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Content ArticleDefensiveness is often implicated in systemic organisational failures to explain why early warning signs were ignored and organisational resilience was compromised. But how does an organisation become defensive? The authors of this study propose that defensiveness can arise as a response to contradictory work demands. The research focuses on UK hospital staff tasked with responding to criticism online (herein complaint handlers). It examines these responses to criticism using a mixed methods explanatory sequential design. Six defensive tactics were reliably identified: redirecting patients to other channels, evading issues, psychologising concerns, invalidating concerns as incomplete, closing the feedback episode, and individualising concerns with bespoke workarounds. These defensive tactics were generally associated with less organisational learning and were sometimes viewed as unhelpful. To explain these results, the authors introduce the complaint handler’s bind: staff are tasked with responding to complaints without a viable pathway for organisational learning and an implicit injunction against voicing this dilemma. This demand-control double bind unwittingly gives staff little alternative but to be defensive. Future research, the authors conclude, needs to conceptualise defensiveness as sometimes a symptom rather than a cause of problems in organisational learning.
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Content ArticleThe way in which healthcare organisations are expected to respond after patient safety events in England changed significantly in August 2022 when the new Patient Safety Incident Response Framework (PSIRF) was introduced. What has actually happened is that the new processes built around the use of the Learning Response Tools in general and for After Action Review (AAR) in particular, are very varied. In this article, Judy Walker looks at the the variation in executing AARs and why this risks jeopardising the very essence of the AAR. *This article was first published in The After Action Review Newsletter May 2025 written by Judy Walker Associates Ltd. The way in which healthcare organisations are expected to respond after patient safety events in England changed significantly in August 2022 when the new Patient Safety Incident Response Framework (PSIRF) was introduced. What has actually happened is that the new processes built around the use of the Learning Response Tools in general and for After Action Review in particular, are very varied This is not surprising and is not concerning, as the PSIRF is purposefully designed to empower healthcare providers to implement in the framework in the way that suits their context best. However, I am concerned that the variation is also being manifested in the approach taken within the execution of the AAR itself, which risks jeopardising the very essence of the AAR. One of the risks is to the quality of the engagement and accountability with those who are attending the AARs. It was an excellent article published by Psychological Safety, on the Spectra of Participation which explores these concepts that gave me the idea for a framework for describing what I have observed that is a concern. Participation doesn’t guarantee engagement Looking at the IAP2 and other frameworks, the article explores the idea that participation doesn’t always guarantee engagement. The quality of engagement is a direct result of the goal of the process and the amount of psychological safety present. This analysis got me thinking about creating a scale of participation to bring to life the variety seen in AARs and is designed to help those leading AARs to be clear on the what their goals are. This table below sets out the five levels of participation that I’ve developed. Involve, Facilitate and Empower are all possible and healthy uses of the After Action Review approach. Organisational requirements will impact on how the AAR approach is deployed in each context and the full “Empower” approach where AAR participants are given full scope to act on the learning and their own recommendations, may not be appropriate for AARs taking place within a PSIRF governed process. However, it is a legitimate and valuable approach in project teams and other contexts. The continuum When you look at the continuum, you can see there is a shift from left to right of the AAR Conductor having knowledge of the event to needing to have very little. The Inform position is one where the AAR Conductor already has knowledge and is inviting participants to contribute to enrich the knowledge already held. This is not genuine engagement and along with the Consult approach, can be experienced as a tokenistic application of the AAR. The Facilitate and Empower positions, are those where the AAR Conductor needs have little knowledge prior to the AAR since the work is centred around the participants’ contributions and responses the AAR questions alone. This ensures meaningful engagement with the participants and requires skill in creating the psychological safety for honest conversations and asking the searching questions. The Empower position is different in that the aim is not to hand back the responsibility for action and reporting to the AAR Conductor, but to enable the participants to be ready to take the learning forward. Examples of the types of questions asked along the continuum Inform – “Did you have enough staff on duty?”, “ Was the NatSSIPS process followed?” Consult – “How did the patient respond?”, “Why weren’t the police called?” Involve – “What else was happening on the ward at the time?”, “What might prevent this happening again?” Facilitate – “Communication between agencies has been mentioned a few times: what might improve communication between agencies in future?” “Which of these ideas would make most impact?” Empower – “What do you want to do with this learning?” What support do you need to put this into action?” In summary As an AAR Conductor, you have to operate within your organisations’ context but it is vital to build trust in the AAR process. You will do this by ensuring your actions match your stated intentions and you are transparent about the level of participation you’re aiming for. Getting this right isn’t just about the integrity and standardisation of the AAR approach, it is also about maximising the potential for improvements in patient safety. Those AARs where Involving, Facilitating and Empowering are the goal, increase the level of accountability for change owned by the participants. We know from the research that when staff are fully engaged in the AARs they attend, their behaviour changes and patients are safer as a result.
