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Edition 13 of the After Action Review newsletter shares an example of a new application of the SEIPS tool. SEIPS was meant to help us review incidents. But what if it’s quietly changing how we think about safety every day? The use of the System Engineering Initiative in Patient Safety, mostly commonly known as SEIPS is now widely applied in the learning responses to healthcare incidents. What makes it really interesting is how it is now also working reduce risk proactively and influence how we think in healthcare.

This Health Services Safety Investigation Body (HSSIB) report examines patient safety in relation to electronic prescribing and medicines administration (ePMA). ePMA is software used to prescribe medication and create a record of the medication: that has been given, or due and not given to a patient. Most people admitted to hospital will receive medication, and most acute hospital trusts in England have ePMA functionality in at least part of their organisations. This report focuses on the procurement process used by acute hospital trusts to purchase new ePMA functionality and/or upgrade their existing ePMA functionality and how patient safety learning about ePMA is identified and shared across the healthcare system. It considers how legal, regulatory, standards and assurance functions apply in relation to ePMA safety. ePMA functionality has been shown to reduce some medication errors. However, the current national mechanisms (legislation, regulation, standards and assurance) for ensuring patient safety in relation to ePMA functionality may not adequately provide staff and healthcare organisations with the assurance that risk and hazard identification process are robust and/or share learning associated with the use of ePMA in an acute hospital setting. Findings There are no core national patient safety standards that inform either the design or procurement of ePMA. This can lead to unwarranted variation in functionality across and between ePMA, other electronic systems, and acute hospital trusts, which may pose challenges for staff when prescribing and administering medication. Current assurance mechanisms do not provide national oversight or enforcement of either manufacturer or healthcare provider compliance with legally mandated standards relating to digital clinical safety and interoperability of digital health technology. The safety risks associated with software such as ePMA are complex and may change rapidly. Legislation, regulation and standards may not keep up with the speed of technological change. Manufacturers must self-assess and report whether their ePMA is compliant with relevant standards for their products to be included on an NHS procurement framework. There is variation in the core safety standards identified by acute hospital trusts when procuring and contracting for ePMA functionality. This leads to trusts identifying safety requirements individually, with limited consistency in the approach taken across trusts. Reliance is placed on acute hospital trusts to determine whether ePMA manufacturers have interpreted the medical device regulations appropriately, and to assure themselves that the trust complies with relevant standards. Some trusts do not have the resources, skills and expertise to do this effectively. Digital safety and patient safety teams at local and national level may work in silos, with limited ability to share information or collaborate on ePMA-related decisions that impact on patient safety. There are challenges with identifying national safety learning relating to ePMA as this is not reliably captured, shared or identified through formal reporting routes. There is ongoing work to improve the NHS reporting system to capture digital-related patient safety incidents. There is a reliance on informal networks for sharing ePMA safety issues which means safety concerns may not always be shared with those who need to be aware. Some ePMA manufacturers, whose ePMA functionality is not registered as a medical device choose to apply equivalent governance and assurance measures as if it is a medical device. This is in addition to complying with the digital clinical safety standard (DCB0129). Acute hospital trusts face challenges prioritising and resourcing procurement decisions for ePMA functionality. This leads to challenges and patient safety issues when ePMA is implemented. Clinical safety officers (CSOs) may not be adequately resourced, meaning they have limited capacity to support in managing clinical risks associated with ePMA. There is variation in how the CSO responsibilities set out in the digital clinical standards are interpreted and implemented by trusts. NHS England is working on plans for a formal curriculum and potential accreditation to improve CSO skills and capabilities. HSSIB makes the following safety recommendations Safety recommendation R/2026/086: HSSIB recommends that the Medicines and Healthcare products Regulatory Agency ensures that: routes for manufacturers and healthcare organisations to engage with them are clear and accessible it reviews and provides further guidance and clarification on when electronic prescribing and medicines administration (ePMA) software should be considered a medical device. This will support how ePMA software can be appropriately classified and regulated to improve patient safety. Safety recommendation R/2026/087: HSSIB recommends that NHS England/Department of Health and Social Care establishes a national framework for core electronic prescribing and medicines administration (ePMA) safety. This will provide a clear set of minimum patient safety requirements, helping to reduce unwarranted variation in the safety of ePMA functionality. Safety recommendation R/2026/088: HSSIB recommends that NHS England/Department of Health and Social Care develops an external assurance framework for information standards notices relating to electronic prescribing and medicines administration (ePMA). This is to reduce unwarranted variation and improve patient safety through expert-led assurance processes. Safety recommendation R/2026/089: HSSIB recommends that NHS England/Department of Health and Social Care provides additional support to acute hospital trusts, in relation to: supporting healthcare providers to access digital clinical safety knowledge, capacity and capability integrating digital clinical safety and patient safety, including the associated terminology supporting robust assurance of whether electronic prescribing and medicines administration (ePMA) manufacturers comply with relevant standards in order to be considered for inclusion on an NHS procurement framework. This will support effective decision making and oversight by acute hospital trusts and reduce unwarranted variation in the understanding of, and approach to, adopting ePMA. Safety recommendation R/2026/090: HSSIB recommends that the Care Quality Commission reviews the sector-level assessment frameworks it is developing to include assurance of ongoing compliance with the digital clinical safety standard (DCB0160) for electronic prescribing and medicines administration (ePMA) software. This will help to ensure oversight of ePMA functionality to improve patient safety. HSSIB makes the following safety observations Safety observation O/2026/086: Commercial manufacturers can improve patient safety by applying the standards and expectations for a medical device when developing electronic prescribing and medicines administration (ePMA) functionality, to help provide further assurance to acute hospital trusts procuring or updating ePMA functionality. Safety observation O/2026/087: Commercial manufacturers and NHS organisations can improve patient safety by ensuring the sharing of safety learning about electronic prescribing and medicines administration (ePMA) functionality nationally via incident reporting systems and relevant safety forums. Safety observation O/2026/088: Commercial manufacturers and NHS organisations can improve patient safety by contributing to and engaging with ePRaSE (ePrescribing Risk and Safety Evaluation) processes to support ongoing improvement and optimisation of electronic prescribing and medicines administration (ePMA) functionality across the NHS.

