providers have appropriate arrangements in place to coordinate and implement actions required by national patient safety alerts and record when these have been completed. A recent report by Action Against Medical Accidents, An organisation losing its memory?, has indicated that a number of trusts have experienced significant delays in introducing safer practices highlighted by national patient safety alerts. They found in many cases that the trusts experiencing delays ‘indicated that they were in the process of improving internal systems for overseeing the implementation of patient safety alerts’. It is a positive step to see this is now being added to the NHS Standard Contract as a formal requirement for them to do so. However, we have concerns beyond the scope of these contractual obligations that this process does not appear to be monitored at a national level. While these measures place specific responsibilities on providers, we are not clear on what, if any, oversight arrangements will be put in place to accompany these. We think such national monitoring and public reporting is essential and would look for this to be implemented as a priority. Patient Safety Specialists Proposed Change: The NHS Patient Safety Strategy envisages the establishment of a network of patient safety specialists, one in each provider, to lead safety improvement across the system. We therefore propose to include a requirement on each provider to designate an existing staff member as its Patient Safety Specialist. Patient Safety Learning supports this proposal. We support this proposal in principle but have reservations about how this will be implemented in practice. The requirement to appoint a Patient Safety Specialist, as set out in the NHS Patient Safety Strategy, currently lacks detail about the nature of this role. What do we mean by a ‘Safety Specialist’? What knowledge and training should they have? Will the appropriate governance arrangements be in place to make sure their voice is heard by the organisation’s leadership? We think these arrangements should be specified, resourced, monitored and transparently reported. We will be responding to the separate consultation on this which opened on the 30 January 2020 in more detail. Common sources of harm to patients in hospital/Safety Thermometer Proposed Change: Feedback suggests that the existing Contract requirements on use of the Safety Thermometer are creating too great a bureaucratic burden, and not facilitating learning. We therefore propose to remove the specific requirements relating to use of the Safety Thermometer and, instead, introduce a higher-level obligation on acute providers to ensure and monitor standards of care in the four clinical areas which the Safety Thermometer addresses – venous thromboembolism, catheter-acquired urinary tract infections, falls and pressure ulcers. At Patient Safety Learning we believe that the health and social care system should develop models for measuring, reporting and assessing patient safety performance. This data should be gathered centrally and then used for learning and to implement actions that improve care. With regards to the removal of Safety Thermometer requirement, while we recognise that it has been noted that this has not been effective in facilitating learning, we would expect the newly proposed measures to follow these principles. We would also expect patient safety measurement to apply to all NHS organisations, rather than being an obligation limited to acute providers.

The development of the Learning Disability Epilepsy Specialist Nurse Competency Framework was led by a working party of experienced Learning Disability (LD) Epilepsy Specialist Nurses (ESNs), from Focus in Epilepsy Learning Disability (FIELD), in association with the Epilepsy Nurses Association (ESNA). The document has been accredited by the Royal College of Nursing (RCN), with the support of Epilepsy Action to ensure that the perspective of people with learning disabilities (PWLD) has been considered.

The framework for safe, reliable, and effective care, set out by the Institute for Healthcare Improvement, provides clarity and direction to health care organisations on the key strategic, clinical, and operational components involved in achieving safe and reliable operational excellence, a 'system of safety', not just a collection of stand-alone safety improvement projects. This White Paper: describes the framework's two foundational domains, culture and the learning system, outlining what is involved with each and how they interact provides definitions and implementation strategies for nine interrelated components (leadership, psychological safety, accountability, teamwork and communication, negotiation, transparency, reliability, improvement and measurement and continuous learning) discusses engagement of patients and their families, the core of the framework, the engine that drives the focus of the work to create safe, reliable, and effective care. Healthcare organisations and systems may use the framework as a roadmap to guide them in applying the principles, and as a diagnostic tool to assess their work to date. Although initially focused on the acute care setting, the framework has evolved to be more broadly applicable in any setting, in acute care, ambulatory care, home care, long-term care and in the community.

