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This month marks a significant milestone for the Patient Safety Management Network (PSMN) as we celebrate its fourth birthday. Launched in June 2021 with just four members on its inaugural call, the Network has grown exponentially to now include almost 2000 members—a powerful testament to the need for, and value of, a connected, collaborative community focused on patient safety. PSMN founder Claire Cox reflects on its achievements, the impact it is having and how it is evolving.  Over the past 4 years, we have hosted 190 meetings, each one an opportunity for members to learn, reflect and share ideas. From January to June 2025 alone, an average of 107 people joined each session, highlighting the continued appetite for learning and improvement among safety leaders across the UK. The Network draws together a unique and diverse membership. It includes individuals involved in patient safety from inside the NHS, outside the NHS, patient safety partners, regulators, commissioners and those on the peripheries, such as academics. We even have a contingent of safety professionals from the veterinary sector joining us! This breadth allows the PSMN to cross organisational, professional and geographical boundaries, ensuring that a wide range of perspectives are shared and valued. At its heart, the network is committed to fostering a psychologically safe space where everyone can learn, contribute and feel supported. A shift towards collective wisdom While we have welcomed 75 external speakers since our inception, the past year has marked a meaningful shift in how we share knowledge. We are moving away from a traditional model of learning from outside experts to one where our Network members are the experts. This shift recognises the depth of experience and insight within the Network and underscores our commitment to shared learning. As Patient Safety Learning noted, the power of Networks lies in their ability to connect people with a common purpose and enable the co-creation of new knowledge.[1] The PSMN has become just that: a space where members bring real-time challenges, innovative practices and lived experiences to the table, enriching the dialogue and pushing the boundaries of what is possible for patient safety. Building a culture of openness and trust From the outset, the ethos of the PSMN has been one of openness, humility and continuous improvement. As we noted in previous blogs,[2] the network has created a psychologically safe environment where members can speak candidly about what is and isn’t working. This culture has not only fostered trust but has also accelerated learning and adaptation across organisations. One of our highlight meetings in the past year focused on the Duty of Candour. These two sessions led to a valuable collaboration with NHS England, NHS Resolution and the Care Quality Commission, resulting in the development of a Frequently Asked Questions resource.[3] This resource was directly shaped by the questions and discussions raised during our Network meetings, demonstrating the tangible impact of shared learning in action. Collaboration and shared learning Last September, we hosted a highly successful Patient Safety Learning Symposium, bringing together professionals and experts from across our Network. The event provided a dynamic platform for collaboration, with participants sharing insights and best practices to improve patient safety across care settings. A key highlight was the depth of expertise within our Network, showcased through interactive workshops on ACCIMAP and SEIPS. These sessions enabled delegates to explore systems-based approaches to understanding and preventing harm, with practical applications for analysing incidents and designing safer processes. Capturing our learning in print A major success for the Network has been the publication of our first book, Patient Safety: Emerging Applications of Safety Science.[4] This collaborative work showcases a series of case studies contributed by our own members, reflecting the real-world challenges and innovative approaches discussed in the Network. It stands as a lasting record of the depth and breadth of expertise within the community and has been met with widespread acclaim for its practical insights and relevance. Building on this success, we are now in the process of writing the second book in the series. This new volume will further explore emerging themes and continue to amplify the voices of those working at the forefront of patient safety. Impact of the Network The Network is proud to have contributed to the working group informing the Health Services Safety Investigations Body (HSSIB) report on fatigue.[5] Recognising fatigue as a serious risk to both patient and staff safety, our involvement helped ensure the report reflects real-world challenges across healthcare. By sharing frontline insights and data, we helped highlight the systemic factors behind fatigue and the need for a national strategy. In a further positive step, we are delighted to welcome a student from University College London (UCL) who will evaluate the Network’s impact on patient safety and wider system function. This collaboration will offer valuable insight into our progress and help guide our future work. Looking ahead As we celebrate this milestone, we also look forward. The next phase of the PSMN will build on the foundations we have laid together. We will continue to harness the expertise within our membership, support each other through shared challenges and champion the changes needed to deliver safer care. To every member who has contributed to the network over the past 4 years: thank you! Your willingness to share, support and learn from one another is what makes the PSMN not just a network, but a movement. References Patient Safety Learning. Patient safety and the power of collaboration (a blog by Patient Safety Learning). Patient Safety Learning, 9 December 2024. Cox C. “We’ve created an incredible pool of talented safety people who are up for collaboration.” Marking three years of the Patient Safety Management Network. Patient Safety Learning, 2023. Patient Safety Learning. Patient Safety Management Network: Strengthening understanding of Duty of Candour through collaboration. Patient Safety Learning, 2025. Cox C, Hughes H, Nicholls J. Patient Safety: Emerging Applications of Safety Science. Class Publishing: Bridgewater, UK; 2024. HSSIB. Investigation report. The impact of staff fatigue on patient safety.  Health Services Safety Investigations Body, April 2025. How to join the Patient Safety Management Network 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].