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EventuntilInvestigating incidents and accidents is crucial for safety management in high-risk industries. While it is just one component of safety management, it is an essential one. Thoughtful incident analysis promotes learning, enhances safety, and fosters a proactive safety culture. The London Protocol is a method for analysing healthcare incidents, revealing the strengths and weaknesses of the healthcare system. By closely examining a single patient’s journey, valuable insights about the broader system can be gained. Originally published in 2004, it has been widely used around the world. Find out more about the updated 2024 version of the London Protocol In this workshop, you will learn about the updated London Protocol 2024, which has been refined for today’s healthcare landscape. We will cover its history, theoretical background, and our approach to learning from clinical incidents and patient experiences. We will focus on engaging patients and families and supporting everyone affected by incidents. Additionally, we will discuss the importance of fewer, more thorough investigations to drive broader improvement initiatives. There will be opportunities for questions and open discussions on any topics raised. Register .
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Content Article
From Autumn 2023, NHS organisations in England began to change the way they investigated cases of avoidable patient harm and near misses, introducing the Patient Safety Incident Response Framework (PSIRF). As part of PSIRF, organisations are required to create and publish a Patient Safety Incident Response Plan. This blog summarises the findings of a new report, Patient Safety Incident Response Plans: An analysis and reflection by Patient Safety Learning. Drawing from a sample of 13 Patient Safety Incident Response Plans, the report considers what they can tell us about the implementation of PSIRF. PSIRF When something goes wrong with a patient’s care or treatment that causes them harm, or has the potential to cause harm, healthcare staff are required to formally report these incidents. Subsequently, investigations take place into these events, which can act as an important source of insights and learning. These investigations provide an opportunity to identify what went wrong and the actions needed to prevent a similar incident from taking place in the future. In England, the NHS has recently introduced a new approach to these investigations called PSIRF. This represents a significant shift in the way the NHS responds to patient safety incidents and is intended to be a major step towards establishing a systems approach to patient safety in the NHS. A systems approach is one that focuses on understanding how different parts of the healthcare system interact, rather than placing blame solely on individuals when things go wrong. Patient Safety Incident Response Plans As part of PSIRF, NHS organisations in England are required to create and publish a Patient Safety Incident Response Plan. These plans should specify the methods an organisation intends to use to maximise learning and improvement, and how these will be applied to different patient safety incidents. They provide an opportunity for organisations to demonstrate to patients, staff and the wider public how they are seeking to improve patient safety through incident investigations. In our new report, we have analysed a sample of 13 Patient Safety Incident Response Plans (a sample size of 6% out of the 206 organisations included in our Patient Safety Incident Response Plan [PSIRP] Finder). Our intention has been to reflect on what these tell us about the implementation of PSIRF, identify issues that could help organisations update their plans in the future and take action to reduce avoidable harm. Report findings From the sample of Patient Safety Incident Response Plans we analysed, our new report has identified a number of key themes: Variations in approach Although NHS Trusts use a common template to create their Patient Safety Incident Response Plans, their approach to completing these has varied significantly in places. An example of this is the criteria organisations use when deciding to conduct a formal Patient Safety Incident Investigation (PSII). There are some patient safety incidents, such as those classed as a ‘Never Event’, where a PSII must be carried out. However, for incidents where there is no national requirement to do so, Trusts decide whether to carry out a PSII based on their own criteria. In our analysis, we found that in some cases Trusts provided a detailed explanation of factors that they would consider in deciding on whether to undertake a PSII; however, in other plans only a brief explanation was provided. In a few cases, there was no statement on when a PSII would be required. Differences in detail While Trusts in the sample we examined all sought to meet the requirements NHS England set them for their Patient Safety Incident Response Plans, the level of detail they have provided differs considerably. An example of this can be seen when organisations detail how they have identified local patient safety priorities. Patient Safety Incident Response Plans contain both national and local priorities. While NHS Trusts are required to adopt a standardised approach to national priorities, local priorities vary from organisation to organisation. In our analysis, we found that in some cases Trusts had provided a significant amount of detail of the sources they used to identify local priorities and also included the methodology they used in prioritising these sources. Other organisations, however, provided