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In manufacturing a missed signal can cost a product, but in healthcare it can cost a life.  In this blog, Annette Cairns, a leadership development specialist, asks how we can adapt the system-level thinking seen in manufacturing for the unique human complexity, variability and vulnerability that patient care brings. In manufacturing, there was a moment—and you can trace it back through aviation, oil and gas and automotive—when the conversation about safety changed fundamentally. It stopped being about finding the person who made the mistake, and started being about understanding the system that allowed the mistake to happen. That change didn’t come easily or by any means quickly. It required organisations to accept an uncomfortable truth: that in complex, high-pressure environments, human error isn’t primarily a sign of individual failing. It’s a predictable consequence of how systems are designed, how cultures are shaped and how leadership behaves in the moments that really count. The results, where that change has genuinely taken root, have been significant. Aviation is the most cited example—an industry that rebuilt its entire safety culture around the principle that hierarchy, in a cockpit or control tower, cannot be allowed to silence a concern. Crew Resource Management gave co-pilots not just permission but a structured obligation to speak up, regardless of seniority. Near-miss reporting removed the threat of punishment from honesty. Safety culture became something designed into the system, not dependent on the courage of individuals. In manufacturing, parallel principles emerged. James Reason’s Swiss Cheese model gave organisations a language for understanding that failures are almost never caused by one person, but instead they happen when holes in multiple defensive layers happen to align. Toyota’s production system gave every worker on the line the ability to stop everything the moment something didn’t look right. The message was clear and consistent: the system is designed to receive your concern. You don’t need to be brave to raise it. Speaking up is what we do here. Healthcare has borrowed much of this thinking, and rightly so. Just Culture principles, incident reporting frameworks, the language of human factors, all have roots in what manufacturing and aviation learned the hard way over decades. And yet a significant gap remains. It sits not within the clinical team, but between the clinical team and the patient. This is where healthcare faces a layer of complexity that manufacturing simply does not. In manufacturing, the subject of a safety concern, whether it’s the process, the component or the output, has no psychological state. It isn’t frightened. It doesn’t defer to the expertise of the people responsible for it. It has no uncertainty about what ‘normal’ feels like, no anxiety that raising a concern might result in worse treatment, no cultural background or language barrier that makes speaking up feel impossible or unsafe. A patient has all of these things. And they have them at the precise moment they are most vulnerable, most dependent on others and are least certain of their own ground. They are, in the truest sense, inside the system they are being asked to influence. That is a profoundly different position from a worker who can step back from a production line and raise a concern from a position of relative stability. When a patient stays silent about something that concerns them, they are rarely choosing silence because they lack information or awareness. They are making a calculation (often unconsciously) based on the culture they are experiencing: the responsiveness of the people around them, the signals they have received about whether their voice is genuinely welcome, and the very human fear that being perceived as ‘difficult’ might affect the quality of their care. In a system where patients feel they must be compliant to be safe, we have already failed at the most fundamental level. Traditionally, healthcare has tried the route of patient education, but you cannot close this gap just by training patients to be more assertive or by producing better information leaflets about how to raise concerns. It is an organisational and leadership problem—and I believe one that requires the same system-level thinking that transformed safety culture in manufacturing. It requires leaders who understand that psychological safety for patients is not a clinical add-on. It is a core organisational competency. Leaders who ask not just "did we give the patient an opportunity to speak?" but "have we genuinely designed a system in which speaking up is the path of least resistance—and in which our teams have the skills and the capacity to hear what patients say, and act on it?" My extensive work on health and safety behaviour change in manufacturing and technical organisations has consistently shown that the leadership behaviours which create safety: active listening, psychological safety, the reward of raising concerns rather than resolving them quietly, are not industry-specific. They are human. What is industry-specific is the stakes when those behaviours are absent. In manufacturing, a missed signal can cost a product. In healthcare, it can cost a life. The framework for getting this right already exists. Manufacturing and aviation built it over decades of hard-won experience. The question for healthcare is not whether to adopt this system-level thinking, but how to adapt it for the unique human complexity, variability and vulnerability that patient care brings. That work starts with leadership. It always does.

