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Team Based Quality Reviews (TBQR) provide a structured, evidence-based approach to team learning in clinical practice. Building on existing processes such as morbidity and mortality (M&M) meetings and significant event analyses, TBQR supports whole-team reflection from the point of an event through to shared learning, meaningful actions, addressing unintended consequences and follow-up for improvement. This one-day course, developed in partnership with NHS Education Scotland, RCSEd and the GMC, equips healthcare professionals with the tools, frameworks, and strategies needed to embed TBQR into clinical practice. Participants will gain practical skills in implementation strategies, analysing events, identifying meaningful actions, and overcoming barriers—such as time, resources, and system alignment. Designed for colleagues leading or interested in safety reviews, or seeking to improve daily work practices, this course provides an opportunity to enhance the understanding, and application of Human Factors and Systems Thinking into practice. It explores how TBQR can be used not only to learn from harm, but also from success, innovation, and complexity in care delivery. This course provides delegates with an opportunity to join a wider network of professionals and learn from areas of good practice across the globe. By supporting collective learning and psychological safety, TBQR strengthens team performance, staff wellbeing, and organisational resilience, ultimately advancing safe, effective, and sustainable healthcare. Learning style There are two components to this course, as follows: Online / e-Learning training module. This pre-workshop module supports the learner in their understanding of the TBQR process, its underlying principles and provides an overview of designing quality and safety review pathways. Face-to-face workshops which will involve interactive lectures on core topics relevant to safety reviews and practical work. Aims & Objectives To equip surgeons and the healthcare workforce with the knowledge, skills, and implementation strategies to design, lead, and participate in Team Based Quality Reviews (TBQR), grounded in contemporary safety science and Human Factors principles. The course complements existing national safety review policies and frameworks, fostering a culture of learning, improvement, and understanding of resilience in systems. Learning outcomes By the end of the course, participants will be able to: Explain the purpose, principles, and practical relevance of Team Based Quality Reviews (TBQR) within health and care settings. Describe and map a TBQR process tailored to their own team or organisation, applying Human Factors principles to enhance learning and safety. Apply Systems Thinking and appropriate analytical frameworks to review cases in TBQR, M&M meetings, or similar review and reflective practices. Demonstrate the use of the TBQR process in a simulated scenario to identify system strengths, vulnerabilities, and strategies to build resilience within the system. Evaluate, plan, and apply implementation strategies to embed TBQR in their workplace in order to: Enhance learning and innovation Advance training Focus resources where required Improve staff wellbeing Promote psychological safety Engage patients and families. Register

We are proud to announce and delighted to celebrate that five organisations have been awarded a Greener Palliative Care Award (GPCA). The GPCA recognises excellence in environmental sustainability across palliative and end-of-life care services in both NHS and charitable organisations (such as hospices). It celebrates organisations that are reducing their environmental impact, while maintaining the highest standards of compassionate care for patients and families. The Palliative Care Sustainability Network ran a pilot scheme where teams worked through the GPCA framework towards either Bronze, Silver or Gold award. Applicants were supported to work towards achievable standards, set out for each level, and were supported with resources and examples linking the teams with national work by bodies such as Greener NHS and the Centre for Sustainable Healthcare. Teams worked on key organisational changes, such as developing and delivering on Green Plans, together with actions that all staff (and volunteers) could work on. From cutting carbon emissions and reducing waste, to adopting sustainable procurement practices and promoting greener travel, the awardees demonstrated that quality care and environmental responsibility go hand in hand. If you are interested in reducing your own team’s environmental impact, want to meet the Care Quality Commission's (CQC) standard on environmental sustainability, or you just want to improve team working and job satisfaction in your workforce, why not get started on the Bronze GPCA? Open to all palliative care organisations free of charge, the Bronze award focuses on getting together, education, raising awareness and identifying the first areas to tackle in improving environmental sustainability. Sign up to our Palliative Care Sustainability Network page or email [email protected] and join the growing movement of climate conscious healthcare workers! More information can be found here: https://apmonline.org/greener-palliative-care-award/ The Award team have been working with the support of the following organisations: The Centre for Sustainable Healthcare, Hospice UK, Sue Ryder, UK Health Alliance on Climate Change and the Association of Palliative Care Medicine.