significantly less detail—in some cases just a brief list of priorities and data sources. Critical information gaps We also identified a range of issues that Patient Safety Incident Response Plans in our sample either covered very briefly or not at all. This included: Compassionate engagement and the involvement of those affected by patient safety incidents. Detail on this was largely absent in plans, despite this being identified as one of the four key aims of PSIRF. Evidence of the existence of robust mechanisms to ensure that safety recommendations are actioned and monitored effectively. References to sharing learning and insights from patient safety investigations more widely for system-wide improvement. Recommendations Based on the findings in our report, we have identified five recommendations for NHS England and the Department of Health and Social Care. These are intended to improve the approach to creating and implementing Patient Safety Incident Response Plans. Develop a national standardised framework for evaluating individual Patient Safety Incident Response Plans. Create a central NHS repository of Patient Safety Incident Response Plans and Policies. Consider the benefits of introducing independent external reviews of Patient Safety Incident Response Plans. Update Patient Safety Incident Response Plan guidance for NHS and Foundation Trusts so this explicitly refers to sharing insights and learning from the implementation of plans. Commission a full evaluation of Patient Safety Incident Response Plans. We also highlight some key issues that we believe NHS Trusts should consider when it comes to reviewing their Patient Safety Incident Response Plans: Transparency: Trusts should seek to ensure plans are accessible and clearly communicate how approaches are developed, how they impact patients, staff and the public, and how they address patient safety incidents. Investigation quality: To help improve the depth and rigor of investigations, there should be a greater emphasis and understanding of the contributory factors to incidents in these plans. Quality improvement: Trusts should identify issues that lead to tangible actions to enhance patient safety. Knowledge sharing: How plans can help to facilitate widespread dissemination within organisations and encourage sharing across the health system in England. Standardisation of prioritisation: Explore whether a standardised approach—such as outcome-based, contributory factor-based, or a combination of both—could provide a system-wide perspective for reporting and analysis. Commenting on the report, Patient Safety Learning's Chief Executive Helen Hughes said: “Too often in the NHS we see examples of patient safety investigations not resulting in learning and improvement. This is a theme that emerges time and time again in cases of avoidable patient harm and major patient safety inquiries. The introduction of PSIRF presents a significant opportunity to improve the approach to patient safety incident investigation in England. However, if this is to live up to its ambitions, it must have a clear focus on turning insights and learning into action and improvement. The content of early Patient Safety Incident Response Plans suggests that greater work is needed in this area. Plans should have details on how safety recommendations will be monitored and evaluated, as well as including provisions for sharing good practice as widely as possible. PSIRF is intended to be flexible, with NHS guidance on the creation of Patient Safety Incident Response Plans reflecting this. However, from our analysis we have found that the lack of uniformity in these plans has the potential to complicate cross-organisational comparisons and learning. This in turn could hinder the identification of best practices as Trusts’ approaches diverge. If we are to understand and evaluate the impact of PSIRF, we believe a standardised framework for evaluating individual Patient Safety Incident Response Plans is essential.” Share your experiences and views with us Are you involved in your NHS Trust’s plans to review its Patient Safety Incident Response Plan in the near future? What issues are you considering as part of this process? What do you think is needed to deliver this? We would welcome your reflections on the issues raised in the report and are keen to hear further insights from those involved in shaping and delivering Patient Safety Incident Response Plans. You can comment below (sign up to the hub first, for free) or email the team directly at [email protected] to share your experiences. -
Content ArticleThe introduction of the Patient Safety Incident Response Framework (PSIRF) has removed traditional oversight targets, requiring practitioners to take a flexible, improvement-focused approach. While this shift is intended to improve patient safety, it has also created uncertainty for those in oversight roles, who must navigate new responsibilities without the comfort of prescriptive performance metrics. This article provides practical guidance on PSIRF oversight and introduces the Self-Assessment Framework for Event Response (SAFER) Oversight tool. The article outlines the mindset and functions needed to support effective, improvement-focused governance. It explores three aspects of oversight mindset: systems thinking, improvement focus, and compassion - as well as three oversight functions: demonstrating and assuring improvement, supporting and collaborating, and facilitating learning across the system. By clarifying the role of oversight within PSIRF, this article aims to reduce uncertainty and support practitioners in delivering meaningful patient safety improvements.