Aimed at Clinicians and Managers, this national virtual conference will provide a practical guide to human factors in healthcare, and how a human factors approach can improve patient care, quality, process, and safety. The conference delves into integrating human factors into healthcare systems and processes, clinical decision making, healthcare system design, quality of patient experience, medication safety, and workload, fatigue, and stress management. Throughout the day there will be interactive sessions, small breakout groups, and collaborative exercises, fostering a dynamic learning experience. This conference will enable you to: Network with colleagues who are working to embed a human factors approach. Learn from outstanding practice in using human factors and ergonomics to improve patient safety and quality. Reflect on national developments and learning including the patient safety syllabus and the role of human factors within the new Patient Safety Incident Response Framework (PSIRF). Understand the tools and methodology. Develop your skills in training and educating frontline staff in human factors. Understand how you can improve patient safety incident investigation by using a human factors approach. Learn from case studies demonstrating the practical application of human factors to improve patient care and safety. Understand the role of human factors in improving culture and delivering psychological safety. Self assess and reflect on your own practice. Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register We are pleased to offer hub members a free place using the code HCUK00HFPSL

The workshop explores the importance of integrating human factors into healthcare AI design, development, testing, and implementation. Participants will learn how to apply complex systems thinking models to consider, ‘How might integrating AI into this healthcare setting impact on system performance and human well-being?’ Designed for healthcare professionals from all care settings, the workshop content is interactive and engaging. Email [email protected] to book your place

In healthcare, we often talk about 'never events'—serious incidents that should not occur if appropriate systems are in place. But what happens when they do occur? I recently had the great pleasure of working with a group of anaesthetic resident doctor colleagues on a patient safety project that began with exactly that question. Within a short period in 2025, our large UK teaching hospital experienced two wrong-sided peripheral nerve blocks after six years without a single reported incident. We wanted to understand why. Looking beyond individual error Both incidents occurred during a major transition: we were moving anaesthetic records, consent forms and safety checklists from paper to digital. At first glance, the timing felt more than coincidental. After initial governance processes were completed, our team used the Patient Safety Incident Response Framework (PSIRF)[1] to explore what had happened. Introduced in the NHS in 2022, PSIRF promotes a systems-based approach rather than searching for a single 'root cause'. It examines how elements such as people, tasks, tools and technology, environment and organisational factors interact to increase risk. For us, this shift in perspective proved crucial. Instead of asking “who made this mistake?”, we were able to consider “what conditions made this error more likely?”. What we found: small gaps in a complex system We brought together a multidisciplinary 'learning MDT', combining insights from staff interviews and systems analysis. A clear pattern emerged: no single failure caused these incidents. Instead, multiple small vulnerabilities aligned. One issue stood out. In our previous paper-based system, clinicians used a 'Stop Before You Block' (SBYB) sticker—a simple but effective visual cue prompting a final safety pause before performing a nerve block. During the digital transition, this physical prompt disappeared. Other contributing factors reinforced the problem: Staff worked under cognitive overload, juggling interruptions, changing plans and high-acuity patients. Digital consent processes made SBYB checks feel more cumbersome, drawing attention away from the patient and towards the computer. Poor visibility of surgical site markings increased the barriers to performing SBYB. Ergonomic challenges in anaesthetic rooms made equipment setup frustrating. Time pressure on theatre lists encouraged task compression. In both cases, clinicians skipped the SBYB pause entirely—not out of negligence, but because the system no longer reliably supported it. These events didn’t reflect individual failure. They reflected a system under strain during organisational change. From insight to action: designing safer systems We knew we couldn’t eliminate complexity from clinical environments, but we could design systems that make the safe action the easy action. We developed a multi-faceted improvement plan. 1. Strengthening standards and education We updated our local guidance, aligning it with national recommendations from the Safe Anaesthesia Liaison Group and Regional Anaesthesia UK.