“When the medicine no longer works, the patient suffers twice: first from the illness, then from the cost, fear, and uncertainty that follows.” Across Uganda, patients are increasingly experiencing infections that no longer respond to commonly used antibiotics. Conditions that were once easily treatable now require longer hospital stays, repeated courses of treatment and higher out-of-pocket expenditure. These lived experiences reflect the human impact of antimicrobial resistance (AMR), a growing threat to patient safety, equity and health system resilience.[1] Although antimicrobial stewardship (AMS) has traditionally focused on prescribers, laboratories and health facilities, evidence from Uganda demonstrates a critical reality: a large proportion of antibiotic use occurs at community and household level.[2] Without engaging patients and communities as partners, stewardship efforts remain incomplete and unsustainable. Annet Naguudi, Regina Kamoga and Joshua Wamboga from the Uganda Alliance of Patients’ Organizations (UAPO) argue that strengthening AMS in Uganda requires placing patients at the centre of the response and highlights the strategic positioning of the UAPO to lead this shift in line with national and global priorities. The AMR challenge in Uganda: More than a technical problem Uganda is experiencing increasing resistance to widely used antibiotics, including amoxicillin, ciprofloxacin, ceftriaxone, gentamicin and cotrimoxazole.[2][3] Surveillance and hospital-based studies show a rising prevalence of multidrug-resistant organisms, particularly extended-spectrum β-lactamase (ESBL)–producing Enterobacterales and methicillin-resistant Staphylococcus aureus (MRSA).[2] Drug resistance has also been documented across priority disease programmes. Uganda’s first national tuberculosis (TB) drug-resistance survey reported resistance to any first-line anti-TB drug in 10.3% of new patients and 25.9% of previously treated patients, with multidrug-resistant TB reaching 12.1% among the latter group.[4] In malaria, resistance to chloroquine and later sulfadoxine-pyrimethamine emerged in the 1990s and early 2000s, prompting successive changes in national treatment policy toward artemisinin-based combination therapies.[5] HIV drug resistance has similarly increased over time, particularly to non-nucleoside reverse transcriptase inhibitors, contributing to Uganda’s transition to dolutegravir-based first-line regimens with a higher barrier to resistance.[6][7] Together, these trends highlight AMR as a cross-cutting threat requiring coordinated AMS across human health programmes. For patients, AMR translates into: Delayed recovery and treatment failure. Prolonged hospital admissions. Increased healthcare and household costs. Reduced trust in health services. These outcomes are not driven by clinical factors alone. Patient behaviour and community norms, including self-medication, incomplete adherence to treatment, pressure on clinicians to prescribe antibiotics and sharing of medicines within households, are major contributors to inappropriate antimicrobial use in Uganda.[1][8] Addressing this is therefore essential to effective AMS. Strong policy commitment, persistent implementation gaps Uganda has demonstrated strong political commitment to addressing AMR through the National Action Plan on Antimicrobial Resistance II (NAP-AMR II) 2024/25– 2028/29, which aligns with the WHO Global Action Plan on AMR and adopts a One Health approach spanning human, animal and environmental health.[1][8] Key achievements include: Establishment of a national AMR Secretariat. Adoption of the WHO Access, Watch, and Reserve (AWaRe) antibiotic classification. Piloting of AMS committees in selected regional referral hospitals. Annual national AMR awareness campaigns. However, despite these advances, AMS implementation remains uneven. Stewardship activities are largely concentrated in tertiary facilities, diagnostic capacity is limited in many settings, and surveillance systems do not adequately capture community-level antimicrobial use.[8] Critically, patient engagement is not yet systematically embedded within AMS implementation, limiting the reach and sustainability of national efforts. Why patient engagement is central to AMS AMS is most effective when patients are not passive recipients of instructions but active partners in care. Patients influence antimicrobial use at every stage: care-seeking behaviour, expectations during clinical encounters, adherence to prescribed treatment and medicine use within households.[1] Meaningful patient-centred AMS ensures that patients are: Informed, with clear and accessible information about when antibiotics are needed. Empowered, able to ask questions and participate in shared decision-making. Engaged, involved in shaping stewardship messages and interventions. Partners in accountability, reinforcing appropriate use within families and communities. Evidence increasingly shows that stewardship interventions incorporating patient education and community engagement achieve more durable behaviour change than provider-only approaches.