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Content Article
As part of my quality improvement study at university, I developed and introduced an oxygen reference card that was shown to improve newly qualified clinical staffs' knowledge and confidence when using an oxygen cylinder. The project's literature review captured that clinical staff may not have the memory recall to support them in clinical practice and, therefore, a lack of embedded knowledge, which could compromise care. It is paramount that users of oxygen cylinders have the knowledge to understand how to use a cylinder safely and to understand how to assess the remedial gas in the cylinder to support oxygen administration. The study found that there is minimal training accessed to support staffs' knowledge and skill foundations for using cylinders. The outcome of the study recommended that there needs to be better support for clinical staff to use cylinders within their pre/post training to be able to using the device correctly. Introducing a oxygen reference card that they could keep on them whilst at work is a useful tool to support decision-making when using the cylinder. You can download the card from the attachment below. Both NAMDET – National Association of Medical Device Educators and Trainers and Northumbria Healthcare Facilities Management - NHS FOUNDATION supported the QI project.- Posted
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News Article
Blood cancer patients in England first in world to be offered ‘Trojan horse’ drug
Patient Safety Learning posted a news article in News
Thousands of patients in England with blood cancer will become the first in the world to be offered a pioneering “Trojan horse” drug that sneaks inside cancer cells and wipes them out. In guidance published on Friday, the National Institute for Health and Care Excellence (Nice) gave the green light to belantamab mafodotin, which can halt the advance of multiple myeloma for three times as long as standard treatments. The targeted therapy, which is given as an infusion every three weeks with other cancer drugs, is a special type of antibody drug that targets and attaches to cancer cells. It has been described as a Trojan horse treatment because it works by being taken into a cancer cell and unleashing a high concentration of a lethal molecule to destroy the cell from inside. Prof Peter Johnson, NHS England’s national clinical director for cancer, said the drug would be life-changing for patients and their families. “Myeloma is an aggressive type of blood cancer, but we have seen a steady improvement in the outlook for patients over recent years as we have introduced new targeted therapies,” he said. “I am delighted that patients in England will be the first to benefit from this new treatment, which has the potential to keep cancer at bay for years longer, giving people the chance of more precious time with friends and family.” Read full story Source: The Guardian, 13 June 2025- Posted
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When the Covid-19 pandemic arrived in the UK in March 2020, Professor Paul Elkington and a team at University Hospital Southampton NHS Foundation Trust (UHS) quickly developed a new form of respiratory protective equipment (RPE) called PeRSo (Personal Respirator Southampton) for hospital staff to use. PeRSo is a portable, wearable device which blows air through a HEPA filter into a hood, providing a high level of protection against respiratory infection. In this interview, Paul describes how, working with industry partners, his team was able to provide 3,500 members of staff at UHS with PeRSo during the pandemic. Describing the impact this had on staff morale and Covid infection rates, he explains why PeRSo is a preferable alternative to the FFP3 masks recommended by the Government during the pandemic. Paul outlines how, in the event of another pandemic, providing personal respirators would offer effective protection for healthcare workers and the wider population at relatively low cost. He also outlines what the Government needs to do to ensure the UK is prepared for future pandemics, including making changes to the regulatory framework and incentivising the development of personal respirators designed specifically for infection control. Further reading on the hub: A personal respirator to improve protection for healthcare workers treating Covid-19 (PeRSo) Powered respirators are effective, sustainable and cost-effective Personal Protective Equipment for SARS-CoV-2 Respiratory protective equipment: An unequal solution for healthcare workers? A blog by David Osborn "Forgotten heroes" – the sequel: a blog and resources from David Osborn -
News Article
Millions more to have robotic surgery in NHS plan to cut waiting lists
Patient Safety Learning posted a news article in News
Millions more people will have robotic surgery over the next decade under NHS plans to slash the huge waiting list for hospital treatment. The move will mean a significant expansion in how often surgeons use robots when treating people for cancer, hysterectomies and joint replacements, as well as in medical emergencies. The number of patients undergoing robot-assisted surgery is due to rise from 70,000 to 500,000 a year by 2035, the head of the NHS in England will announce on Wednesday. “The NHS has pledged to return to shorter elective waiting times by 2029 and we are using every tool at our disposal to ensure patients get the best possible treatment. “Expanding the use of new and exciting tech such as robotic surgery will play a huge part in this,” said Sir Jim Mackey, NHS England’s chief executive. “Not only does it speed up the number of procedures the NHS can do, but it also means better outcomes, a faster recovery and shorter hospital stays for patients.” By 2035, nine out of 10 keyhole surgery operations, in which the surgeon makes only small incisions into the patient’s body, will involve a robot, up from just one in five today. It will have become so common by then that it will be “the default” for many procedures, Mackey will say. Evidence shows that a robot, either controlled remotely by a surgeon at a console using a 3D camera or when it has been pre-programmed, can be more precise than when a surgeon undertakes the same task and often helps the patient to recover faster and get home from hospital sooner. When surgeons control the robot, they guide the surgical instruments – which in keyhole surgery can be as tiny as 5mm – to undertake the work needed. Read full story Source: The Guardian, 11 June 2025- Posted
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Diabetes UK has launched their new ‘10 Year Vision: For diabetes prevention, care and treatment’, setting out a clear plan for the UK government about how it can improve health outcomes and tackle inequality for people living with diabetes by 2035. The UK government will publish its 10 Year Health Plan in June, which will set out how the health service can make a shift from sickness to preventing ill health. If the government is to succeed with this aim, diabetes must be at the heart of its plans. The ‘10 Year Vision’ gives the government a clear plan for how it can improve health outcomes and tackle inequalities for people living with diabetes, and how this can be achieved by 2035. This vision involves: Stemming the rise in type 2 diabetes – improving our food environment and delivering high-quality support to help people reduce their risk of type 2 diabetes. Ensuring early and accurate diagnosis - which is key to setting people up to manage their diabetes and, in turn, preventing serious complications. Transforming diabetes care and treatment – to help people with diabetes live well. Most diabetes complications can be prevented with simple interventions like annual checks, access to the right treatments and technology, and a focus on reducing health inequalities. Accelerating innovation – Investing in diabetes research and ensuring new treatments and technologies are available to people with diabetes quickly. -