Patients, service users, their loved ones and carers have the right to raise concerns about the care they receive under the NHS in Wales. This can be done through the Listening to People NHS Wales Complaints, Incidents, and Redress process. Raising a concern can be difficult and distressing. People often come forward because something has had a real impact on them or their loved ones. This guidance explains what support you can expect and what will happen when you raise a concern. A concern can include a complaint, patient-safety incident or any other issue relating to an organisation’s health services. Responsible bodies, which are organisations that are legally responsible for your care, have a duty to listen to, act on, investigate and respond to concerns, and to learn from them to improve care and reduce the risk of harm re-occurring in the future. Responsible bodies can be an NHS organisation, a GP practice, dental practice or an Independent Provider delivering NHS funded care. Raising a concern often follows upsetting or traumatic experiences and NHS organisations in Wales aim to respond in ways that are compassionate, respectful and sensitive to the impact on you and your loved ones.  Further reading on the hub: How to make a complaint

In alignment with the implementation of the Patient Safety Incident Response Framework (PSIRF), East London NHS Foundation Trust conducted a comprehensive five-year analysis of reported incidents. This review analyses 411 completed investigations of serious incidents (SIs) and patient safety incidents (PSIIs) reported in the Trust from 2020 to July 2024. With patient safety as a top priority, this analysis examines whether key issues identified in these investigations have shown recurring patterns over time.

This guidance is for users of the new Learn from Patient Safety Events (LFPSE) service, to provide context and guidance on selection of appropriate categories when recording incidents. It focuses on which Event Type is appropriate for different circumstances, and how to select the most appropriate options for the Levels of Harm categorisation required within Patient Safety Incidents. It covers the following topics: Definitions – event types Definitions – harm grading When are harm grading fields mandatory? Recording guidance questions and answers

Stef Cormack, Patient Safety Specialist at Sandwell and West Birmingham Hospital NHS Trust, recently presented at the Patient Safety Management Network meeting on the work she has been doing on the Patient Safety Incident Response Framework (PSIRF) and with coroners. Attached is the template the Trust uses to supplement the evidence the Trust provides to the Coroner for the purposes of the Inquest investigation, and to summarise the investigations, findings, conclusions, learning points and actions, which form the Trust’s response to the relevant patient safety incident(s) under PSIRF. Steph is happy for other organisations to adapt and use. Patient Safety Management Network You can apply to join the Patient Safety Management Network by signing up to the hub today. When you complete the registration form you’ll see a section called ‘Join a private group’, please tick the box by the relevant Network. If you are already a member of the hub, please email [email protected].