We asked the Patient Safety Group (PSG) of The Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top 10 priorities for patient safety in surgery. This resource is for surgeons, anaesthetists and other healthcare professionals who work in surgery and contains links to useful tools and further reading. See also: Safety in surgery series Top 10 tips for surgical safety: ‘Think Safety, think SEIPS’ Top 10 patient safety tips for surgical trainees 1. Foster a culture of safety through design Establish a psychologically safe environment, through design, where staff feel empowered to speak up without fear of blame. Promote a Just Culture, balancing personal accountability with systems-based learning from adverse events and near misses. Actively encourage multidisciplinary teamwork and peer support, with support from senior leadership, to enhance safety and well-being. Other useful RCSEd resources: Anti bullying and undermining campaign Sexual misconduct in surgery - Lets remove it campaign Addressing conflict in surgical teams workshop 2. Implement team-based quality and safety reviews Use team-based quality reviews (TBQRs) and structured case analysis to learn from everyday work, incidents and near misses. Translate findings into sustainable improvement initiatives that enhance both patient outcomes and staff experience. Foster a culture of collective learning, ensuring safety insights lead to actionable change. Other useful RCSEd resources: Making sense of mistakes workshop 3. Apply Human Factors principles and systems thinking principles in surgical and clinical practice Design resilient systems that mitigate work and cognitive overload and enhance performance reliability. Use TBQR principles to support this. Standardise workflows, optimise usability of IT systems and medical devices, and integrate cognitive aids (e.g. WHO Safe Surgery Checklists, prompts). Ensure governance processes support safe, efficient and user-friendly surgical environments. Other useful RCSEd resources: Systems safety on surgical ward rounds Improving the working environment for safe surgical care Improving safety out of hours 4. Enhance communication & handover processes Implement structured communication tools such as SBAR (Situation, Background, Assessment, Recommendation) to improve clarity and effective decision-making. Optimise handover processes with digital tools, checklists and standardised documentation. Reinforce closed-loop communication, ensuring critical information is confirmed and acted upon. Other useful RCSEd resources: Consultation Skills that matter for Surgeon (COSMOS) 5. Strengthen leadership & accountability in patient safety Senior leaders must visibly support safety initiatives and proactively engage frontline staff in decision-making. Embed structured mechanisms for raising concerns, including TBQR, safety huddles and escalation pathways. Ensure staff have access to training, resources and protected time for safety and quality improvement work. 6. Minimise medication errors in surgery Implement electronic prescribing and technology assisted medication administration to mitigate errors. Enforce double-check procedures for high-risk medications and standardised drug labelling. Improve intra and peri-operative medication safety with clear labelling, colour-coded syringes and real-time verification. 7. Improve early recognition & response to deterioration Appropriate regular training of teams on processes and pathways supported by good design of staff rota ensuring adequate staffing levels. Implement early warning scores and establish rapid response pathways for deteriorating patients. Standardise post-operative surveillance strategies, ensuring timely escalation and intervention. Other useful RCSEd resources: Recognition and prevention of deterioration and injury (RAPID) course for training in recognising critically ill patients 8. Engage patients & families as safety partners Encourage shared decision-making to align treatment plans with patient expectations and values. Provide clear communication on risks, benefits and post-operative care, using tools like patient safety checklists and focus on informed consent processes. Actively involve patients and families in safety and quality initiatives and hospital discharge planning. Other useful RCSEd resources: Patient/carer/families resources and information Informed consent courses (ICoNS) 9. Standardise, simplify & optimise surgical processes Reduce unnecessary complexity in clinical workflows, making processes intuitive, efficient and reliable. Co-design standard operating procedures, policies and pathways with frontline teams to minimise variation. Implement automation and digital solutions where feasible to streamline repetitive tasks. Other useful RCSEd resources: NOTSS (Non Operative Technical Skills for Surgery) courses for surgeons DenTS courses for dentists 10. Promote continuous learning & simulation-based training Conduct regular simulation training for critical scenarios (e.g. sepsis, airway emergencies, human factors). Use insights from TBQR and incident reviews to target training needs and refine clinical practice. Ensure ongoing professional development by providing staff with time, resources, incentives and institutional support for learning. Other useful RCSEd resources: Education pages Edinburgh Surgery OnLine MSc in Patient Safety and Clinical Human Factors

Promoting Psychological Safety Masterclass is the ideal session for purpose-driven leaders who want to create safe, enriching spaces for employees. Develop your leadership skills to enhance employee and stakeholder wellbeing, and instill a sense of inclusivity and belonging within your community. Join this informative masterclass to explore psychological safety in the workplace. Reflect upon a range of evidence-based strategies and audits, to support workplace wellbeing. This masterclass/session will enable you to: Understand the concept of psychological safety Reflect upon different leadership styles and how this impacts psychological safety Develop evidence-based strategies for workplace wellbeing Explore psychological safety from a diversity, equity and inclusion perspective Engage in reflective discussion on how to embed psychological safety into workplaces Register hub members receive a 20% discount. Email [email protected] for discount code.

