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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 January to March 2025. Count of Event Types in LFPSE – based on patient safety event records from January 2025 to March 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 the current period, 832,301 events were recorded to LFPSE, the majority of which were recorded as patient safety incidents (96.73%). Count of patient safety incidents by maximum physical harm – based on patient safety incident records from January 2025 to March 2025 Grading the degree of harm to a patient resulting from a patient safety incident can be a challenge for recorders, but by grading patient safety incidents according to the harm they cause patients, local organisations can ensure consistency and comparability of data. This consistent approach locally will enable LFPSE to compare, analyse and learn from data nationally. This grading can also be used to “triage” incidents for review both locally and nationally, ensuring the most serious events are looked at first. LFPSE also allows 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 previous National Reporting Learning Service (NRLS). Currently, NHS England states that 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.

A tracheostomy is a common procedure done for patients who need prolonged mechanical ventilation, are unable to protect their airway or have pathologies of the oropharynx leading to the potential for upper airway obstruction. While a tracheostomy is relatively safe, complications are common, and it is essential to understand the management steps to ensure that the patient’s tracheostomy functions as intended. In a single centre study of 100 patients undergoing tracheostomy, the complication rate was 47% during the initial hospitalisation. The most common complications included obstruction of the tracheostomy (19%), bleeding (16%), infection (14%), and accidental decannulation (13%). While these complications are common, if managed appropriately, mortality directly related to the tracheostomy has a very low incidence. This article in the Anaesthesia Patient Safety Foundation newsletter discusses how to keep patients safe during emergency tracheostomy management.

The Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest patient safety data repository of its kind in the United States and one of the largest globally, housing over 5 million reports submitted since 2004. This article presents data from reports submitted to PA-PSRS in 2024. In 2024, 315,418 reports were submitted to PA-PSRS, marking a 9.5% increase from 2023. Reports of serious events rose by 7.3%, while high harm events increased by 1.1%. Of all reports, 96.0% came from hospitals, while 4.0% originated from nonhospital facilities (ambulatory surgical facilities (ASFs), birthing centres, and abortion facilities). The vast majority (96.0%) were incidents, while the remaining 4.0% were classified as serious events. Preliminary 2024 reporting rates show 32.2 reports per 1,000 patient days for hospitals and 11.4 reports per 1,000 surgical encounters for ASFs, with both rates increasing by 1.1 points from 2023 Error Related to Procedure/Treatment/Test (P/T/T) remained the most frequently reported event type overall, accounting for 33.4% of reports from all facilities combined and 47.6% from nonhospital facilities. Among serious events, Complication of P/T/T was the most common type, making up 57.7% of serious event reports from all facilities combined and 71.4% from nonhospital facilities.

Patient safety is a fundamental aspect of any healthcare system. Edmund Bailey and Mohammed Dungarwalla explore the development of patient safety both generally and in relation to dentistry over the past ten years. Other aspects of healthcare and various concepts are explained and described, including human factors, Safety I and Safety II, patient safety culture, managing patient safety incidents and the second victim concept, perfectionism and punishment myths, and hierarchy, along with wellbeing and support for practitioners. They bring together ten years of experience in patient safety related to dentistry and discuss this in the context of wider developments in patient safety, with reference to reports and policies that have influenced this field. The paper also includes helpful resources and suggestions to allow readers to discover more about patient safety in dentistry, and to examine the safety culture in their own organisations. They conclude by contemplating on what the next decade might bring.

Operational guidance to support health boards boards undertaking perinatal adverse event reviews incorporating the additional reporting required of maternity services. See also Maternity and neonatal (perinatal) adverse event review process for Scotland: Operational guidance to supplement the HIS national framework

The last two or three years have seen an unprecedented number of developments in the UK (England in particular) which can be loosely described as being advances or planned advances in patient and family empowerment (or “engagement” in patient safety). This editorial from Peter Walsh explores the potential and challenges of Martha's Rule, Hillsborough Law, Patient Safety Partners, the Harmed Patient Pathway and the Independent Advice and Advocacy.

The COVID-19 pandemic had a profound impact on healthcare systems globally, with potential to aggravate levels of healthcare-associated harm. Due to radical changes within service provision, this period was considered likely to influence patient-reported safety concerns. This study aimed to characterise the nature of these safety concerns at different time periods after the first UK lockdown. The most frequently reported safety incidents involved access to healthcare professionals (12 months/18 months), and errors managing healthcare appointments (24 months). Prominence of themes fluctuated over time, as the context and policies that influenced the safety reports shifted. For example, geographical limitations on healthcare were evident at 12 months, mitigation from healthcare-associated harm by family members at 18 months, and concerns surrounding healthcare professional and other patient’s behaviour at 24 months. Healthcare organisations are undoubtedly still undergoing a protracted period of recovery. However, to protect health services from any further threats to functioning, organisations must review patient safety data systems and examine staff perspectives on the issues identified, notably in relation to infection control policies, social distancing, and patient access to health services. Learning from patient-reported experiences and considering how safety incidents are defined would support improvements in patient safety.