In March, Healthgrades recognised 438 hospitals in 40 US states that excel in quality care while preventing serious safety events during hospital stays. These hospitals represent the top 10% in the nation for patient safety. Becker’s reached out to five recognised hospitals to find what initiatives contributed to their top patient safety performance.

A hypothetical proposal for a national incident reporting system in the United States. Drawing on lessons from aviation safety history and patient safety literature, a detailed plan is progressively built (initially centred in psychiatry), covering aspects that make an incident reporting system effective. Incident reporting systems have faced many implementation problems. This article shows that by exploring fields adjacent to medicine and much further afield, solutions to long-standing problems can be found. It proposes potentially novel ideas, yet to have been tried in incident reporting both in the United States and in the UK.

This article chronicles the development of patient safety incident reporting systems. From the first implementation by nurses in the 1930s to learn from medication errors, to the accidental revolution in anaesthesiology, and the explosion of reporting systems at the turn of the millennium. The predominant narrative is that patient safety incident reporting was 'imported' from the aviation industry (and other similar high-risk industries) in the last 25 years. While there is little doubt that other industries have had a major influence on current patient safety incident reporting systems, the narrative ignores the previous 70 years of incident reporting development from within medicine. The history is important because incident reporting has the potential to be seen as an alien concept to healthcare professionals, when, actually, medicine has historically been independently tied to these systems. The article emphasises that healthcare practitioners have long seen the value of such systems—and how they are a key part of a learning culture and patient safety.

Morbidity and mortality (M&M) conferences are regular meetings where healthcare teams review adverse outcomes and complications to learn from errors and improve future practice. In surgical specialties, M&M meetings are long-established and considered integral to patient safety, quality improvement, and medical education. Surgical governing bodies, including the Royal College of Surgeons, strongly recommend participation, reflecting the value placed on these conferences in identifying system issues and preventing recurrence of harm. The Royal College of Surgeons of Edinburgh further developed this approach through team-based quality reviews (TBQR), a structured and evidence-based framework for team learning in clinical practice. Historically, however, ophthalmology has lagged other specialties in adopting M&M meetings. There are no Royal College of Ophthalmologists (RCOphth) guidelines on M&M meetings and limited research exploring their benefits in ophthalmic practice. This commentary discusses redefining M&M meetings in ophthalmology.

This update presents statistics from the Learn from Patient Safety Events (LFPSE) service, a national NHS system for the recording and analysis of patient safety events that occur in healthcare. The LFPSE definition of a patient safety incident is something unexpected or unintended has happened, or failed to happen, that could have or did lead to patient harm for one or more person(s) receiving healthcare. This report shares the patient safety incident data from October to December 2025. Count of Event Types in LFPSE – based on patient safety event records from October 2025 to December 2025 LFPSE brings the feature to record patient safety event types beyond incidents. Recorders can now also upload patient safety risks, outcomes and instances of good care. This is to ensure the database contains more instances of care that the healthcare system can learn from instead of only detailing errors involving patients. In this period, 855,535 events were recorded to LFPSE, the majority of which were recorded as patient safety incidents (97.01%). Count of patient safety incidents by maximum physical harm – based on patient safety incident records from October 2025 to December 2025 Sometimes a problem in care can affect more than one patient, or none at all. To capture this, as a new feature of LFPSE, recorders can submit information for multiple patients per incident, meaning there can be multiple degrees of harm per incident. For the following figure and table NHS England have taken the highest harm level per incident. NHS England identified and removed 66,080 incidents where the number of patients affected was unknown. Preliminary analysis suggests that these records likely represent incidents with no patients involved. NHS England will continue further data quality checks to validate these figures. During this quarter, 763,905 incidents had recorded a degree of harm. The majority of these incidents (94.07%) recorded low or no physical harm to patients. LFPSE has a new variable for grading of the psychological harm associated with the recorded patient safety incidents. This is an experimental field which seeks to explore if responses to safety incidents need to be different if psychological harm is considered separately from physical harm, rather than rolling them together into one measure, as was done in the National Reporting Learning Service (NRLS). Currently, there is low confidence in the grading of psychological harm, as users familiarise themselves with its use, and as such, it is excluded from this report. Related reading – previous quarterly data publications NHS England: Patient Safety Event Data Quarterly Publication – Quarter 2 2025/26 (July to September 2025) NHS England: Patient Safety Event Data Quarterly Publication – Quarter 1 2025/26 (April to June 2025) NHS England: Patient Safety Event Data Quarterly Publication – Quarter 4 2024/25 (January to March 2025) NHS England: Patient Safety Event Data Quarterly Publication – Quarter 3 2024/25 (October to December 2024)