[9] The strategic role of patient organisations Patient organisations occupy a unique position within health systems. Rooted in lived experience and trusted by communities, they can translate complex technical guidance into culturally relevant messages, strengthen trust and support accountability for quality and safety. UAPO is a national umbrella body representing 18 patient organisations across diverse disease areas. UAPO provides a unified, patient-centred platform that aligns closely with Uganda’s AMR priorities, particularly in: Rational medicine use. Community awareness and behaviour change. Patient safety and quality of care. Accountability and transparency in health systems. UAPO does not replace government leadership or clinical stewardship. Rather, it complements national and facility-based AMS efforts by anchoring stewardship in lived experience and community practice, consistent with WHO guidance on meaningful patient engagement.[10] Demonstrated patient-led innovation: The CHAIN experience A compelling example of patient-centred AMS in practice is provided by Community Health and Information Network (CHAIN), a UAPO member organisation. CHAIN has developed an innovative gamification-based approach to antimicrobial stewardship education that targets children as agents of change. Through interactive play, storytelling and peer learning, children are taught: When antibiotics are needed—and when they are not. The importance of correct dosing and completing treatment. Hand hygiene and infection prevention. The risks of sharing or misusing medicines. To date, this approach has reached over 20,000 children in rural and urban communities and has demonstrated measurable improvements in hygiene and medicine safety behaviours (UAPO internal programme data). Children trained through the programme act as AMR champions, influencing parents and caregivers and reinforcing responsible antimicrobial use at household and community levels. This early-life intervention addresses AMR at its behavioural roots and complements facility-based stewardship and regulatory interventions.[8] UAPO’s positioning to lead a national patient-centred AMS campaign UAPO is uniquely positioned to lead a national campaign on strengthening AMS through patient engagement by offering: National convening power to bring together patients, clinicians, policymakers, regulators, and partners. Trusted community reach through established patient networks. Strong alignment with national policy, particularly NAP-AMR II. Scalable community-based models that complement technical AMS interventions. A sustainability focus, embedding stewardship behaviours early and across generations. Through this role, UAPO can help ensure that AMS is not only implemented, but understood, owned and sustained by the communities it serves, reinforcing national AMR objectives.[8] Conclusion: From policy to people Uganda has laid strong foundations for addressing antimicrobial resistance through robust policies and multi-sectoral coordination. However, the next phase of progress depends on translating policy and technical guidance into everyday decisions made by patients and families. Strengthening antimicrobial stewardship without engaging patients risks short-lived gains. By placing patients at the centre of AMS and by supporting patient organisations, such as UAPO as partners and conveners, Uganda has an opportunity to demonstrate how meaningful patient engagement can accelerate stewardship, protect life-saving medicines and strengthen health system resilience. Investing in patient-centred AMS is not optional; it is essential. References World Health Organization. Global action plan on antimicrobial resistance, 2015. Okiror JJ, Aruhomukama D, Kajumbula H. Kateete DP. Trends in antimicrobial resistance from sentinel surveillance sites in Uganda. BMC Infectious Diseases 2024; 24: Article 912. Ndugga P, Mboowa G, Karamagi C, Taremwa IM. Antimicrobial resistance patterns among priority bacterial pathogens in Uganda. BMC Infectious Diseases 2024; 24: Article 930. https://doi.org/10.1186/s12879-024- 09806-y. Lukoye D, Adatu F, Musisi K, et al. Anti-tuberculosis drug resistance among new and previously treated sputum smear-positive tuberculosis patients in Uganda: Results of the first national survey. PLoS ONE, 2023; 8(8): e70763. https://doi.org/10.1371/journal.pone.0070763. Kamya MR, Bakyaita NN, Talisuna AO, et al. Increasing antimalarial drug resistance in Uganda and revision of treatment guidelines. The Lancet 2002; 360(9341): 451–2. https://doi.org/10.1016/S0140-6736(02)09609-7. WHO. HIV drug resistance report 2019. World Health Organization, 2019. Wittkop L, Günthard HF, de Wolf F, et al, WHO HIVResNet. Effect of transmitted drug resistance on virological and immunological response to initial combination antiretroviral therapy for HIV. The Lancet HIV 2021; 8(3): e167–e77. https://doi.org/10.1016/S2352-3018(20)30338-7. Ministry of Health (MoH), Republic of Uganda. National Action Plan on Antimicrobial Resistance II (2024/25–2028/29). Government of Uganda, 2025. WHO. Antimicrobial stewardship programmes in health-care facilities in low- and middle-income countries: A WHO practical toolkit. World Health Organization, 2019. WHO. Framework on integrated, people-centred health services. World Health Organization, 2016. Further reading on the hub: Why won’t my doctor give me antibiotics? Ron Daniels explains My involvement with the Commonwealth Partnerships for Antimicrobial Stewardship Scheme (CwPAMS) in Zambia Top picks: Key resources on antimicrobial resistance Do you have insights to share around patient safety? We would love to hear from other countries and organisations on the work they are doing. Are you a member of the hub? Why not join our global community today (it’s free and easy to sign up) and submit an article or share a resource? You can also contact the editorial team at [email protected].