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Event
Investigation and learning from deaths
Patient Safety Learning posted an event in Community Calendar
This National Conference focuses on improving the investigation and learning from deaths and will update delegates on the death certification reforms which came into force in September 2024. There will be an extended focus on engaging and involving patients, families and staff following a death, and on learning from deaths including an update from a coroner. The conference will discuss learning from deaths which is now being extended to all non-coronial deaths wherever they occur and will provide a practical guide to learning from deaths and improving practice in your service. The conference will also update delegates on the National Patient Safety Incident Response Framework (PSIRF) and the implications for patient safety incident investigation and learning from deaths. For further information and to book your place visit: https://www.healthcareconferencesuk.co.uk/virtual-online-courses/investigation-learning-deaths-hospital-mortality or email [email protected] Follow on X @HCUK_Clare #LearningFromDeaths hub members receive a 20% discount. Email [email protected] for discount code. -
Content Article
Learn how to spot the red flags for harmful cultures in healthcare. The Patient Experience Library's Responding to Challenge report reveals the patterns of behaviour that crop up time and again in healthcare disasters. It explains what poor cultures look like - in teamwork, compliance, accountability, organisational learning and more. It can support staff training and organisational learning - helping people to get a better idea of what "culture" actually means in healthcare, and how it can go wrong. Use the Red Flag Tracker to find real-life examples of warning signals, drawn from ten years of official inquiries in UK health and care settings. The tracker will be useful for people charged with the task of "reading the signals" of harm - complaints managers, patient experience staff, Freedom to Speak Up Guardians and local Healthwatch staff, as well as service managers and Trust Board members. -
Content ArticleThe 'Learning Response Review and Improvement Tool' is intended to be used by: Health and care professionals conducting safety learning reviews and investigations and writing or signing-off related written reports. It would also be useful for written reports related to complaints from patients, service users, families, and carers. Peer reviewers of written reports to provide constructive feedback on the quality of reports and to learn from the approach of others. Educators involved in designing and delivering training programmes related to safety and/or complaints learning reviews. Leaders charged with undertaking national inquiries and investigations. The tool was developed and validated by NHS Education for Scotland (NES) in partnership with the NHS England Patient Safety Team and the Health Services Safety Investigation Body. The latter two organisations also recommend its use as part of Oversight processes for safety investigation and learning. The Tool is embedded in NES training programmes related to safety learning reviews. It has also been adapted and recommended for use in the New Zealand health system. Related reading on the hub: Top picks: PSIRF insights and opinions Top picks: PSIRF tools, templates and examples
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Content ArticleSWARM is one of the Patient Safety Incident Response Framework (PSIRF) learning tools. At a recent Patient Safety Management Network meeting, SpaMedica shared insights into their Patient Safety Incident Response Framework (PSIRF) journey, offering a unique perspective on how the independent sector implements PSIRF. They have shared their SWARM templates and SWARM Charter with the hub. Generic SWARM template: Generic SWARM Template.docx Endophthalmitis SWARM template: Endophthalmitis SWARM Template.docx Falls SWARM template: Falls SWARM Template.docx SWARM Charter: SWARM Charter (1).pdf The Patient Safety Management Network (PSMN) is an innovative network for patient safety managers and everyone working in patient safety. You can join by signing up to the hub today. When putting in your details, please tick Patient Safety Management Network in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected].