[2] We rebranded it as the 'Prep Stop Block LocSSIP' (Local Safety Standard for Invasive Procedures). We promoted this through clinical governance meetings and delivered targeted teaching to consultants, trainees and anaesthetic practitioners. To support sustainability, we embedded a training video into the anaesthetic resident doctor induction programme and uploaded it to our intranet. 2. Fixing friction in the system We addressed practical barriers: Improved access to longer ultrasound cables. Standardised surgical site markings to improve visibility. Explored integrating anaesthetic complexity into theatre scheduling. Trialled LED signs to indicate when the anaesthetic room is in use; thus creating a 'sterile cockpit' by discouraging interruptions during anaesthetic procedures. Introduced electronic tablets so consent forms could be viewed alongside the patient and checklist. Each of these changes aimed to reduce cognitive load and create space for safer practice. 3. Introducing a physical safety barrier Our most impactful intervention was the 'Prep Stop Block Lid'. We designed a lidded box displaying a safety infographic. Clinicians place prepared local anaesthetic inside and cannot access it until they complete the SBYB pause. This shifts safety from memory to physical design, creating a clear pause point in the workflow. We refined the intervention through Plan–Do–Study–Act (PDSA) cycles with frontline feedback before wider rollout. What we’ve learned so far Early data show improvements in process measures, including increased visibility of the SBYB step. Audits of Prep-Stop-Block compliance suggest an improvement from 34% during digital transition to 100% at most recent review. However, we remain cautious. We are still in a 'zone of vulnerability', where changes are ongoing and their full impact is unclear. Because never events are (fortunately) rare, it will take time to determine whether these interventions reduce harm. That said, several key lessons have already emerged: Never events are rarely about individuals. They arise from system conditions that make errors more likely. Digital transformation can unintentionally remove safety cues. We must actively design these back into new systems. Education and policy are necessary but insufficient. The most reliable safety interventions are embedded into workflow, especially physical or procedural 'forcing functions'. A call to action If your department is undergoing digital transformation, take a moment to ask: “What safety cues might we be losing—and how will we replace them?” We need to move beyond simply digitalising existing processes. Instead, we should use these transitions as opportunities to design safer, more resilient systems from the ground up. Because when it comes to patient safety, 'never' is not a guarantee, it’s a goal we must actively work towards. References https://www.england.nhs.uk/long-read/patient-safety-incident-response-framework/ https://www.salg.ac.uk/salg-publications/stop-before-you-block/

This practical and engaging two-day course will explore how the SEIPS (Systems Engineering Initiative for Patient Safety) framework can be applied within health and care investigation and design to support safer, more effective systems and services. Whether you are involved in patient safety, investigation, quality improvement, service design or systems thinking, this course will provide valuable insight and practical tools to apply in your organisation. SEIPS in Health and Care Investigation and Design is an interactive two-day face-to-face course designed to introduce participants to practical systems-based investigation and design using the Systems Engineering Initiative for Patient Safety framework (SEIPS). Through collaborative workshops and realistic scenarios, learners will work alongside others to explore and analyse real-world incidents and system challenges commonly encountered across health and care settings. Participants will develop practical skills in identifying how people, environments, technologies, organisational factors, and workflows interact to influence safety, quality, and care outcomes. Delivered in a supportive learning environment, the course is facilitated by experienced faculty leading work across systems thinking, human factors, and safety investigation. Learners will have opportunities to discuss ideas, test approaches, and build confidence applying SEIPS methods through guided simulation and group-based activities. By the end of the course, participants will have developed a structured approach to investigating complex system issues and designing practical, system-focused improvements for health and care services. To find out more or book your place, please email: [email protected]