Published by the American Association of Medical Colleges (AAMC), Quality improvement and patient safety competencies across the learning continuum is designed for: faculty medical education curricula developers residents medical school administration Designated Institutional Officials (DIOs) clinical leaders at teaching hospitals  and others interested in undergraduate, graduate, and continuing medical education. There have been many advancements in medical education over the past 20 years, including how outcomes such as competencies are defined and used to guide teaching and learning. To support this positive change, the AAMC has launched the New and Emerging Areas in Medicine series. This first report in the series focuses on quality improvement and patient safety (QIPS) competencies across the continuum of medical education. It presents a roadmap for curricular and professional development, performance assessment, and improvement of healthcare services and outcomes. The competencies can help educators design and deliver curricula and help learners develop professionally. The competencies are for use in: engaging diverse health care professionals in collaborative patient-safety-improvement discussions, including cross-continuum and cross-discipline colleagues conducting gap analyses of local curricula and training programmes planning individual professional development developing curricular learning objectives developing assessment tools furthering research and scholarship in medical education and quality improvement guiding the strategic integration of QIPS into the curricula and the clinical learning environment.

This report describes the lack of clear roles, responsibilities and accountability for workforce planning and supply in England. In reality, this means that the health and care workforce is not growing in line with increasing population need for health and care services, and there are large numbers of vacant posts throughout the system. This impacts upon patient safety and outcomes, and leads to a challenging working environment for staff. To resolve this, the Royal College of Nursing (RCN) make the case for this to be resolved through legislation, alongside additional investment in the nursing workforce and a national health and care workforce strategy for England. 

Given an unacceptably high incidence of diagnostic errors, the authors sought to identify the key competencies that should be considered for inclusion in health professions education programmes to improve the quality and safety of diagnosis in clinical practice. Olsen et al. believe that one of the most promising and sustainable ways to improve diagnosis is to improve education and training in the health professions. The first step in this process is to define the outcomes that trainees in each profession must achieve in order to be effective members of a diagnostic team in the modern healthcare setting. This paper, published in Diagnosis journal, defines these competencies.

Patient safety is typically seen as a strategic priority. This sounds important, but it means that, in practice, health and social care decision-makers will weigh (and inevitably trade-off) the importance of patient safety against other priorities, like finances, resources or efficiency. We believe that patient safety is not just another priority: it is part of the purpose of health care. Patient safety should not be negotiable. Our report, A Blueprint for Action, sets out the action needed to progress towards the patient-safe future. Underpinned by systemic analysis and evidence, it proposes practical actions to address the six foundations of safer care for patients. These foundations are shared learning, leadership, professionalising patient safety, patient engagement, data and insight, and Just Culture. Shared learning for patient safety Organisations should set and deliver goals for learning from patient safety, report on progress and share their insights widely. We have created the hub, an online platform and community for people to share learning about patient safety problems, experiences and solutions. We research and report on the effectiveness of investigations into unsafe care. Leadership for patient safety We call for overarching leadership for patient safety across the health and social care system. We propose a Leadership Forum for Patient Safety that will lead the design and co-ordination of safe care and emphasise a systems approach and human factors. We recommend that all health and social care organisations publish annually their goals and outcomes for safer care. We recommend that integrated care systems set standards for patient safety in service commissioning, care delivery and care pathway design. We will work with the health and social care system to support strengthening leadership for patient safety. Professionalising patient safety Standards and accreditation for patient safety need to be developed and implemented. These need to be used by regulators to inform their assessment of safe care. We will work with the health and social care system to support the development of these standards. A competency framework for patient safety is needed to ensure that all staff are ‘suitably qualified and experienced’. We propose to work with Health Education England and others to develop this. Health and social care organisations need specialist patient safety and human factors experts with leadership support, resources and governance. hese roles must be clearly defined, with reporting lines to the board (both Executive and Non-Executive). These specialists will help lead re-design for safety, as well as learning from unsafe care, patient engagement, complaints, near misses, clinical reviews and audits. Guidance, resources and toolkits need to be developed and implemented with the support of specialist expertise in patient safety and human factors. We will promote and share these through the hub. Patient engagement for patient safety We will work with the health and social care system to encourage and support the actions necessary to ensure patients are valued and engaged in patient safety. We will initiate development of ‘harmed patient care pathways’ for patients, families and staff following a serious incident. We will help develop and support effective patient advocacy and governance for patient safety. Data and insight for patient safety Models for measuring, reporting and assessing patient safety performance are needed that include quantitative as well as qualitative data. We will convene a panel of experts to identify the critical data and insight needed to measure and monitor patient safety. We will work to ensure that patient safety is designed into digital health initiatives as a core principle, rather than an add-on. Just Culture All health and social care organisations should develop programmes and publish goals to eliminate blame and fear, introduce or deepen a Just Culture and measure and report their progress. We will celebrate great work and innovation for patient safety through our Patient Safety Learning Awards and the hub.