News Article
‘Revolutionary’ DNA blood test to offer thousands in England tailored cancer care
Mark Hughes posted a news article in News
Thousands of cancer patients in England are to benefit from a DNA blood test that saves lives by fast-tracking them on to personalised treatments. In a world-first, the NHS will offer patients with lung and breast cancer – two of the most common forms of the disease – a liquid biopsy that detects tiny fragments of tumour DNA. Rapid results from the groundbreaking test mean patients can immediately be offered drugs and treatments specifically tailored to the genetic profile of their disease, significantly increasing their survival chances and paving the way for a new era of precision medicine. Read full article Source: The Guardian, 29 May 2025 -
News Article
Medical errors are still harming patients. AI could help change that
Patient Safety Learning posted a news article in News
Despite ongoing efforts to improve patient safety, it’s estimated that at least 1 in 20 patients still experience medical mistakes in the health care system. One of the most common categories of mistakes is medication errors, where for one reason or another, a patient is given either the wrong dose of a drug or the wrong drug altogether. In the US, these errors injure approximately 1.3 million people a year and result in one death each day, according to the World Health Organization. In response, many hospitals have introduced guardrails, ranging from colour coding schemes that make it easier to differentiate between similarly named drugs, to barcode scanners that verify that the correct medicine has been given to the correct patient. Despite these attempts, medication mistakes still occur with alarming regularity. Dr Kelly Michaelsen, an assistant professor of anaesthesiology and pain medicine at the University of Washington wondered whether emerging technologies could help. As both a medical professional and a trained engineer, it struck her that spotting an error about to be made, and alerting the anaesthesiologists in real time, should be within the capabilities of AI. “I was like, ‘This seems like something that shouldn’t be too hard for AI to do,’” she said. “Ninety-nine percent of the medications we use are these same 10-20 drugs, and so my idea was that we could train an AI to recognize them and act as a second set of eyes.” Michaelsen focused on vial swap errors, which account for around 20% of all medication mistakes. All injectable drugs come in labelled vials, which are then transferred to a labelled syringe on a medication cart in the operating room. But in some cases, someone selects the wrong vial, or the syringe is labelled incorrectly, and the patient is injected with the wrong drug. Michaelsen thought such tragedies could be prevented through “smart eyewear” — adding an AI-powered wearable camera to the protective eyeglasses worn by all staff during operations. Working with her colleagues in the University of Washington computer science department, she designed a system that can scan the immediate environment for syringe and vial labels, read them and detect whether they match up. In a study published late last year, Michaelsen reported that the device detected vial swap errors with 99.6% accuracy. All that’s left is to decide the best way for warning messages to be relayed and it could be ready for real-world use, pending Food and Drug Administration clearance. Read full story Source: NBC News, 25 May 2025- Posted
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Leadership Futures recently published a report 'Harnessing technology for human progress: Advancing into Industry 5.0', which is driven by a bold ambition: to transform organisations worldwide through technological advancements. In this blog, Caroline Beardall looks at the implications of this for healthcare and suggests five actions that organisation's should take to ensure we achieve the benefits from technology while keeping patient safety at the forefront of an evolving landscape. The recent Leadership Futures report 'Harnessing technology for human progress: Advancing into Industry 5.0' provides a valuable framework for integrating technology with human-centered leadership, which is highly applicable to advancing patient safety in health and care. Its vision of Industry 5.0 as a collaborative human-AI partnership offers a route to reduce errors, enhance clinician capacity and improve patient outcomes. However, realising these benefits requires caution—ethical and inclusive implementation strategies that address the complexities and risks unique to health and care settings. It throws up three fundamental challenges: How can healthcare leaders ensure AI tools are safe to use and that clinical staff can trust them? Who should be responsible if an AI system makes a mistake that affects a patient? How can healthcare organisations use technology to work better without losing the importance of human interaction and the skills needed for high levels of patient satisfaction and safety? In order to answer these questions, and deepen the discussion on harnessing technology responsibly to safeguard and improve patient care, there are some actions we can take to build on the report and begin to gain evidence and experience specific to healthcare. As the landscape of healthcare shifts and evolves, we should consider applying the following five actions (with examples of how to do this) so we can achieve the maximum benefits from technology for patient safety. 1. Foster collective, collaborative leadership across boundaries Leaders should actively promote cooperation and shared responsibility across organisational and professional boundaries, focusing on the overall patient journey rather than siloed departmental goals. This aligns with the report’s emphasis on human-machine collaboration and the need for integrative leadership cultures that support safe, seamless care delivery. By working collectively, leaders can ensure technology is implemented with broad input and oversight, reducing risks and enhancing patient safety. Implement interdisciplinary collaboration practices: Organise regular team meetings involving diverse healthcare professionals to discuss patient care holistically, ensuring all voices contribute to decision making. Create shared goals and aligned metrics: Develop common objectives focused on patient safety and quality that unify departments and reduce siloed working. Lead by example: Demonstrate collaborative behaviours and openness to input, encouraging a culture of trust and teamwork. 2. Embed ethical, human-centred use of technology Leaders must champion ethical principles in technology adoption, ensuring AI and digital tools augment rather than replace human judgment and empathy. This includes rigorous validation of new technologies, transparency in AI decision-making, and ongoing monitoring to prevent harm or bias. Prioritising patient experience and human values in technology deployment safeguards safety and trust. Prioritise transparency and clinician involvement: Engage frontline staff early in AI and technology design and deployment to ensure tools meet clinical needs and ethical standards. Establish continuous monitoring and feedback loops: Use data and user feedback to identify and mitigate risks or biases in technology that could impact patient safety. Promote ethical leadership training: Equip leaders with skills to balance innovation with patient experience and accountability. 