When repeated harm occurs in healthcare, public debate often centres on identifying an individual responsible. Although accountability is essential, patient safety may be better served by asking another question first: Were there earlier signals that something was going wrong? This blog reflects the perspective of Aditi Desai, a surgeon with nearly three decades of clinical experience and an interest in patient safety systems, surgical quality monitoring and organisational learning. Recent high‑profile cases, such as the case of surgeon Yasser Jabbar at Great Ormond Street Hospital,[1] have prompted difficult reflection across the profession about how systems detect repeated patient harm. These situations understandably lead to questions about individual responsibility, but they also highlight the importance of recognising warning signals earlier. After nearly three decades in surgical practice, I have seen how outcomes can fluctuate. A surgeon may perform many procedures safely, then experience several complications in close succession. Some of this represents natural variation. But sometimes patterns emerge that should prompt earlier concern. Modern healthcare systems collect large amounts of clinical data, yet we rarely use it systematically to detect deteriorating performance early.[2] Risk‑adjusted monitoring of outcomes over time, combined with supportive mentoring and fair accountability, could help organisations intervene sooner, protecting both patients and clinicians. Improving patient safety requires moving beyond a simple choice between blaming individuals or fixing systems. Safer care depends on recognising both the human realities of clinical practice and the need for strong organisational oversight. Recognising the early warning signs of unsafe surgical practice Having practised surgery for more than 28 years, I have learned that clinical outcomes are rarely perfectly predictable. A surgeon may perform a hundred operations without complication. Then, within a short period, several adverse outcomes may occur—like unexpected bleeding, infection or an unintended injury during surgery. When this happens, patients suffer first and most. For clinicians, complications also carry a heavy emotional weight. Many doctors recognise the sleepless nights and intense self‑reflection that follow when a patient is harmed. In recent years, public discussions around cases of repeated patient harm have raised difficult questions about how healthcare systems detect unsafe practice. The case of Yasser Jabbar at Great Ormond Street Hospital, widely reported in the UK, has prompted reflection not only about accountability but also about whether earlier signals of unsafe care might have been detectable. The instinctive response is often to ask: “Who is the rogue clinician?” But from a patient safety perspective, an equally important question may be: “Where was the signal that care was becoming unsafe?” Distinguishing variation from unsafe care All clinical practice carries risk. Even highly skilled surgeons experience complications. Medicine is complex, and outcomes vary according to patient condition, procedural difficulty and chance. The real challenge is distinguishing between: Expected complication rates and natural variation, and Patterns that may indicate deteriorating performance or unsafe practice. This distinction is rarely straightforward. It requires careful interpretation of clinical outcomes and trends over time. The human side of surgical practice Medicine often expects clinicians to perform at a consistently high level throughout long careers. Yet surgeons, like everyone else, experience illness, fatigue, personal stress and periods of reduced resilience. Most clinicians continue working through these pressures because the culture of medicine places great value on strength, reliability and professionalism. Recognising this human reality does not diminish professional responsibility. Instead, it highlights the importance of systems that can identify when a clinician may be struggling and offer support or review before patient harm accumulates. The missing safety infrastructure Healthcare organisations collect vast amounts of data about procedures and outcomes. Yet in many systems, we still lack robust mechanisms that can: Risk‑adjust outcomes for patient complexity. Monitor outcome trends over time. Identify negative outliers early. Trigger timely peer review or mentoring. Such systems are not primarily about punishment. Their purpose is to protect patients while supporting clinicians to maintain safe practice. Moving beyond 'individual versus system' Patient safety discussions often frame harm as either the fault of an individual clinician or the result of system failure. In reality, safety depends on both. Strong systems should be able to detect emerging risks early, while still ensuring fair accountability when unsafe practice becomes clear. This approach aligns with the principles of a just culture, where organisations seek to understand and respond to risks rather than relying solely on retrospective blame.