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Content ArticleSWARM is one of the Patient Safety Incident Response Framework (PSIRF) learning tools. This infographic explains what SWARM is, when you would use it, who should be involved in it and who should lead it, and it's strengths and weaknesses.
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Content ArticleEpsom and St Helier Hospital have developed a SWARM guide and fictional example video, for use by those who wish to use the Swarm debrief learning response as part of their Patient Safety Incident Response Framework (PSIRF) work. Swarm is one of the four learning responses and can be used whenever there is something new to learn, and does not have to be initiated by a patient safety incident. Typically, a Swarm debrief happens within 48 hours after the event and includes the multiprofessional staff that were involved. The Swarm Guide suggests useful phrases and prompts across three distinct phases, starting with 'setting the scene'. This phase is important as it helps to create group psychological safety, where all participants can feel safe to speak up and share their perspectives, without fear of ridicule or reprimand. A Swarm debrief is informed by the Systems Engineering Initiative for Patient Safety SEIPS and Systems Thinking principles, that theorise most problems and possibilities for improvement belong to the work system. Therefore, the aim of a Swarm is to understand and explore important or relevant work system factors that helped or hindered event outcomes and crucially whether these system issues are present in our everyday work. You can spend most of the debrief 'exploring WSF & everyday work' as the questions and prompts within this phase support a curious approach. Finally, you can draw the debrief to a close in 'next steps', by thanking participants, summarising key learning and checking for understanding. Then informing participants of how you will document and escalate any important system issues or findings, so that these can inform ongoing or future improvement work.
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Content ArticleAfter another damning coroner’s report following the preventable death of a baby at a Lancashire hospital, this HSJ podcast take a closer look at why the NHS is beset with so many maternity scandals.
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Content ArticleThe biggest area of risk – in terms of lives lost and cost – involves NHS maternity units. Organisation upheaval must not distract us from what matters most, writes Jeremy Hunt, former health secretary. He highlights three key things that need to happen. First, it is essential that improving maternity safety is part of the new 10-year plan as it was in the last one. We also need a system to make sure that recommendations from public inquiries, the independent Health Services Safety Investigation Body (HSSIB) and coroners are actually implemented. There needs be a central repository of recommendations with public accountability as to who is responsible for implementing which ones by an agreed date. It is also critical to put in place a turnaround programme for the 10% of trusts where maternity safety is rated inadequate by the Care Quality Commission (CQC). Finally – and most challengingly – we need a renewed focus on dismantling the blame culture that makes it difficult for clinicians to be open about mistakes and failures, and therefore make sure the system learns the necessary lessons.
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News ArticleBy the entrance to Furness General Hospital in Barrow-in-Furness sits a sculpture of a moon with 11 stars. It is a memorial to the mother and babies who died unnecessarily due to poor care at the hospital between 2004 and 2013. When the memorial was unveiled in 2019, Aaron Cummins who is chief executive at University Hospitals of Morecambe Bay NHS Trust, which runs the hospital, said: "We will never forget what happened. We owe it to those who died to continually improve in everything that we do." Barely a month later, Sarah Robinson stepped into a birthing pool at the Royal Lancaster Infirmary, a hospital run by the same NHS trust. She was about to give birth to her second child. Within an hour, Ida Lock was born; within a week, she was dead. The inquest into Ida Lock's death, which concluded last week, exposed over five weeks why maternity services across England have long struggled to improve - and this one case holds a mirror to issues that appear to be prevalent across a number of trusts. 'That investigation, carried out by Dr Bill Kirkup and published in March 2015, found there had been a dysfunctional culture at Furness General, substandard clinical skills, poor risk assessments and a grossly deficient response to adverse incidents with a repeated failure to properly investigate cases and learn lessons. Morecambe Bay became a byword for poor maternity care and the trust promised to enact all 18 recommendations from the Kirkup review. And yet that never happened. Ida Lock's inquest began last month, more than five years after she died - the delay was down to several reasons, including its particular complexity. What emerged was just how profoundly many of those lessons had not been learned. Particularly egregious, says Ms Robinson, was a suggestion from a midwife – shortly after the birth - that Ida's poor condition was linked to her