3. Develop and support workforce readiness and engagement Preparing staff to work effectively alongside new technologies is vital. Leaders should invest in training that builds digital literacy, critical thinking and resilience, while also fostering a positive work climate where staff feel valued and supported. Engaged and confident clinicians are better able to use technology safely and maintain high standards of care. Invest in targeted training and digital upskilling: Provide contextual, in-app guidance and interactive training to help staff adopt new technologies confidently and efficiently. Foster a culture of psychological safety and empowerment: Encourage open discussion, honest feedback and staff involvement in decision making to build trust and resilience. Practice empathetic leadership: Focus on emotional and professional needs of staff to reduce burnout and improve engagement. 4. Set clear, aligned objectives focused on quality and safety Leadership should establish clear, challenging and aligned goals at every level that prioritise patient safety and quality improvement over mere efficiency or target-driven metrics. This clarity helps reduce staff stress and confusion, enabling teams to focus on delivering compassionate, safe care supported by technology. Communicate clear expectations and priorities: Use consistent, transparent communication to align teams around patient safety goals and reduce ambiguity. Implement continuous feedback and learning systems: Regularly review performance data and patient feedback to refine objectives and improve care quality. Balance efficiency with human factors: Ensure operational goals do not compromise critical human skills or patient-centred care. 5. Champion diversity, inclusion and accountability in leadership Inclusive leadership practices that promote equality and diversity are essential to fostering innovation and ethical decision-making in healthcare technology adoption. Leaders must also clarify accountability frameworks for technology-related decisions and errors, ensuring responsibility is shared and transparent to maintain patient safety. Promote inclusive leadership practices: Value diverse perspectives and foster equity to enhance innovation and ethical decision-making Clarify accountability frameworks: Define roles and responsibilities clearly, especially concerning technology-related decisions and errors, to maintain trust and safety Model human-centred leadership traits: Practice self-awareness, compassion and mindfulness to create cultures of excellence, trust, and caring. By integrating these strategies, human-centric leaders can effectively translate the insights from the Leadership Futures report into practical actions that improve patient safety, staff satisfaction and overall health system resilience. This approach embraces complexity and change as opportunities, not obstacles, which then enables sustainable progress in better health and care delivery. Further reading Amelia N. 6 Effective Leadership Strategies for Healthcare in 2025. Edstellar, 31 December 2024. West M, et al. Leadership in Healthcare: a Summary of the Evidence Base. Kings Fund; Faculty of Medical Leadership and Management; Center for Creative Leadership, 2015. LeClerc L, Kennedy K, Campis S. Human-Centered Leadership in Health Care: An Idea That's Time Has Come. Nursing Administration Quarterly 2020; 44(2):p 117-26.- Posted
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News Article
A groundbreaking artificial intelligence (AI) model is being trained using NHS data from 57 million people in England in the hope it could predict disease and complications before they occur. The world-first study, spearheaded by researchers at University College London (UCL) and King’s College London (KCL), has the potential to “unlock a healthcare revolution”, officials said. The AI, known as Foresight, uses technology similar to that of ChatGPT, however, instead of predicting text, Foresight analyses a patient's medical history to forecast potential future health issues. As part of the pilot, it will be trained using eight routinely collected datasets, including hospital admissions, A&E attendances and Covid-19 vaccination rates, which have been stripped of personal information. “Foresight is a really exciting step towards being able to predict disease and complications before they happen, giving us a window to intervene and enabling a shift towards more preventative healthcare at scale,” Dr Chris Tomlinson of UCL said. Read full story Source: The Independent, 7 May 2025- Posted
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NHSE could impose new cancer system on struggling trusts
Patient Safety Learning posted a news article in News
Trusts failing to meet cancer standards may be encouraged to use a new tool on the federated data platform, HSJ understands. NHS England today announced the launch of the Cancer 360 tool on the FDP, which it says will help clinicians to “identify and address delays immediately” in cancer treatment pathways. In a media briefing attended by HSJ, NHSE said no trust would be “forced” to take up the tool. It said there would be “no questions asked” if another system was already in place and the organisation was meeting performance targets, such as the faster diagnosis or 62-day referral-to-treatment standards. However, there “would be a conversation” about the need to use Cancer 360 if a trust had another system in place and was not meeting standards, officials confirmed. Read full story (paywalled) Source: HSJ, 4 May 2025- Posted
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Robotics approved for use in NHS surgeries across England
Patient Safety Learning posted a news article in News
State-of-the-art robotic systems approved for use on the NHS could transform treatment for thousands of people across England. The technology, given the green light by the National Institute for Health and Care Excellence (NICE) under its early value assessment programme, offers a range of applications, from helping remove tumours to replacing a patient’s knee. The rollout is expected to reduce hospital stays, faster recovery times, and a lower risk of complications. A total of 11 systems have been approved, including five for soft tissue surgeries, such as removing tumours, repairing hernias and removing gallbladders and six for orthopaedics, including knee and hip replacements. Some allow surgeons to perform operations using mechanical arms controlled from a console, while others are hand-held. Dr Anastasia Chalkidou, programme director of NICE’s HealthTech programme, said: “These innovative technologies have the potential to transform both soft tissue and orthopaedic surgical care in the NHS. “Robot-assisted surgery may help overcome key limitations of conventional techniques through precise movements and enhanced 3D visualisation, potentially transforming surgical options and outcomes for NHS patients. “Both applications could benefit patients who might not otherwise be candidates for minimally invasive approaches.” Read full story Source: The Independent, 17 April 2025- Posted
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New device gives female patients more dignity
Patient Safety Learning posted a news article in News
It is hoped a device adapted to allow immobile female hospital patients to go to the toilet more easily could be rolled out nationwide. Great Western Hospitals NHS Foundation Trust, Swindon, has called its move to bring in the UniWee a "groundbreaking project" which has now got the support of the NHS supply chain. Staff at the emergency department there started adapting the disposable male urinal bottle for women to use, lessening the need for catheters and making life more dignified and pain-free in hospital. The design has now been formalised and researched, with plans in place for it to be used more widely in the future. Many women who are forced to sit or lie down for long periods in hospital struggle to urinate without pain and movement. Emergency department and trauma and orthopaedic staff at the Great Western Hospital started using the adapted bottle, collaborating with staff from NHS Trusts across the South West. Research was done into how effective they were, with results published in the British Medical Journal's Emergency Medicine Journal, external. Now the manufacturer of the male bottles, OmniPac, has developed formal prototypes and is preparing to increase production. Read full story Source: BBC News, 6 April 2025 -