The ability of healthcare staff to raise concerns safely and effectively is a cornerstone of good workforce culture and safe patient care. The extent to which employee voice is heard and acted upon is a good measure of the inclusiveness and psychological safety within teams, particularly whether concerns are raised “in the moment”. In turn, inclusiveness and psychological safety contribute to whether staff feel speaking up is safe and effective. In this review attached, Roger Kline, Research Fellow at Middlesex University Business School, explores the literature on patient safety and speaking up, arguing that staff being able to raise concerns safely and effectively is essential for patient safety, but the NHS continues to struggle with creating a culture where this happens reliably. Despite years of inquiries, policies, and the introduction of Freedom to Speak Up Guardians (FTSUGs), employee silence, fear of detriment and a sense of futility remain widespread. This review was written ahead of the publication of the Dash Review of patient safety across the health and care landscape and the NHS 10 Year Plan but the issues explored will be highly relevant to whether the Review and the Plan achieve their stated aims for quality and safety. Roger has written an accompanying blog discussing the findings of his review: Power and the sound of silence—A blog by Roger Kline

Although insulin is used daily by millions of people around the world, it is considered a high-alert drug that has been associated with more medication errors than any other medication type or class. One challenge in administering insulin is that it is measured in “units” rather than milliliters (mL), requiring unique insulin syringes with the appropriate markings. Using a syringe intended for other medication to administer insulin could lead to an overdose of up to 100 times the intended dose. To identify contributing factors and develop strategies to reduce the risk of wrong dose errors related to the use or selection of syringes, researchers focused on event reports submitted by Pennsylvania facilities in the USA over the last decade that involved U-100 insulin and syringe-related issues resulting in dosing errors or near misses. Some of the key takeaways of their detailed study—which encompassed 74 reports from 47 facilities—are that over a third of errors that reached the patient were serious events and among reports specifying syringe volume, 73.8% involved a 1-mL syringe. Contributing factors included using the wrong syringe due to improper syringe storage, similar cap color or packaging, and provider’s lack of experience. Variability in hospital insulin protocols and formularies was also observed. The authors encourage facilities to evaluate and standardize their existing insulin protocols and formularies, and implement the suggested safety strategies for preventing syringe-related insulin dose errors.

A recent US Office of Inspector General (OIG) study revealed a startling statistic: US hospitals are missing approximately half of all patient harm events. While this figure undoubtedly represents a failure, it isn’t a failure of intention or individual providers; it’s a failure of our systems, as they are set up today, to capture the full picture of safety risks that patients are facing.  At the core of this report lies a simple fact: If we can’t see harm happening, we can’t prevent it. While healthcare has made remarkable progress in reducing infections, preventing falls and minimising medication errors in recent years, we’re still operating with a fundamentally incomplete understanding of the extent of patient harm.  Some in healthcare safety have suggested that we abandon safety event reporting altogether, arguing that current systems are too ineffective to justify the investment. But this perspective misses a critical point: the problem here lies not in the act of reporting itself, but in how we’re doing it.  As AI continues to reshape the way we live, work, and process information, Tejal Gandhiit suggests two transformative capabilities that can revolutionise the way we report and address safety events. 

In 2025 the Department of Health in Northern Ireland held a consultation on the introduction of a new Regional Framework for Learning and Improvement from Patient Safety Incidents to replace the existing Serious Adverse Incident Procedure. This report provides an analysis and summary of the comments made in response to each consultation question. It also covers comments and views shared during consultation events and those in formal consultation response submissions to the Department of Health. Summarising the responses received as part of this consultation, the report states that overall there was strong support for the strategic direction set out in the consultation. It notes that respondents endorsed the proposals as a significant step towards fostering a culture that prioritises openness and learning to improve patient safety and the delivery and quality of care. It advises that the Department will now take time to consider the responses in further detail and will work with partners to consider additions, amendments and refinements that are required to the strategic proposals. This will include ensuring alignment with the implementation of other ongoing policy development in this area including, for example, the Being Open Framework. The report concludes by stating that once considered and approved by the Minister, publication of the Framework, Standards, and Principles will establish the agreed strategic governing framework for learning and improvement from Patient Safety Incidents. A managed transition and implementation phase is anticipated to begin in early 2026. It notes that the Department will keep interested parties informed about future developments relating to the new strategic approach and its implementation.

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