smoking, something Sarah had never done in her life. As the coroner found on Friday, Ida's death was wholly avoidable, caused by a failure to recognise that she was in distress prior to her birth, and then a botched resuscitation attempt after she was born. By the time she was transferred to a higher dependency unit, at the Royal Preston hospital, she had suffered a brain injury from which she could not recover. Having failed to deliver their daughter safely, Ida's parents would have expected that the trust would properly and openly investigate her death. Instead, they pursued an investigation that Carey Galbraith, the midwife who completed it, would later describe as "not worth the paper it was written on". They didn't take responsibility for their failings despite having an independent report from the Healthcare Safety Investigation Branch (HSIB). Clearly, the Morecambe Bay report was not, as was hoped, a line in the sand for maternity services across England, or a rallying cry for widespread improvements. As the inquest has shown, it did not even lead to sustained improvement at Morecambe Bay. Read full story Source: BBC News, 24 March 2025 Further reading: Ida Lock: Baby girl died from brain injury because midwives failed to provide basic care, coroner rules
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Content ArticleAfter Action Review (AAR) is a debriefing methodology for learning from events. The method is a facilitated discussion among a team exploring what they expected to happen, what did happen, and what they learned. Ireland’s Health Service Executive includes the AAR methodology as part of its national Incident Management Framework. This paper explores enablers and barriers to AAR implementation in an Irish tertiary specialist hospital.
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Content ArticleThis guidance aims to provide an overview and an understanding and the benefits of AAR and advice to assist with its introduction and implementation within services so that it adds value and is sustainable.
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Content ArticleIn 2016, the Care Quality Commission looked into how acute, community and mental health trusts investigate and learn from deaths. This resulted in new national guidance. Here they report on their assessments of how NHS trusts are putting it into practice.
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Content ArticleOverloaded with duplicative recommendations, the healthcare system must prioritise impactful actions, improve collaboration, and ensure meaningful implementation to enhance patient safety and restore public trust, writes Rosie Benneyworth, chief executive officer of the Health Services Safety Investigations Body (HSSIB).
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Content ArticleA Learning Health System is not a technical project. It is the evolution of an existing health system into one capable of learning from every patient. This paper outlines a recently published framework intended to aid the understanding, design, development and evaluation of Learning Health Systems.
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Content Article
The Learning Healthcare System: Workshop summary (2007)
Sam posted an article in Research, data and insight
The Learning Healthcare System is a summary of the Institute of Medicine (US) two-day workshop held in July 2006, convened to consider the broad range of issues important to reengineering clinical research and healthcare delivery so that evidence is available when it is needed, and applied in health care that is both more effective and more efficient than we have today. Embedded in these pages can be found discussions of the myriad issues that must be engaged if we are to transform the way evidence is generated and used to improve health and health care—issues such as the potential for new research methods to enhance the speed and reliability with which evidence is developed, the standards of evidence to be used in making clinical recommendations and decisions, overcoming the technical and regulatory barriers to broader use of clinical data for research insights, and effective communication to providers and the public about the dynamic nature of evidence and how it can be used. -
Content ArticleThe Department of Health is undertaking a consultation on the introduction of a new Regional Framework for Learning and Improvement from Patient Safety Incidents and supporting documentation to replace the current Serious Adverse Incident (SAI) Procedure in Northern Ireland. The closing date is 20 June 2025 at 5.00pm. The proposed new draft Regional Framework for Learning and Improvement from Patient Safety Incidents is intended to replace the existing SAI procedure in Northern Ireland. Evidence from inquiries and reports – including the Regulation and Quality Improvement Authority Review of Systems and Processes for Learning from Serious Adverse Incidents, the inquiry into Hyponatraemia-related Deaths report and the Independent Neurology Inquiry - highlight that aspects of the current SAI procedure need to be refreshed and redesigned. The key aims of this new draft Framework is to: Providing a more streamlined and simplified process for reviewing Patient Safety Incidents, to ensure reviews are of a high quality; Place all those affected at the heart of the process; Focus on understanding how and why a Patient Safety Incident has occurred to identify system-wide learning leading to demonstrable and sustainable improvements in care. The consultation will focus on the following four draft documents: The Framework for Learning and Improvement from Patient Safety Incidents Regional Standards for the Conduct of Patient Safety Incident Learning Reviews Principles for Engaging, Involving and Supporting All those Affected by a Patient Safety Incident Principles for Engaging, Involving and Supporting Staff Affected by a Patient Safety Incident