Event
Innovation in Women's Health
Patient Safety Learning posted an event in Community Calendar
The rapid development of technology and innovation in women’s health, from fertility and maternal care to menopause, presents immense opportunities for improving patient outcomes. However, challenges persist in ensuring patient safety, demonstrating clinical utility, and driving adoption within health systems. Additionally, barriers to equitable access and persistent health inequalities continue to limit impact. This panel will explore best practices in women’s health innovation, drawing on international perspectives to identify where progress is being made and what lessons can be applied globally. How can we accelerate safe, effective, and equitable adoption of new technologies to transform women’s health at scale? Confirmed speakers include: Professor Henrietta Hughes - Patient Safety Commissioner for England Professor Naveena Yanamala - Associate Professor of Medicine and Chief of Clinical Research & AI Innovation, Rutgers Robert Wood Johnson Medical School Mary Akangbe - CEO and Founder, Zenith Global Health Dr Farah Al-Saif - Public Health Expert, Ministry of Health, Saudi Arabia Karina Vazirova, CEO and C0-Founder of the FemTech Lab Register -
Content Article
The need for fast-paced innovation in healthcare is widely acknowledged. And ensuring that healthcare innovation is shaped by the people it serves remains a pressing priority – one made all the more evident by the growing emphasis on health equity in the 10 Year Health Plan. Patient voices are often cited as central to healthcare innovation, yet in practice, those voices can be overlooked or engaged too late in the process. On 26 February, the Health Innovation Network invited patient representatives to join them at HETT North in Manchester. They visited innovators exhibiting with the Health Innovation Network, and were encouraged to share experiences and reflections on Patient and Public Involvement and Engagement, common challenges and best practices. In partnership with The Patients Association, a roundtable discussion was convened to explore how Patient and Public Involvement and Engagement can deliver more inclusive, sustainable healthcare innovation. What emerged from the roundtable discussion is a comprehensive set of recommendations that outline how sustained, well-structured patient engagement can enable more equitable, impactful and inclusive healthcare innovations. Forging a more equitable future through Patient and Public Involvement and Engagement sets out these recommendations, exploring how patient voices can be embedded in the development of digital technology, the need to move beyond conventional pathways, and how to build trust through local communities. A consistent theme was the emphasis on meeting people where they are. Addressing health inequalities requires acknowledging how social, economic, and cultural contexts shape individuals’ access to—and perceptions of—care. Explore the full report to discover real-world case studies, expert insights and actionable recommendations that can shape the future of patient involvement in healthcare innovation.- Posted
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The provision of high-quality personal protective equipment (PPE) was a critical challenge during the Covid-19 pandemic. This study evaluated an alternative strategy—the mass deployment of a powered air-purifying respirator (PeRSo), in a large university hospital.- Posted
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News Article
Global first as NHS hospital uses AI for instant skin cancer checks
Patient Safety Learning posted a news article in News
An NHS hospital is pioneering the use of artificial intelligence to diagnose skin cancer, enabling patients to get lifesaving checks for the disease without seeing a doctor. In a global first marking a “new era” of cancer care, staff at Chelsea and Westminster Hospital are now using an iPhone with a magnifying lens to take photos of any suspicious-looking moles, with the image analysed in seconds by an AI app. Nearly half of patients get the all clear and are automatically discharged with no further appointments, while those with cancer or who need further investigation are booked in to see a specialist doctor and begin treatment. Thousands of NHS patients have had urgent cancer checks using the AI tool, freeing up doctors to focus on the most serious cases and helping to bring down waiting lists. The system conducts the checks in five minutes, compared with around 20 minutes required for face-to-face examinations with a consultant dermatologist. Trials show the device called Derm, developed by UK firm Skin Analytics, is 99.9 per cent accurate at ruling out melanoma — the most serious type of skin cancer. It is the first AI technology in the world to be approved to make clinical decisions on cancer treatment autonomously, without requiring a doctor to double-check its findings. Read full story (paywalled) Source: The Times, 21 March 2025 -
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NHS robots and scanners ‘must be used more intensively’
Patient Safety Learning posted a news article in News
Expensive scanners and surgical robots are underused and “lying fallow” at NHS hospitals, a report has said. Analysis shows a tenfold difference in how often NHS trusts use surgical robots — cutting-edge machines used for minimally invasive surgery that cost about £1.5 million each. There are also huge regional variations in the use of CT and MRI scanners, which help to diagnose illnesses including cancer and cost about £1 million each. Experts urged the NHS to ensure that each machine was used to the utmost to boost productivity and tackle hospital waiting lists of 7.4 million people. The report also warned that hospitals are failing to make full use of surgical robots, which can blitz through waiting lists by speeding up recovery times. In 2022 Buckinghamshire Healthcare Trust used its surgical robot less than once a week while other NHS hospitals used theirs nine times a week. Jonathan Eida, a researcher at the TPA, said: “Our analysis of high-value machines in the NHS further adds to the body of evidence that the health service is not in a healthy state. “It is absolutely absurd for such expensive equipment to lie fallow, particularly given the swollen waiting lists. If Labour wants to deliver the efficient and productive health service that taxpayers are paying for, maximising the use of these machines has to be a priority.” Read full story (paywalled) Source: The Times, 16 March 2025- Posted
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Top picks for Healthcare Science Week
Patient Safety Learning posted an article in Patient Safety Learning