On the 8 September 2023, following on from the success of the Patient Safety Management Network, the Patient Safety Education Network (PSEN) was created. The PSEN is a network for those in patient safety education and training. Chris Elston, Patient Safety Education Lead for University Hospital Southampton NHS Foundation Trust, reflects on the past year that has seen the Network grow to over 470 members. Wow, as a colleague of mine used to say “Tempus fugit.” Time flies, doesn’t it just. Can it really be one year that the Patient Safety Education Network (PSEN) has been meeting and supporting each other? All I can say is that it has given me a range of emotions: Fear—what if it falls flat on its face? What if nobody turns up? Please no technical issues! Apprehension— it's 2 minutes before the meeting starts and the person presenting has not logged in yet? What can I do to fill the gap? Confidence—everyone turns up and the meeting is ended with great feedback from the audience. Pride—proud to have listened to the team that set this Network up and proud to be currently leading it. Surprise—that there are so many people willing to share information, resources and experiences, and all wanting to improve the way healthcare keeps our patients safe. We had humble beginnings following someone on the FutureNHS platform asking if there was any way that Trusts could share learning. Several discussions later, we had decided as a group that we would set up a Patient Safety Education Network and use this Network to share lessons, teaching methods and subjects. Learn from each other to promote good quality teaching, share lessons learnt, findings from learning responses and provide some peer mentoring and support. So how have we done? Have we achieved our initial plans? As a former military man, there is a phrase that has stuck with me from those days: No plan survives first contact! There is nothing false about that statement. The greatest part of this adventure has been the sharing of information. At our monthly meetings we have shared a Patient Safety Incident Response Framework (PSIRF) journey, observations and walk through talk throughs (WTTT or WT3, depending on your choice of acronym), engagement, a falls project, culture, SEIPS and AcciMaps, Swarms, Initial Safety Reviews, how to share learning. (As a member of the Network, if you miss a meeting you can access all the notes and presentation slides from these meeting—you will need to be signed into the hub.) I am not sure we have managed to provide everything we set out to, for example, the mentoring aspect of the Network, although the proof will be asking the Network members if we have. We have shared some learning from incidents but not much. There is scope to increase this and maybe we should have a standing item in the meeting for sharing these lessons. But we need to ensure that we keep to the Network rules of ensuring it is a safe space for all to be able to share their thoughts, worries and concerns. However, I think if we dedicated 10 minutes for the sharing of findings then it could strengthen the Network. It will need discussion and a decision from the Network members, as this is not a one-man band. I'd love to hear your thoughts. Highlights from the past year So, what has been my highlight, apart from getting this up and running? I would say there are two. I am not too keen on being in the limelight and leading things. I can and do, but I much prefer being a team member and offering help, support and guidance. So doing this, and having you all come back time after time, is a highlight. The second may be a little unusual. At the beginning of the year, I presented a slide about mittens—the now notorious mittens case. Someone asked a question about what this would look like as an AcciMap or SEIPS. So why is this a highlight? Well, it made me think. I made up an AcciMap and a SEIPS, it provided a kick start to my teaching and persuaded me that a new workshop/lesson was required at work. From this Network, my SEIPS and AcciMap Master Classes were born. Looking forward Future topics for the PSEN include venous thromboembolism (VTE), a culture change workshop, and change management and staff support. I am always on the lookout for new topics and people to present. I find myself listening to presentations and wondering how it would land with you, the Network members. Looking at my own development, I have had to improve my skills. My time management is a little wayward at times and that causes me a lot of discomfort. Everybody’s time is precious and I need to get the communications out to everyone, early enough to make a difference. Here is my opportunity to apologise for the late communications, at times. Final thoughts In summary, this has been a busy 12 months, a year of firsts (many firsts) and we have just had our first PSMN/PSEN symposium where I got to meet many of you face to face. The work that we are doing to improve the safety in healthcare for patients and their families, with the same effort put into the wellbeing of the staff, is immense and gathering pace. I am glad to be part of it and proud to be involved. I feel that we can move mountains with the tenacity, passion and knowledge that we possess, but the key for me, is the mutual support we give each other. From the smallest of roots grows the strongest of trees. Friday 8 September 2023 saw the first meeting of the PSEN with 28 members attending and a Network membership of 52. Today we have a membership of 479 and the meeting on the 13 September 2024 had 65 Network members attend. There remains only one other thing to say: Thank you and here is to another 12 months! How to join the Patient Safety Education Network Do you work in patient safety? If you are interested in joining the Patient Safety Education Network, you can join by signing up to the hub today. If you are already a member of the hub, please email [email protected]. You can also find out more about the growing number of informal peer support networks hosted and supported by Patient Safety Learning. These networks now include: Patient Safety Management Network – this