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News Article
Grieving dad says NHS not learning from mistakes
Patient Safety Learning posted a news article in News
A dad whose son died following a series of hospital errors has warned the NHS is still failing to learn from its mistakes after an increase in serious patient safety incidents. Fraser Morton's baby son, Lucas, was one of six "unnecessary" baby deaths at Crosshouse Hospital in Kilmarnock nearly a decade ago. The scandal sparked a shake-up of how safety incidents are reviewed but concerns have been raised about the quality and effectiveness of these investigations. More than 800 safety incidents were reported in the NHS last year - a 41% increase from 2020 - and health watchdogs are now revamping the reporting system to improve scrutiny. The rise in reported Significant Adverse Event Reviews (SAERs), which include avoidable deaths, comes as the NHS has faced unprecedented pressure since the Covid pandemic. Mr Morton said he'd seen little of the promised changes, such as the appointment of an independent patient safety commissioner, since the death of his son in 2015. He said: "In 2016, the Organisation for Economic Cooperation and Development (OECD) said Scotland's healthcare system was marking their own homework when it came to reviews and investigations and we've not made any progress since then. Mr Morton's son Lucas died after a series of failings, including not properly monitoring his heartbeat during childbirth, but the death was not investigated as an SAER. Only after pressure from the family and a BBC investigation was a fuller review launched with NHS Ayrshire and Arran then admitting Lucas's death was "unnecessary" and issuing the family an "unreserved apology". Mr Morton added: "It is the lack of independent scrutiny that concerns me. "Mistakes will always happen, but the NHS is the only high- risk, high-consequence organisation or sector that doesn't have an external regulator, a truly independent regulator you [can] compare to say the rail, airline or nuclear industry." Read full story Source: BBC News, 7 March 2025 -
Content ArticleThis Swarm video was developed to demonstrate how you can carry out a Swarm debrief using the Swarm guide. This content is intended for use by those who wish to use the Swarm debrief learning response, as part of their Patient Safety Incident Response Framework (PSIRF) work. Swarm is one of the four learning responses and can be used whenever there is something new to learn and does not have to be initiated by a patient safety incident. Typically, a Swarm debrief happens within 48 hours after the event and includes the multiprofessional staff that were involved. Please note this example is fictional and the actors are all gesh staff.
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Content ArticleLearning Health Systems help organisations to learn and act fast to drive improvement. Find out from UCL Partners Health Innovation the five core principles that underpin success.
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Content ArticleInternationally there is recognition that a holistic quality management system (QMS) approach will enable healthcare organisations to meet the needs of their populations and continuously improve the care and experience provided. In NHS Wales, the Duty of Quality was introduced in 2023 through the Health and Social Care (Quality and Engagement) (Wales) Act 20201 and requires Welsh NHS bodies to establish an effective QMS where appropriate focus is placed upon Quality Control, Quality Planning, Quality Improvement and Quality Assurance The 90-day cycle methodology was used to explore how high performing organisations manage for quality – identifying universal findings across all the organisations, a summary of what a QMS can achieve and the importance of the role of the Board. The findings informed the development of a QMS Framework for healthcare which has supported the development of the Duty of Quality and includes: A definition of quality: Continuously, reliably and sustainably meeting the needs of the population that we serve (aligned to the Duty of Quality). A definition of QMS for NHS Wales: An operating framework to continuously, reliably and sustainably meet the needs of the population we serve. Descriptions of the four aspects within a QMS: Quality Planning, Quality Improvement, Quality Control and Quality Assurance and examples of tools and resources that can be used to support their implementation. Descriptions of the organisation enablers for a QMS: leadership, workforce and culture; learning, improvement and research; whole system approach; and, information (aligned to the Duty of Quality Standards). A methodology to implement and embed a QMS: an adaptation of Quality as an Organisational Strategy (QOS) informed by the experience of piloting the approach at directorate and organisation level.