Healthcare Science Week, 10–16 March 2025, brings together over 50 scientific specialisms and professional groups to celebrate and raise awareness of this diverse NHS workforce. These experts play a crucial role in diagnosing diseases, developing treatments and ensuring the effectiveness of medical technologies. Their work is essential for patient care. To celebrate Healthcare Science Week, Patient Safety Learning has pulled together 13 blogs and interviews published on the hub showcasing the important work healthcare professionals, scientists and researchers are doing to improve patient safety. 1. Decoding diabetes research – an innovative approach that makes scientific knowledge accessible to everyone D-Coded is an online resource that presents easy-to-understand summaries of diabetes research studies. It aims to make the latest knowledge and developments accessible to people who don't have a medical or scientific background. In this blog, Jazz Sethi, Founder and Director of the Diabesties Foundation and part of the global team that developed D-Coded, discusses the need for the resource and outlines how it will help people living with diabetes to better understand and manage their condition. 2. WireSafe®: Designing a new patient safety solution WireSafe® is an innovative solution designed to prevent retained guidewires during central venous catheter (CVC) insertion. Retained guidewires are never events that require urgent removal if accidentally left in. They occur in about 1 in 300,000 procedures. We interviewed Maryanne, who developed the WireSafe®, on the innovation, the human factor considerations in designing it and the difficulties she faced getting a new product into the NHS. 3. Using barcode scanning technology to improve blood group testing in unborn babies In this blog, the NHS Blood and Transfusion (NHSBT) and the Scan4Safety Team in the NHS England National Patient Safety Team explore how barcode scanning technology has improved testing for the D blood group in unborn babies. This technology has made the process more efficient, reduced errors and improved patient experience. 4. Patient Safety Spotlight interview with Chidiebere Ibe, medical illustrator and medical student Chidiebere Ibe is passionate about increasing representation of Black people in all forms of medical literature. In this interview, he explains how lack of representation at all levels of the healthcare system leads to disparities in healthcare experiences and outcomes. He outlines the importance of speaking openly about how racial bias affects patient safety, and argues that dispelling damaging myths about particular patient groups starts with equipping people with accurate health knowledge from a young age. 5. Applying a robust approach to digital clinical safety in diagnosis Diagnostics and digital go hand in hand. Digital healthcare has brought so many advancements in diagnostics and we are at the point of another paradigm shift with the advancements in artificial intelligence (AI), with some early and convincing diagnostic-use cases. New things also bring (new) risks. Some we can predict and plan for, perhaps some we haven’t, and some we can’t yet. In this blog, Ben Jeeves, Associate Chief Clinical Information Officer and Clinical Safety Officer, looks at the digital clinical safety aspects in relation to diagnostic safety. 6. Lost tissue samples a thing of the past with new innovative tracking system? The stress and anxiety felt by patients awaiting a potential cancer diagnosis can be made much worse if they are told their sample has been lost. Delays can impact treatment options and patient outcomes. Dil Rathore is a Biomedical Scientist and Pathology Innovation Lead at Leeds Teaching Hospitals NHS Trust. In this interview, he tells us about a new tracking system he’s developed to reduce the number of patient tissue samples going missing. 7. Medical device safety: effective testing is key In this blog, University of Sheffield based researcher Dr Nicholas Farr explains why investing in the development of testing methods is key to ensuring medical devices are safe to use. Nicholas and colleagues at the University of Sheffield have developed innovative testing methods that mimic key features of the human body within the lab. He believes this will improve our understanding of the materials being used in the development of medical devices at an early stage in the process – saving time and money, and reducing the risk of patient harm. 8. “Our message about public involvement is don’t be afraid to start.” Interview with Barbara Molony-Oates from the NHS Health Research Authority In this interview, we speak to Barbara Molony-Oates, public involvement manager at the Health Research Authority about why it's important to involve patients and members of the public in health research. Barbara tells us about the Shared Commitment to Public Involvement, a partnership of research organisations working together to promote, support and improve public involvement in health and social care research. She describes how the Shared Commitment was developed and how it is helping researchers involve individuals and communities who have never before considered taking part in research. 9. Coil procedures: Exploring negative experiences through qualitative research Trainee Clinical Psychologist, Sabrina Pilav tells us about her latest research project exploring negative experiences of coil/ intrauterine device (IUD) procedures. Sabrina explains how their in-depth qualitative methodology could contribute to improvements in the future. 10. Patient Safety Spotlight interview with Mark Sujan, Chartered Ergonomist and Human Factors Specialist Mark talks to us about how he came to work in healthcare, the vital role of safety scientists and human factors specialists in improving patient safety, and the challenges involved in integrating new technologies into the health system. 11. Improving diagnostic safety in surgery: A blog by Anna Paisley Safe diagnosis requires the gathering of information from multiple sources, including clinical history, examination, and laboratory and radiological tests. This information must then be distilled and interpreted to form a working diagnosis for treatment or further investigation. In this blog, Anna Paisley, a Consultant Upper GI Surgeon, talks about the challenges to safe surgical diagnosis and shares some of the strategies available to mitigate these challenges and aid safer, more timely diagnosis. 12. CardMedic: Empowering staff and patients to communicate across any barrier In this interview, anaesthetist Rachael Grimaldi tells us about CardMedic, the organisation she founded to empower staff and patients to communicate across any barrier. Rachael explains how their tools can be used to support vulnerable groups and reduce inequalities. 13. Implementation of bedside electronic transfusion checks at Barts Health Trust: Quantifying benefits In this blog, Laura Green, Consultant Haematologist at NHS Blood and Transplant and Barts Health NHS Trust, describes how a new electronic process to improve the safety of blood transfusions was implemented across all four Barts Health sites. She explains why the new system was needed, outlines the benefits for staff and patients and highlights the role of project governance and staff training in successful implementation. Can we help you with your research? Where the topic is relevant to patient safety, we can work with researchers in a number of ways: To help recruit participants To share links to published papers via the hub and through our social media. To create content (blogs, interviews, videos) that help provide context around findings or research projects. Contact the hub team at [email protected] to discuss further.- Posted
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News Article
Speedy finger-prick tests to diagnose strokes trialled in Cambridgeshire
Patient Safety Learning posted a news article in News