The British Medical Association (BMA) is the trade union and professional body for doctors in the UK. This website links with some of the work that the BMA do: Trade union representation. Individual support and advice. Lobbying. Legal and financial services. Patient information - signposting on how the NHS works.

National safety standards for invasive procedures (NatSSIPs), published by NHS England in 2015, recommend the creation and implementation of local safety standards for all invasive procedures. This includes procedures undertaken outside a hospital environment, such as surgical procedures undertaken by dentists. In order to implement a local safety standard for invasive procedures (LocSSIP) for oral surgery procedures at a large London teaching hospital, a clean sheet redesign of our service was carried out based on a bottom up model of transformation, using a 'diagnose, design and implement' strategy. In an article  published in the British Dental Journal, three lead consultants in oral surgery based at Kings College, London, discuss creating local safety standards for invasive procedures. Key points of the paper: Suggests national safety standards for invasive procedures (NatSSIPs) should be read and acted on by all invasive procedure teams, including dentists. Highlights that involvement of all staff in development of a local safety standard for invasive procedures is important to ensure a policy that is successful in improving patient safety in your workplace. Suggests the whole dental team should take responsibility for continually improving patient safety.

The first global experts’ consultation for the development of the WHO Leaders Guide on Patient Safety and Quality of Care in Service Delivery took place 20-21 March 2014. Over 25 experts from around the world in the areas of health care management, financing, patient safety and quality of care gathered at WHO to address the global need for strengthening leadership capacity to deliver safe and quality health services. A draft Leadership Competencies Framework on Patient Safety and Quality of Care was developed by WHO through a literature search and analysis of findings, which was debated by participating experts and formed the basis for: technical discussions during the consultation; agreement on the competencies necessary for enhancing leaders’ capacity to prioritize and direct the delivery of safe and quality health services; agreement on the learning topics/chapters and content of the Leaders’ Guide. The Framework identifies the competencies and areas necessary for organisational leadership and management of health services, acknowledging there should be a balance between three domains: Personal attributes. Core functions of leadership: competencies relating to a leader’s ability to set direction and know how to prepare an organisation for safe and effective service delivery. Ability to ‘Execute’/Mise-en-place: competencies relating to a leader’s ability to create enabling environments, systems, processes and mechanisms, and to empower people for delivering patient-centered, quality and safe services.