[3] A role for data, mentorship and oversight In other high‑performance fields, such as aviation and elite sport, continuous monitoring and coaching are routine. Medicine has traditionally been slower to adopt this approach. Yet supportive oversight and mentoring could help clinicians identify and address problems earlier in their careers or during periods of difficulty. Clinicians may benefit from ongoing coaching and feedback, not only during training but throughout their professional lives.[4] Surgeon and writer Atul Gawande, the WHO checklist pioneer, highlighted this idea in his TED Talk “Want to get great at something? Get a coach”, where he describes how even experienced surgeons can improve performance and safety through structured coaching and peer observation.[5] Looking forward Cases where repeated harm occurs inevitably raise questions about accountability. Where clear incompetence or unsafe practice exists, fair accountability is essential. But patient safety improves most when healthcare systems are able to recognise warning signs early, before serious harm accumulates. By combining risk‑adjusted data, supportive oversight and a culture of learning, healthcare organisations can better protect patients while supporting clinicians to maintain safe practice. Ultimately, safer care depends not only on responding to failure, but on building systems capable of recognising risk sooner. References Triggle N. Great Ormond Street doctor who botched surgery harmed nearly 100 children. BBC News, 29 January 2026. Royal College of Surgeons of England. Surgical outcomes data and transparency. Outcomes FAQ. NHS England. Being fair tool: supporting staff following a patient safety incident. 9 May 2025. Pradarelli JC, Yule S, Panda N, et al. Optimising the implementation of surgical coaching through feedback from practicing surgeons. JAMA Surgery, 2021; 56;(1): 42-49. doi:10.1001/jamasurg.2020.4581. Gawande A. Want to get great at something? Get a coach. TED Talk, April 2017.

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

MedLed, in partnership with Midlands Air Ambulance Charity, is hosting a Human Factors & Patient Safety for Clinical Leaders course this June and spaces are now open to the wider healthcare sector. Human Factors & Patient Safety for Clinical Leaders is a 2-day face-to-face course built with pre-hospital care as its foundation: the high-stakes, time-pressured, operationally complex environment where Human Factors challenges are most visible. But the principles apply across all of healthcare, and we now have spaces available for clinical and non-clinical professionals beyond the pre-hospital community. What's covered? How human capabilities and limitations influence leadership, management, and the quality of care. Systems thinking and models of safety, moving beyond individual blame and the flawed concept of human error. Why practice doesn't always make perfect and how to recognise error-provoking conditions. The relationship between stress, physiological needs, and performance. Strategies for leading high-performing teams, including ad hoc teams under pressure. How to create an environment of psychological safety for your team. Register

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

Phil Ross is the Chair of the Design in Mental Health Network, Co-Founder of Safehinge Primera, and a Trustee at the Centre for Mental Health (UK). In this blog, Phil describes a collaborative Quality Improvement project that aimed to ensure a door alarm system acted as a trusted safety aid, not a constant distraction. When it comes to service user safety in mental health settings, every second counts. That’s why Aspen Wood, Mersey Care NHS Foundation Trust’s new 40-bed low secure unit for people with learning disabilities, installed 67 full-door ligature alarm systems. The system that invisibly transforms the entire door into a weighing scale, detecting any sustained load and triggering an alert for staff to proactively intervene and save a life. However, frontline NHS teams using full-door ligature alarms and other full-edge systems shared a challenge: frequent false alarms. These alarms are disruptive, distracting, and desensitising. For staff already stretched, these alerts became a barrier to the calm, therapeutic environments we’re all working to create. Not one to shy away, we listened. Then we acted and together, co-launched a Quality Improvement (QI) initiative to solve the issue. The cost of constant alarms in mental health wards Imagine being a nurse on a mental health ward where an alarm sounds 10-20 times every day. Each alarm demands immediate attention – a possible ligature attempt – yet almost every time it turns out to be a false alert. Front-line caregivers were understandably anxious that alarm fatigue – the desensitisation to alarms due to overexposure – could undermine patient safety. The false alarms were also distracting staff from providing care. Alarm fatigue is not a trivial inconvenience; it’s a well-documented clinical risk. In healthcare settings, when clinicians face an overload of alarms, they can become desensitised, leading to slower responses or ignored alerts.