Ambulance crews in Cambridgeshire are piloting the use of finger-prick blood tests to diagnose the deadliest form of stroke, with preliminary data suggesting they may be up to twice as effective as relying on patients’ symptoms alone. The tests, which work on a similar principle to the lateral flow tests (LFTs) used to detect Covid, are designed to rapidly identify whether someone suspected of having a stroke has suffered a large vessel occlusion (LVO), where a blood clot blocks a major artery in the brain. Although LVOs account for about a third of strokes, they are responsible for 95% of disabilities and deaths. However, a patient’s chances of recovery are markedly improved if they undergo a thrombectomy procedure to manually remove the clot within hours of symptom onset. The problem is that there are only 24 hospitals in the UK that can provide thrombectomy treatment, and LVO is difficult to diagnose without a brain scan because many other conditions show similar symptoms. Unless a patient is lucky enough to live near a specialist centre, they will usually be assessed at a general hospital and then transferred. According to national audit data from 2022-23, it takes an average of three hours or more from arriving at a first hospital to arriving at a thrombectomy centre. “Early identification of LVO strokes by ambulance clinicians could offer opportunities for fast-tracking patients to thrombectomy-capable hospitals, avoiding delays to care when taken to other non-specialist hospitals,” said Larissa Prothero, an advanced research paramedic at the East of England ambulance service NHS trust (EEAST), which is involved in the feasibility study. Read full story Source: The Guardian, 9 March 2025 -
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Digital technology offers the opportunity to revolutionise patient care, supporting the NHS to become more efficient, productive, cost-effective, and importantly, safer. This report published Public Policy Projects, in collaboration with Patient Safety Learning, highlights that the NHS will fail to unlock these opportunities without the prioritisation of patient safety. It sets out that although there are examples of successful technology implementation across the NHS, patients continue to be put at risk as efforts to digitalise services are not adequately considering patient safety. Key findings from this report include: A lack of user-centric design and interoperability between digital technologies is limiting scalable digital transformation and putting patients at risk. Digital clinical safety is being developed across the NHS, but a lack of resource and siloed working limits the ability for consistent monitoring of digital systems. A lack of understanding of digital technology and data is often tolerated among NHS leadership and the workforce is not adequately trained and/or supported to utilise digital technology. Opportunities to learn from the NHS patient safety reporting system are limited by a lack of data transparency and capacity for analysis. Digital poverty presents inherent patient safety risks where non-digital routes of access are not maintained, meaning digital transformation risks inadvertently widening inequalities. Commenting on the publication of this report, Patient Safety Learning's Chief Executive Helen Hughes said: “Digital health technologies will be key to delivering the forthcoming Ten Year Health Plan. However, if we are to fully realise the benefits of these changes, patient safety needs to be at the heart of these developments. When designing and implementing new technologies in health and care, we need to take a user-centred approach, with patient safety at its core. As this report highlights, there are some promising examples of where this is already happening. Though as the recommendations set out, greater action is needed with system-wide collaboration, to ensure that the opportunities of new technologies are realised and the risks to patient safety are addressed. Patient safety needs to be at the centre of everything we do.”- Posted
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Surgical airway securement: A standardised approach is needed
Dawn Stott posted an article in Surgery
This blog from Pentland Medical and Dawn Stott Associates highlights the findings from their report ‘Surgical airway securement: A report analysing responses to a survey, focus groups and freedom of information requests’.[2] The aim of the work is to look at patient harm from surgical airway securement in critical care environments and, ultimately, to underscore the importance of continuous learning, a culture of transparency and collaboration across disciplines to sustain improvements in patient safety. Background Securing an airway device is a critical component of patient safety, particularly in situations where airway management is essential to life support, such as during surgery, emergency care or critical illness. The airway device, typically an endotracheal tube or laryngeal mask airway, ensures that a patient’s airway remains open for adequate oxygenation and ventilation. The WHO Guidelines for Safe Surgery states that “Securing the airway of a patient undergoing general anaesthesia is the single most critical event during induction.”[1] As all healthcare professionals working in the anaesthetic environment will know, properly securing the device is paramount as any displacement or dislodgement can lead to life-threatening complications like hypoxia, aspiration or airway obstruction. Ensuring that the airway stays in place for the time needed is an equally important part of this process. Currently, this is often done with the use of off-label materials, such as tape and ties, which can cause facial damage ranging from minor redness to severe tissue damage. This tape can also pose an infection risk, but, perhaps more pertinently, any off-label methods are not fit for purpose. Although they are embedded in healthcare practice and are used world over, tape and ties were never designed to perform airway securement. Consultation on airway device securement Following an inaugural round table discussion meeting led by Dawn Stott Associates, a ‘cross sector’ Short Life Working Group (SLWG) was formed to consult on the way an airway device is currently secured when a patient is undergoing a surgical intervention. The group’s goals were to identify systemic barriers to the standardisation of airway management and to develop guidance to support a more robust and consistent way of securing the airway device. The group’s mission was to: review current policy, guidance and legislation to help interpret and apply them to daily anaesthetic practice to support healthcare facilities and personnel with materials and resources on airway device securement and management to help ensure compliance with policy to establish an environment where standardisation of approach is accepted to make guidance available to support healthcare professionals ensure that the patient is safe. The group also reviewed the broader issues around patient safety and the cultural challenges around change management in securing an airway device with tapes. Current guidance What has been astonishing for the SLWG is that no guidance exists from any recognised bodies in the UK on securing an airway device. The Difficult Airway Society (DAS) is generally regarded as the leading authority on anything airway related, not just in the UK but also internationally. However, while the DAS guidance states that healthcare professionals should secure the airway device, it does not go beyond this to advise on best techniques or materials that should be used. This absence of national guidance has resulted in an inconsistent approach to securing an airway device within UK hospitals, and with it the risk of facial harm, infections and more serious incidents that are entirely preventable. Until now there has not been any solution designed and risk-assessed to secure an airway device in the theatre environment, leaving a vacuum where healthcare professionals worldwide are forced to improvise by developing their own techniques and by using off-label generic materials such as tape and ties. There are also a huge number of varying circumstances encountered involving the use of different airway products and surgical positions that further complicates matters when it comes to a standardised approach to airway device securement. It is the opinion of the SLWG that the report we have produced provides compelling evidence for an urgent review of the existing practices for airway