Despite 20 years of effort, every year avoidable unsafe care still leads tens of thousands of patients to suffer death or serious, life-changing harm. A Blueprint for Action, a report from Patient Safety Learning, furthers the analysis of the systemic causes of this harm and describes actions to make patient care safer. Last September, health and patient safety professionals and patients overwhelmingly welcomed the analysis of avoidable unsafe care offered in Patient Safety Learning’s Green Paper, A Patient-Safe Future. Matt Hancock, Secretary of State for Health and Social Care described it as “…the blueprint for action that we need.” Following widespread consultation on the Green Paper, A Blueprint for Action extends this analysis to identify actions to address the systemic causes of unsafe care. A Blueprint for Action identifies two core issues that underpin the persistence of avoidable harm. The first is that by treating patient safety as a ‘priority,’ healthcare organisations make the safety of patients open to compromise. A Blueprint for Action makes the case that patient safety it is more than a ‘priority’ – it is part of the core purpose of healthcare. The second core issue identified in A Blueprint for Action is that unlike, for example, fire safety, no person or body sets patient safety standards for healthcare organisations. As a result, the health and social care systems have no way to ensure that patients everywhere receive the same high standards of safe care. A Blueprint for Action identifies six foundations of safe care. These include shared learning, leadership, professionalising patient safety, patient engagement, data and insight, and culture. A Blueprint for Action proposes a range of actions to address these foundations. These include the development of the hub for clinicians, researchers and patients to share learning and solutions for patient safety with communities of peers; establishing a forum of leaders to set standards and good practice for leadership of patient safety; developing a competency framework for patient safety; creating harmed patient care pathways to better support patients and staff following incidents of patient safety; convening a symposium of experts to develop better ways to measure and manage patient safety; and advocacy for adoption of what Professor Sydney Dekker has termed a Just Culture. Download A Blueprint for Action in full. Alternatively, you can download the Executive Summary. In addition, we have created a visual summary of A Blueprint for Action, primarily for print purposes but also available to download. We would love to hear your thoughts on our Blueprint for Action and work with you to explore pushing these actions forward. If you would like to be part of this work, please contact [email protected] We’ve already received strong support from patient, clinical and patient safety thought leaders and campaigners, including the following statements. Dr Ted Baker, Chief Inspector of Hospitals, Care Quality Commission, said, “In our recent report “Opening the Door to Change” I called for a new era of leadership, focused on safety culture, engaging staff and involving patients. I strongly welcome “A Blueprint for Action” as it lays out how everyone involved in healthcare, including patients, can work together to bring about the change in culture that is needed to make our healthcare as safe as it can be.” Dr Annie Hunningher, Barts Health, said, “This paper sets out the vision that we can change the way we structure, describe the processes and measure outcomes for true safety. It is leading the charge to understand and support a culture, a system, the multidisciplinary education and ‘metrics that matter’ to deliver safer care. Safety has been the Cinderella of healthcare management, not a priority and under-resourced. We now have an opportunity to collaborate and commit to genuine safety improvement. By setting standards, professionalising safety with ward to board safety understanding, and involving our patients we can collaboratively find the path to transform the future. Thank you Patient Safety Learning!” Rachel Power, Chief Executive of the Patients Association, said, “Patient Safety Learning’s blueprint offers a convincing analysis and a coherent set of solutions – we support their approach, and their aim to bring patient safety into the mainstream. We agree that the solution must involve recognising patients as active partners in their care, ensuring that they are able to raise concerns when things are going wrong, and engaging them fully in all aspects of patient safety. It must be an over-riding priority for the NHS that patients are safe when they are in its care.” Tom Kark QC, author of the 2019 Kark Review of the Fit and Proper Person Test, said, “The Patient Safety Learning Blueprint for Action is an important paper and could make a significant change to patient safety if… its proposals are put into effect.” Professor Albert Wu of Johns Hopkins Bloomberg Center for Public Health, said, “Knowledge and know-how are crucial to improving the safety of health care. This first entails awareness, and then actual learning, on the part of clinicians, leaders and managers, and patient and families. Patient Safety Learning is dedicated to engaging the hearts and minds of all of these essential players. I foresee that they will play an important role in helping us learn together. Their publication, A Blueprint for Action, lays out a way forward.” For the Academic Health Sciences Network (AHSN), Dr Cheryl Crocker, Network Patient Safety Lead and Natasha Swinscoe, Network Lead MD Patient Safety, said, “We welcome the Blueprint for Action report and fully support the call to co-ordinate improvement programmes better across systems. This encapsulates the focus of our patient safety work through The AHSN Network. We are delighted to be supporting Patient Safety Learning and are well-placed to make an active contribution in both health and care to all six recommended actions.” Peter Walsh, Chief Executive, Action against Medical Accidents (AvMA), said, “This report is a welcome and sensible reminder of the sort of approach that I believe most people agree is needed to breathe new life into work on patient safety. We must not allow patient safety to be put in the ‘too difficult box’. It is far from fixed and it is vital that we have an approach which is fair and sensitive to the needs and contributions of both patients and staff.” Andrew Corbett-Nolan, Chief Executive (Partner), Good Governance Institute, said: "This Blueprint for Action provides a crucial contribution to improving patient safety in health and social care. The report is a practical resource to support and sustain safe care. It is a must read for Board members of health and care organisations." Peter Homa, Chair, NHS Leadership Academy, said, “A Blueprint for Action” is a magisterial summary of how we can, together, create a safer, more humane environment for patients, their loved ones and staff. International evidence is drawn upon to describe the preconditions for success including the requirement to learn from errors. We should ensure that the positive impact of learning from an error is far greater than the negative impact of the original error. This report and its authors, Patient Safety Learning, are powerful positive forces that will help us create a healthcare that is “patient safe”