[1] In the context of mental health, the stakes are especially high – an ignored alarm could mean a patient death by suicide. Recent findings in the UK have highlighted this danger: an NIHR review noted that “‘alarm fatigue’ associated with surveillance technology use can even have fatal consequences”.[2] Tragically, this was echoed by a real-world incident in Essex, where an 18-year-old patient was found unresponsive after staff failed to respond for over 52 minutes to a bathroom sensor alert. The inquest revealed that staff had grown so accustomed to frequent alerts on their digital monitoring system that “alert fatigue” had set in.[3] Aspen Wood’s alarm challenge: 600+ alerts and a team determined to help At Aspen Wood, the alarm overload soon after installation quickly became recognised as an urgent patient safety and operational issue. The Trust’s leadership moved swiftly, bringing us in to discuss the issue and creating a cross-functional working group to explore ways to resolve it. Around the table were clinicians from the wards, Estates managers, the Trust’s risk and patient safety leads, our team of experts from Safehinge Primera, who developed the full-door anti-ligature alarm, and Pinpoint, who provide the staff attack alarm system that relays door alerts to staff devices. This collective approached the problem to try and understand the issue in greater detail and explore ways to solve it. Everyone agreed on a critical point: expecting zero alarms wasn’t realistic, but we should aim to get as low as possible (there will always be some incidents or tests). The team set an initial target: roughly one ligature alarm per day across Aspen Wood – ambitious yet attainable with the right improvements. Collaborative problem-solving Several concrete solutions emerged from the discussions and subsequent development work: ● Adjusted sensitivity threshold: When the QI team discussed weight sensitivity, the Trust’s Risk team highlighted that the door alarm was much more sensitive than other safety devices within the room - the load release curtain tracks released around 20 kg. Our full door alarm was set to a 7 kg weight threshold, unnecessarily sensitive. Here, the adjustable weight threshold became a big advantage for the Trust, changing to 15 kg for this user group (with the benefit of keeping lighter weight sensitivity when used for people with eating disorders). This change sharply cut false positives without compromising safety (indeed, the team carried out a series of lab tests based on a range of different previous ligature attempts). ● Firmware enhancements and battery life: Our team also rolled out a new approach to greatly improve battery life. The new firmware also introduced smarter data logging – essentially enabling the system to be more intelligent about what triggered it, so that staff could get feedback if improper use of the door was causing alarms (like wedging the door open or hanging objects). These behind-the-scenes tweaks enhanced the system’s robustness and reduced nuisance triggers by providing helpful feedback for staff. ● Localised and silent alerting: Initially, a door ligature alarm at Aspen Wood would broadcast an alert across the entire hospital network via the staff attack alarm system. This meant a single bathroom incident could set off alerts on multiple wards, needlessly alarming staff beyond the affected area. The system was reconfigured so that door ligature alarms now alert only the local ward. This change empowers the ward staff to quickly verify and respond, and, if it is a serious incident, staff can still escalate using their Personal Infrared Transmitter (PIT) alarm. The result is fewer interruptions hospital-wide and a more scalable response protocol. The Mersey Care team had always opted for silent alarms to prevent disrupting service users with learning disabilities, an approach we’re seeing adopted nationally across all care pathways. ● Staff training refreshers: We worked with the Trust to co-create simplified support materials to ensure staff felt confident managing the alarm system. A quick-reference poster was designed (with input from Aspen Wood’s clinical team) to support new or bank staff on how to swiftly reset a door alarm after an incident. Training sessions were scheduled, including hands-on practice using our mobile training unit. This conscientious approach acknowledged that technology is only as effective as the people using it. ● Stronger interface and support: Both Safehinge Primera and Pinpoint also recognised that closer integration and joint support when complex technical issues arise would help Mersey Care’s Estates team resolve issues quickly and easily. We also worked together to create a joint troubleshooting guide for the Aspen Wood team, so any issues could be quickly pinpointed (no pun intended) and resolved. By improving the interface between the two systems and