is an innovative network for patient safety managers and everyone working in patient safety. In just over three years this has grown to now over 1700 members from more than 650 different organisations Patient Safety Partners Network – a group for Patient Safety Partners, paid and voluntary roles within NHS organisations aimed at improving patient safety. National NatSSIPs Network – a group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. Patient Safety Paediatric Leaders Network – 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 in the UK. VTE Specialists Network. The networks provide a forum for people involved in patient safety to meet up, share ideas and initiatives and learn from others. Related reading Application of SEIPS and AcciMap to a patient safety incident Is the NHS ready for PSIRF? A blog by Chris Elston “We’ve created an incredible pool of talented safety people who are up for collaboration.” Marking three years of the Patient Safety Management Network The voice of the patient safety frontline—An introduction to the Patient Safety Partners Network Patient Safety: Emerging Applications of Safety Science

Normalisation of patient care refers to the process of standardising healthcare practices to ensure consistent, high-quality care for all patients, regardless of their background or condition. This concept is vital in today’s healthcare systems, where variability in care can lead to disparities in outcomes. By normalising care, healthcare providers aim to reduce these disparities, improve patient outcomes and enhance the overall efficiency of healthcare delivery. However, if poor care becomes normalised; i.e., treated as routine, it can have detrimental effects on patients and their outcomes. In this blog, Dawn Stott discusses the importance of consistency in care delivery, why healthcare systems must continue to develop and refine strategies for normalising care, and how she and her colleagues are developing global guidance on securing an airway when delivering anaesthesia.  Consistency in care delivery One of the primary goals of normalisation is to ensure that every patient receives the same standard of care. This means that the treatment a patient receives should not depend on the time of day, the healthcare provider’s experience or the facility where they are treated. Standard protocols and guidelines help to minimise variations and ensure that all patients receive evidence-based care. When care is standardised, it often leads to better health outcomes. For instance, standard protocols for managing chronic diseases like diabetes or hypertension ensure that all patients receive the most effective treatments, reducing the risk of complications and improving long-term health. Normalisation also enhances the efficiency of healthcare delivery. Standardised protocols streamline processes, reduce the need for unnecessary tests or treatments, and make it easier for healthcare providers to coordinate care. This, in turn, can reduce costs and improve the overall functioning of healthcare provision. An example of a change to a standardised way of working is the securement of an intravenous (IV) cannula. Many articles have been written on the subject of IV securement, which essentially broke down the silos and made it clear, based on evidence, that after insertion of the cannula, the next most significant consideration was the securement of the device.[1][2] Historically securement was achieved with tapes, ties or sutures. Adhesive securement devices became the preferred method over sutures because they offered securement without additional skin punctures. The introduction of the IV dressing for cannula securement was revolutionary and is now a custom practice internationally. Developing global guidance on securing an airway In a recent survey, and following several professional focus groups, our project team have found that inflammatory damage to a patient’s skin following anaesthesia was a ‘real’ problem because of the way the airway was secured. There is a risk of these practices becoming normalised and therefore not being reported as a patient incident. As a result of a freedom of information study undertaken by the project team, the information gained suggests that many hospitals do not measure poor airway management outcomes and there does not appear to be any central database to support this either. There is a risk of damage to a patient’s skin when tapes are used to secure the airway. However, this is often not reported because it is ‘just the tape’ causing the harm. As a result of this type of practice happening quite often, it has become accepted and engrained into healthcare practice, similar to how it used to be with an IV cannula, and is another example of where normalisation of a practice is detrimental to a patient’s care. To improve this, a group of individuals have come together to work on developing global guidance on securing an airway and delivering anaesthesia safely in the pursuit of precision and vigilance. The idea was that as a project team we could, together, envision a future where anaesthesia safety is not just an aspiration but a standard of care that we exceed every single time.[2] Our goal is to standardise securing an airway to eliminate harm to a patient’s skin, airway displacement and infection risks. Although the project team appreciate that anaesthetics is deemed to be one of the safest areas of healthcare practice, our project’s aim is to provide evidence that current practices in airway securement are unsafe and are leading to patient harm, and that a better, licenced and regulated, solution is needed. Tapes and ties are still the mainstay for securing an airway in operating theatres and these methods are unlicensed with varying adhesive capabilities, which could cause inadequate safety to the patients. With this evidence we hope to influence nationally recognised bodies to establish clear guidelines and recommendations to support safer patient outcomes through education and learning. Strategies for effective normalisation of care Healthcare providers may resist the implementation of