This study described the characteristics of voluntarily reported patient safety events (PSEs) in primary care, specialty, and emergency veterinary facilities in the US and Europe. It found errors in veterinary healthcare occurred at a predictable rate. Veterinary practices of all types should collect data on the PSEs occurring in their facilities to identify opportunities to improve the safety of their patients. Patient safety in veterinary care settings reflects some of the challenges we face in healthcare.

Professor Frank Smith's presentation to the Royal College of Surgeons of Edinburgh on confidential reporting and surgical safety.

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 (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.

Ensuring Patient Safety in healthcare is essential and requires efficient methods to reduce risks and improve the quality of care. Although incident reporting tools are commonly used to identify possible and actual care failures, their efficacy differs among various environments. The aim of this study was to evaluate the effectiveness of incident reporting tools in enhancing patient safety.

Expectations of patient and family involvement in investigations of healthcare harm are becoming conventional. Nonetheless, how people should be involved, is less clear. Therefore, the “Learn Together” guidance was co-designed, aiming to provide practical and emotional support to investigators, patients and families. This study evaluated the use of the Learn Together guidance in practice—designed to support patient and family involvement in investigations of healthcare harm. Findings The guidance supported the systematic involvement of patients and families in investigations of healthcare harm and informed them how, why, and when to be involved across settings. However, within hospital Trusts, investigators often had to conduct “pre-investigations” to source appropriate details of people to contact, juggle ethical dilemmas of involving vs. re-traumatising, and work within contexts of unclear organisational processes and responsibilities. These issues were largely circumvented when investigations were conducted by an independent body, due to better established processes, infrastructure and resources, however independence did introduce challenge to the rebuilding of relationships between families and the hospital Trust. Across settings, the involvement of patients and families fluctuated over time and sharing a draft investigation report marked an important part of the process—perhaps symbolic of organizational ethos surrounding involvement. This was made particularly difficult within hospital Trusts, as investigators often had to navigate systemic barriers alone. Organisational learning was also a challenge across settings. Conclusions Investigations of healthcare harm are complex, relational processes that have the potential to either repair, or compound harm. The Learn Together guidance helped to support patient and family involvement and the evaluation led to further revisions, to better inform and support patients, families and investigators in ways that meet their needs (https://learn-together.org.uk). In particular, the five-stage process is designed to centre the needs of patients and families to be heard, and their experiences dignified, before moving to address organisational needs for learning and improvement. However, as a healthcare system, we call for more formal recognition, support and training for the complex challenges investigators face—beyond clinical skills, as well as the appropriate and flexible infrastructure to enable a receptive organisational culture and context for meaningful patient and family involvement. Related reading on the hub: The Learn Together programme (part A): co-designing an approach to support patient and family involvement and engagement in patient safety incident investigations

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 2024. Count of Event Types in LFPSE – based on patient safety event records from October 2024 to December 2024 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, 814,560 events were recorded to LFPSE, the majority of which were recorded as patient safety incidents (96.46%). Count of patient safety incidents by maximum physical harm – based on patient safety records from October 2024 to December 2024 Grading the degree of harm to a patient resulting from a patient safety incident can be a challenge for recorders, but by grading patient safety incidents according to the harm they cause patients, local organisations can ensure consistency and comparability of data. This consistent approach locally will enable LFPSE to compare, analyse and learn from data nationally. This grading can also be used to “triage” incidents for review both locally and nationally, ensuring the most serious events are looked at first. LFPSE also allows 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 previous National Reporting Learning Service (NRLS). Currently, NHS England states that 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.

The being fair tool will support decision-making for patient safety incidents referred to workforce, and to ensure that staff are not treated unfairly after a patient safety incident. In rare circumstances a learning response may raise concerns about an individual’s conduct or fitness to practise. It is in these specific circumstances that the being fair decision-making tool can help decide what next steps to take.

The Patient Safety Authority (PSA) 2024 Annual Report highlights PSA's commitment to safer care for Pennsylvanians. With over 5 million patient safety event reports, the Pennsylvania Patient Safety Reporting System (PA-PSRS)  is the largest repository of its kind in the United States and one of the largest in the world. PSA's accomplishments last year include: Analysed serious event reports identifying neonatal injuries or death related to labour and delivery, published our findings in a report, and shared evidence-based strategies for mitigating the risks associated with shoulder dystocia. Worked with ambulatory surgical facilities to improve surgical site infection surveillance and reporting, including regional, in-person symposia throughout Pennsylvania on the identification of infection through the application of criteria and using hospital-acquired infection data to evaluate infection prevention programs. Published monthly newsletter articles featuring Patient Safety Reporting System (PA-PSRS) reports, such as "What to Know About Glacial Acetic Acid: Stop Using It" and "Pica Behavior in Acute Care Hospitals: Strategies for Screening and Mitigating Risk of Harm." These were also disseminated in PSA's peer-reviewed journal, Patient Safety, which reaches more than 150,000 readers worldwide. Embarked on an ambitious five-year strategic plan, Reimagine Patient Safety 2029, built on three main pillars: push the boundaries of information science to identify and understand patient safety issues, leverage relationships to implement changes that improve patient safety, and maintain a strong organizational culture that focuses on people and continuous organisational improvement.

The 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.