securement and for guidelines to be established, which include the requirement for dedicated medical devices to perform airway device securement. The study We used three approaches to gather information: A survey for healthcare practitioners was developed to explore whether there is a standardised approach to securing an airway device in their hospital. The intention was to use the findings to support ongoing work around safer patient care and better clinical outcomes. Focus groups were held to provide insight into how things are currently being done. Freedom of Information (FOI) requests were sent to NHS Foundation Trusts. The information requested was for the period between the 1 January 2020 to 31 December 2023. The FOI requests were designed to define how patient safety is delineated around securing an airway device and how standardisation can be improved to ensure the reduction of current incidents of failure and infection to patients. What we found The responses from the FOI requests show that a substantial number of trusts have experienced inadequate patient outcomes because of poor airway management (see the tables below). It also highlighted that many trusts do not report these patient safety incidents. This is sometimes due to the normalisation of the process and that the incidents are so ‘small’ it is not felt necessary to report them. Feedback from one Trust suggested that many professionals involved in the management of airway did not want to change their practices. Several Trusts stated that they did not routinely record this type of information and would therefore only be able to fulfil the FOI request if they were paid to do so under Section 12 of the FOI Act, underlining the lack of normal visibility of this data. Total responses to the FOI questions Five hospitals were unable to provide the information in the format requested but responded as follows: Key findings from the survey 23% of the people surveyed were aware of incidents of poor patient care resulting from their airway securement techniques. How people currently secured an airway: - 57% used tapes and ties - 20.16 % used elastoplast or similar - 4.3% used a fit for purpose device (not specified) - 8.7% used a mixture of methods depending on procedure - 9.4% didn’t respond. 56.5% of the respondents were aware of the infection risks associated with using tapes. However, they continued to use this as a method of securing the airway device even though it is an unlicenced and unhygienic way of managing the securement. 95.7% of the respondents were aware that the airway may migrate during the intervention and could cause serious harm to the patient but continued to use the same methods of securement. During the focus groups we asked about communication. The responses below showed that there wasn’t always an open and honest culture within the operating department. Infection Prevention and Control guidance The National Infection Prevention and Control Manual, Chapter one, Standard Infection Control Precautions (SICPs) states that care equipment can be easily contaminated with blood and other bodily fluids and infectious agents.[3] They classify care equipment as either: Single use – equipment which is used once on a single patient then discarded. Must never be reused even on the same patient. Single patient use – equipment which can be reused on the same patient. Reusable invasive equipment – used once then decontaminated e.g. surgical instruments. Reusable non-invasive equipment (often referred to as communal equipment) – reused on more than one patient following decontamination e.g. commode, patient transfer trolley. Multi-patient rolls of tape are, by definition, classified as ‘non-invasive re-usable equipment’, which by reason of the SICPs above, must be decontaminated to adhere to the National Infection Control Standards. As findings from our surveys/focus groups made clear, this is not happening because rolls of tape by their structure cannot be decontaminated. Education Ongoing education is one of the most crucial elements of managing the securement of the patient airway. Many organisations have integrated crisis management training, including human factors education into their anaesthesia and airway management programmes.[4] Simulated learning offers a dynamic and risk-free environment where learners can apply theoretical knowledge to practical scenarios, enhancing understanding and retention. By mimicking real-world situations, it allows individuals to develop critical skills, problem-solving abilities and confidence without the consequences of real-life errors. Encouraging innovation and change There is a continuing desire to make airway management safer. Innovations and new equipment continue to be developed to support safer anaesthetic practices; however, if healthcare professionals were to put forward the suggestions of tapes and ties to the regulatory bodies that manage new innovations, they would not pass the scrutiny and rigor and endure the processes in place to get the product to market. This speaks volumes about the archaic way of securing an airway device – but how do we encourage change within an environment that is entrenched in history and a ‘this is the way we have always done it’ mentality? New regulatory systems and sometimes political unawareness can cause pressures on the industry due to their often single-minded need to cut headline costs. Only recently, the Association for British Healthcare Industries announced that £50k worth of registration projects have been withdrawn due to the costs associated with compliance. This will have a catastrophic impact on much needed healthcare innovation and products that are designed to support patient safety.[5] How collaboration can make things happen This project has highlighted the importance of a team approach when trying to develop a standardised approach to different parts of the critical care environment. Another issue the project group discussed was how standardisation of certain practices made things much easier. However, it was thought that all approaches for standardisation should be backed up by rationale and be evidence based. Those involved in the discussions felt that training of new members of the team would be much easier if certain ways of working were standardised. Conclusion Effective airway device securement is a critical component of patient safety in clinical settings. Proper securement techniques reduce the risk of unplanned extubation, displacement, infection risks, facial tissue harm and compromising the airway, which can lead to life-threatening complications. Healthcare providers must be well-trained in securing airway devices and remain vigilant in monitoring their stability throughout patient care. Standardised protocols, high-quality materials and evidence-based practices are essential for ensuring the reliability of airway device securement. Regular assessments, interdisciplinary collaboration and the use of checklists further enhance safety by promoting consistency and reducing errors. In their WHA 72.6 Resolution (2019), WHO Health Ministers mandated for the global patient safety action plan 2021-2030 to be implemented.[6] Within the resolution at 5.3 they suggest they will make available guidance on how to create cultures that operate transparently and encourage speaking up.