clarifying responsibility, the Trust gained confidence that “issues” would no longer fall into a void between different suppliers, but instead, a collaborative team of experts. Results: from 600 alarms to just 6 – a transformative difference The results were even better than we’d hoped for…not 30 alarms per month, but just 6 alarms. When the stakeholders reconvened at the end of April 2025, our door alarm dashboard evidenced that alarm rates had plummeted. This has restored the alarm system to its intended role: a trusted safety aid, not a constant distraction. Reliability through the system's continual monitoring (avoiding the costly daily check requirements from push-bar, door edge type alarm systems) and adjustable weight sensitivity meant the alarms were keeping staff focused on time to care, whilst ensuring service user safety too. “The current pressure on frontline teams is huge, so when the built environment adds noise instead of support, it’s a problem that Estates are asked to resolve quickly. What made this initiative work was the openness on all sides. Together, we made the Safehinge Primera full-door ligature system smarter and safer for everyone, and something that we hope will help other NHS Trusts across the country.” Chris Murphy, Assistant Director of Estates and Facilities, Mersey Care NHS Foundation Trust A model for best practice: hopeful lessons beyond Aspen Wood The journey at Aspen Wood carries hopeful lessons for mental health facilities everywhere. Alarm fatigue in an inpatient mental health setting is not an insurmountable fate; it’s a challenge that can be overcome through empathetic, curious, and determined collaboration. Mersey Care didn’t shy away from flagging the problem, and in partnership with suppliers, they created the space to carry out an analysis and co-create solutions. The outcome made our alarm smarter, more user-friendly, and tailored to the ward’s needs. In doing so, they upheld a core principle of patient safety: technology must augment, not hinder, the human care process. This story also underlines a broader point in NHS mental health services: collaboration and continuous improvement are key. Just as we strive to co-produce care with service users, here we see collaboration between clinicians, engineers, and estates teams. The result – a dramatic reduction in alarms and a safer, calmer ward – speaks to the power of being conscientious (putting service user and staff needs first) and determined (not giving up on a good idea, even when it hits bumps in the road). By staying curious (asking “Why is this happening? How can we fix it?”) and maintaining a positive mindset that a solution would be found, the Aspen Wood team exemplified the best of NHS innovation culture. Looking ahead, Mersey Care’s Aspen Wood can serve as a model of best practice that we’re actively rolling out with other mental health Trusts. References 1. HSSIB. Investigation report: The impact of staff fatigue on patient safety. 2025. (Accessed online 11.02.26). 2. Griffiths JL, Saunders KRK, Foye U et al. The use and impact of surveillance-based technology initiatives in inpatient and acute mental health settings: a systematic review (preprint). 2024. (Accessed online 11.02.26). 3. BBC News. Essex mental health patient died despite staff alarm – inquest. (Accessed online 11.02.26) Further reading Reiter-Millard B. Tackling Alarm Fatigue. Safehinge Primera. 2025. (Accessed online 11.02.26) Opinions expressed in blogs and other content are those of the author. Patient Safety Learning welcomes sharing content and opinions that promotes safer patient care and for the reduction of avoidable harm. The views expressed on the hub however do not necessarily represent Patient Safety Learning's views or values. References to a specific product or service does not imply a recommendation or endorsement.

What does it mean to take a “human factors” approach to healthcare improvement? In this SafetyNet Patient Safety 101 session, we will consider what constitutes human factors (a.k.a. “ergonomics”), key concepts and methods within this field, and how they are typically applied to healthcare. The session will include interactive exercises, demonstration of human factors/ergonomics methods and an overview of resources for further study and application. SafetyNet Patient Safety 101 sessions are intended for researchers who may not be experienced in patient safety and would like to know the basics on a range of Patient Safety topics or those who would like a refresher. Register

Human factors science helps leaders understand the powerful connections among people, processes, and technology. IHI has partnered with MedStar Health, experts in Human Factors, to deliver this virtual interactive course. You’ll learn how to identify system vulnerabilities, apply human factors tools to real-world challenges, and co-design solutions that reduce harm, improve efficiency, and enhance the care experience—while practicing these concepts on a problem of your own. Register