Latest update of the Care Quality Commission's 'Inspection framework: Maternity Framework (Acute, community, independent)'.

Serious Incidents in health care are adverse events, where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified. This Framework, set out by NHS England, describes the circumstances in which such a response may be required and the process and procedures for achieving it, to ensure that Serious Incidents are identified correctly, investigated thoroughly and, most importantly, learned from to prevent the likelihood of similar incidents happening again.

Australia’s national clinical quality registries (CQRs) play a unique and vital role in Australia’s health system, contributing to ongoing improvements in the safety and quality of care. The Australian Commission on Safety and Quality in Health Care in has released the revised Australian Framework for National Clinical Quality Registries (2024) to support and encourage the use of data to inform clinical practice and policy. By fostering the timely sharing of health information and adopting best practices, this Framework aims to reduce risks and improve patient outcomes. The Framework supports CQRs in collecting, analysing, and reporting clinical data, to maximise the value of Australia’s clinical data. It aligns with the Australian Government’s National Strategy for Clinical Quality Registries and Virtual Registries 2020–2030, ultimately leading to better patient outcomes across Australia. What’s new about the Framework: Emphasises the role CQRs play in driving improvements across the health system. Practical guidance on CQR governance. Quality Standard for CQRs and self-assessment checklists. First released in 2014, the Commission developed the Framework to provide best-practice guidance for establishing and operating CQRs. Over 120 clinical registries are now listed on the Australian Register of Clinical Registries.

Quality is complex and difficult to define, and institutions and organisations often have their own definitions, measurements and assurance processes. The Care Excellence Framework (CEF), developed and used at University Hospitals of North Midlands NHS Trust, is a unique, integrated framework of measurement, clinical observation, patient and staff interviews and benchmarking. It also has an internal accreditation system that provides assurance from ward to board based on the five Care Quality Commission (CQC) domains and reflects CQC standards. The CEF has been established in its existing form since autumn 2016 and has been used in all areas of the organisation. This article provides an overview of the development and use of the CEF in an acute care setting, demonstrates how the framework acts as an internal accreditation system, and shows how it can encourage staff to undertake effective change and transform care from ordinary to excellent.

At the second annual Patient Safety Learning conference, held on 2 October 2019, we interviewed Tom Kark QC. QEB Hollis Whiteman and Verita, Tom joined a conversation with Ted Baker and Dr Elaine Maxwell on the topic of 'Leadership for patient safety'. View video (3:54)

This guide aims to support NHS organisations to apply a framework for measuring and monitoring safety. It describes some broad principles to bear in mind when using the framework and provides some prompts for each of the framework’s dimensions to help people focus on some of the main challenges to understanding safety. The guide also provides a brief summary of the research underpinning the framework and details of further resources available to find out more.