[7] Unfortunately, through the research we have undertaken and discussions we have had with individuals throughout this project, we have witnessed a damaging culture that exists within the healthcare environment. We believe that this is leading to a nation of healthcare professions who feel let down, devalued and unable to speak up and speak out to support better patient results. We did meet and talk to some professionals who worked in an environment of support and nurture, but sadly the majority of individuals felt unheard in a massive environment of ‘noise’. It has become evident that trusts generally only change their practices following an incident which is costing them more than it would have done to use a product that is designed for purpose. Failure to see the impact of such obstinacy on the patient and their wellbeing is a very blinkered approach to improvement and innovation. By prioritising proper securement practices, healthcare teams can improve patient outcomes, prevent adverse events and reinforce a culture of safety in airway management. Ongoing research and innovation in device design and securement techniques will continue to advance this critical aspect of patient care. Despite its contributions, this study is not without limitations and future research is needed with larger and more diverse samples, refining methodology and exploring additional variables. However, the outputs do highlight the issue that the project is championing for change. We are pleased to report that our work has garnered international interest, prompting efforts to replicate the exercise in both the USA and Europe. This global recognition underscores the significance of our findings and highlights the potential for broader applications in enhancing safety standards worldwide. These strategies, combined with continuous education and integration of innovative technologies, demonstrate the potential for significant improvement in patient safety related to airway device management. References World Health Organization. Guidelines for Safe Surgery 2009. Safe Surgery Saves Lives, 2009. Pentland Medical and Dawn Stott Associates. Surgical airway securement: A report analysing responses to a survey, focus groups and freedom of information requests, November 2024. NIPCM. National Infection Prevention and Control Manual, Chapter one; Standard Infection Control Precautions (SICPs). Tankard K, Sharifpour M, Chang MG, Bittner EA. Design and Implementation of Airway Response Teams to Improve Patient Safety. J Clin Med 2022; 11(21): 6336. https://doi.org/10.3390/jcm11216336. Fick M. Insight: Medical device makers drop products as EU law sows chaos. Reuters, 19 December 2022. World Health Organization. WHO Global Patient Safety Action Plan 2021 – 2030. Towards eliminating available harm in healthcare, 3 August 2021. World Health Organization. Consensus statement: Role of policy-makers and health care leaders in implementation of the Global Patient Safety Action Plan 2021–2030, 13 July 2022. You can read the full report of this study here or by scanning the QR code below:- Posted
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New AI initiative to transform urgent and emergency care in North East London
Patient Safety Learning posted a news article in News
NHS North East London in collaboration with Health Navigator and UCLPartners have launched a new, three-year programme, providing preventative care for patients with long-term conditions. This comes at a time when urgent and emergency care services in North East London are facing unprecedented pressure and demand is at an all-time high. Through advanced AI screening technology and targeted, phone-based clinical coaching, patients at high risk of needing unplanned emergency care will be identified and offered personalised support from healthcare professionals trained in delivering preventative care and self-management techniques. The initiative is designed to identify and better support people with long-term conditions, like asthma, by taking a proactive and preventative approach to healthcare delivery. Forecasting models estimate that the programme will save 26,673 unplanned bed days in North East London hospitals across the three years of the programme, with an anticipated reduction of 13,000 A&E attendances annually. Read full story Source: UCL Partners Health Innovation, 12 December 2025- Posted
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The World Health Organization (WHO) started developing the Guidance for conducting a country COVID-19 intra-action review (IAR) in April 2020 when it became clear that the COVID-19 pandemic would be a protracted acute emergency. In conducting an IAR, countries have the opportunity to bring all stakeholders together from different parts of government, the private sector and civil society to collectively reflect on their response, identify best practices, challenges and lessons learned, and recommend both immediate and middle- to long-term actions to continually improve their COVID-19 preparedness and response in real time. This report aims to outline how governments worldwide not only used existing systems and resources, but also developed innovative new solutions and strategies during the pandemic. This report also examines the views of countries on how the COVID-19 IAR was customized to fit their needs, as well as the value of the IAR process to their COVID-19 response and beyond. Important topics of interest that are rarely or inadequately reviewed during an IAR, such as provision for vulnerable and marginalized populations during the COVID-19 pandemic, are also considered.- Posted
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Healthcare policies and initiatives are designed to save lives and enhance well-being, but they can also entrain unintended negative effects, writes Gary Humphreys for the Bulletin World Health Organization.- Posted
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The Advancing Healthcare Awards 2025 are open to healthcare scientists, Clinical Research Practitioners (CRPs) and those working alongside them across the UK. Celebrating the 20th anniversary of this event, these awards are a fantastic opportunity for colleagues to shine a spotlight on some of the fantastic work that they, their teams or their departments have been doing. These awards are more than just accolades; they are a testament to the invaluable contributions that healthcare scientists, allied health professional and those working alongside them make to patient care. By submitting an entry, you are not only celebrating achievements but also helping to raise awareness of the vital role they play in transforming patient care, driving innovation, and shaping the future of health services. The Academy for Healthcare Science are proud to have two awards at the Advancing Healthcare Awards UK 2025. The lightbulb moment: The award for driving forward patient safety What is your lightbulb moment? This award aims to attract entries and nominations from healthcare scientists, clinical research practitioners and life science industry representatives who had a ‘lightbulb moment’, those who can describe how they brought into play innovative approaches to long-standing problems or found unconventional solutions to unexpected challenges, or through registration and regulation, they can show how this enhanced patient safety and how it inspired others? It is open to healthcare scientists, CRPs and LSI representatives working in any setting in the UK. My inspiration: The AHCS award for the most inspiring leader Who is your inspiration? We are inviting you to nominate a healthcare science leader who has been an inspiration to you at any stage of your career. To make a nomination you must be a registrant on a part of the AHCS register, or on one of our directories, or who has successfully been through equivalence, or who is an associate or fellow of the Academy for Health Care Science. We encourage you to reflect on the inspiring stories around you. Do you know someone who has had a “lightbulb moment” that revolutionised the way you work or solved a longstanding problem? Or a leader whose vision and guidance have positively impacted you or your team? Now is the time to share their stories with a wider audience! The entry process is simple. Please head over to the AHAwards website where the awards, entry guidance and entry forms are available. Entries close: Friday 14th February 2025