standardised protocols, particularly if they feel that these protocols limit their clinical judgment. Overcoming this resistance requires effective communication and education about the benefits of normalisation, including: Developing and implementing clinical guidelines, which should be evidence-based with regular updates. These guidelines will serve as the foundation for standardisation of procedures across different settings and providers. Ongoing training and education, which are crucial to ensuring that providers understand and can effectively implement standardised protocols. The education should form the basis for induction as well as continuous professional development. Continuous monitoring and evaluation, which are essential to ensure that normalised efforts are effective. This will involve tracking outcomes, gathering feedback from both patients and providers, and adjusting care protocols as required. Moving forward, healthcare systems must continue to develop and refine strategies for normalising care, balancing the need for standardisation with the importance of individualised, patient-centred treatment. By doing so, a more equitable and effective healthcare system can be provided for all. Conclusion This year’s World Patient Safety Day slogan is ‘Get it right, make it safe’. Our project is all about getting it right and making the securing of an airway safe for the patient. The team are aiming to highlight the importance of prioritising patient safety over financial constraints. As healthcare professionals it is important to raise awareness of the value it will have to the patient; i.e., the quantity of harm to the patient to promote the value of the quality outcomes for the patient versus the cost of the product. Healthcare is a high-risk industry and professionals should follow guidance developed from the best available evidence (NICE guidance) rather than any traditional or ritualistic practice. As practitioners we are accountable for our actions and safety is everyone’s responsibility. References Barton A. Universal Adhesive Vascular Access Securement with GripLok Devices. BJN, 2020. https://doi.org/10.12968/bjon.2020.29.8.S28 Docherty V. The Importance of Airway Training. CSJ, 2024.

Nurses and nursing support workers in every setting have a vital role in improving outcomes for people with sepsis and with new guidelines published, there has never been a better time to update your knowledge and practice in this area. Why attend Latest information: Nurse specialists will give you the information on the signs and symptoms of sepsis and bring you up to date on the latest guidelines from NICE and the Academy of Royal Medical Colleges Practical application: Gain practical strategies for raising concerns effectively, including the latest information about Martha’s Rule Expert advice: Our experts offer advice on how to spot a deteriorating patient in a range of settings, including hospital, community and care homes PLUS all your clinical questions answered by our panel and networking. Register

Energising excellence. Bringing research, education, practice and leadership to life The RCM conference is back for 2024. Professional and educational standards of proficiencies have made clear the importance of midwives working across the professional pillars of the profession: research, education, clinical practice and leadership. Safe and effective care needs an evidence base from research, which is then disseminated and supported through education and strategically implemented into clinical practice and sustained through effective leadership. Furthermore, understanding midwifery professional pillars is relevant for promoting career pathways and ensuring professional recognition alongside our multi-disciplinary colleagues. Register

This global webinar is organised to promote and mark the launch of "My 5 Moments: The Game," an innovative digital game developed through a collaboration between the WHO Infection Prevention and Control Unit and Hub, WHO Academy, game designer, learning game expert, and end users. Aimed at revolutionising hand hygiene education, this game-based learning programme integrates the concept of "My Five Moments for Hand Hygiene" into an engaging, compassionate, and scientifically-backed gaming experience. Set in the futuristic International Alien Hospital, the game challenges players to maintain optimal hand hygiene practices to ensure the safety of both alien patients and the Earth. This session aims to introduce healthcare professionals, educators, and other relevant stakeholders to the game's unique approach to infection prevention and control through gamification, design insights, and the importance of empathy in healthcare. Objectives: To introduce "My 5 Moments: The Game" to healthcare professionals, IPC practitioners, educators, and stakeholders, highlighting its innovative approach to hand hygiene education through gamification, and demonstrating how it can transform traditional learning methodologies in IPC. To provide insights into the game's design and development process, emphasizing the integration of compassion, care, and empathy into its gameplay, and illustrating the importance of these elements in creating a more effective and engaging learning experience for healthcare workers. To encourage the adoption of "My 5 Moments: The Game" within healthcare training and education programmes, to bring behavior change among healthcare workers, and offering guidance on integrating this innovative tool into existing IPC efforts. Register

'The Family Oops and Burns First Aid' is a free children's book written by Kristina Stiles, beautifully illustrated by Jill Latter, created to support children and their families learning about burns prevention and first aid principles together. The book describes an accident prone family who are not burns aware, who have to go to school to learn about burn safety and first aid principles within the home. The book is aimed at KS1 children and their families, and is available as hard copy book by request from Children's Burns Trust and also as an audio/video book via YouTube.

NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. In this blog, Kenny Fraser, CEO of Triscribe, explains why we need to deliver quick, low-cost improvement using modern, open source software tools and techniques. We don’t need schemes and standards or metrics and quality control. The most important thing is to build software for the needs and priorities of frontline pharmacists, doctors and nurses. A study in 2018 found that 237 million medication errors occur each year in the NHS in England alone. Three quarters of these cause harm and there are 1,700–22,303 deaths from avoidable adverse drug reactions. Two things immediately strike me about these numbers: Medication safety is a huge issue. The breadth of the estimate suggests that data about the scale and impact of medication safety errors are incomplete and unreliable. I have not seen a similar published study since. My experience working with NHS hospitals since 2018 suggests slow progress. There are four reasons: The spaghetti medusa of data. Millions of staff hours spent to capture and store medicines data in a variety of legacy siloed hospital systems such as EPMA, pharmacy stock and EPR. The NHS employs 1.5 million people and at least the same number again work in social care. Yet there are almost no tools specifically built for either NHS or social care workers. Slow progress of clumsy digital initiatives that focus on the wrong thing, made worse by the fear of digital monsters. Lack of change and innovation. Lots of noise around schemes and gateways rather than actual solutions for real people. Layer the pandemic impact over these underlying issues and the position seems hopeless. It's not. “Data isn’t oil, it’s sand.” The tech industry has invested trillions of dollars and the time of millions of the world’s smartest experts. Much of this goes into solutions that capture and use epic quantities of data. Over the past 15 years, multiple standard, open source software tools and techniques have emerged that tackle exactly this kind of problem. Behind all the hype, hysteria and scaremongering, the current AI boom is just a manifestation of all this money and intellectual capital. It is outrageous that this is not used for the benefit of hard pressed frontline hospital staff. So what does this mean in practice? How can tools, like Triscribe, actually improve medication safety? Those 237 million errors include a lot of different things. Adverse drug reactions are just a small portion and the severe reactions are pretty rare. Using the existing data collected from a multiplicity of systems, we believe that more meaningful analysis is possible by: Reporting of adverse drug risks updated at least daily. Note: using a little AI, we can predict the risk of adverse drug reactions and give clinicians the information needed to stop at least some from happening. Much better than just reporting the incidents. Monitoring adherence key safety policies and guidelines. For example, VTE prophylaxis, allergy reviews and oxygen prescribing. Tracking and reporting late and omitted doses every day across all systems, including ward comparisons to identify learning and share better ways of working. Safe use indicators for specific medications; for example, early/ late administration of Parkinson’s medicines and opioid deprescribing. Reporting key compliance measures, including IV to oral switching for antibiotics, high dose prescribing of opioids and usage of methotrexate The possibilities are limitless. There is no shortage of data in the NHS. However, the ability to share that data between systems and organisations is something the health and care sector still lacks. It’s a solvable problem. Deliver quick, low-cost improvement using modern, open source software tools and techniques. We don’t need schemes and standards or metrics and quality control. The most important thing is to build software for the needs and priorities of frontline pharmacists, doctors and nurses. Keep learning and keep improving every day.