In this blog, Clare Wade, Patient Safety Learning's Director, draws attention to the impact toxic cultures have on staff and how, sadly, most often nothing is done about it. Clare shares her own personal reflections from past experiences in her career. There is a clear link between toxic cultures and patient safety, and while there are no easy answers these behaviours must be acknowledged, challenged and cured if the NHS is to survive. I’ve personally experienced toxic culture and behaviour on many occasions, but I found two examples particularly tough to navigate. The first was more than 20 years ago when I worked clinically in a trust largely staffed by the local population where most colleagues were either related or friends; I lived some distance away and commuted in. I’d witnessed troubling behaviour from one senior time-served nurse several times, but one day I heard a blatant, serious breach of patient confidentiality between her and another patient. I was shocked and initially didn’t know what to do. I raised it with the nurse involved who laughed at me, and then the sister in charge who told me to just forget it. After much deliberation, I went to the matron in charge of the department. Conversations took place behind closed doors and eventually I was hauled into trust HQ for a formal meeting, alone—the nurse was nowhere in sight. I was accused of causing upset and the nurse had denied any wrongdoing. In no uncertain terms it was made clear that I should keep my head down and mouth closed if I wanted to remain in post. From that day on my time was made miserable, colleagues closed ranks, stopped talking to me and I was ostracised until the day I left the trust. Later in my career, at a different trust, a new director was recruited to lead my department. From the start something felt off as several senior leaders quickly left their roles. It became obvious that the director was a bully; we largely worked in open plan offices, and the director thought nothing of shouting at and belittling people in front of everyone, even other directors and the CEO. It was impossible for senior colleagues not to know what was happening, but no action was taken. The situation worsened with many people taking sick leave or leaving the trust completely. I came under fire as the director didn’t agree with how I led my team or how we worked, even though our performance was excellent. An external consultant was brought in to identify issues with my practice and help build a case against me. The consultant admitted this to me and said they couldn’t find anything wrong to report back. At the time I had a mentor relationship with a senior board member, and I chose to confide in them with the hope of gaining some insight into how I might be able to better deal with the situation. I didn’t know until sometime later, but my mentor was informing the director about our conversations. As time passed, the behaviour worsened and, although many colleagues were experiencing it too, it was obvious I was on my own in wanting to speak up. I was encouraged to go to a senior HR colleague who would be empathetic, so I did and eventually the director agreed to mediation. I was so nervous ahead of the meeting, but it went ahead and to my surprise the director admitted to some of the allegations and agreed some actions. If I thought my treatment had been bad to this point, I had no idea what was to come. It felt like open season with the director’s full toxicity focussed on me. Derogatory rude emails would be sent daily, raising my anxiety as they landed in my inbox. Meetings where we were both present made me feel sick; they would think nothing of singling me out in front of everyone for their derision and nastiness. The barrage was constant and debilitating, affecting every part of my life and breaking my confidence. One day I couldn’t take any more so left work early and crawled into bed at home where I felt safe. I decided to call the senior HR colleague who had facilitated the previous mediation to ask for an update about the agreed actions. I was absolutely shocked to my core at their reaction, they shouted down the phone that I’d had my opportunity to air my grievances, nothing more was going to happen, the director wasn’t going to be held accountable for the agreed actions and I just needed to forget it and get on with my job. Was I naive to expect a different response? I hit rock bottom, felt scared to go into work and knew I had to get out of there for my health and sanity. Even when I left, the impact followed me to my next role; my confidence and resilience were shot and took a long time to rebuild. The director stayed in post for another couple of years until there were so many grievances that the CEO had to act. The sickening part is that after a period of ‘gardening leave’ the director secured another senior role in another trust in the area so will be perpetrating the same toxic behaviour onto others. I know there are thousands of experiences throughout the NHS just like mine and, unfortunately, in many organisations culture and behaviours aren’t improving. This problem is endemic and has decades of history behind it. There is a clear and acknowledged link between toxic cultures and patient safety. Within the NHS Patient Safety Strategy, NHS England states that: "positive patient safety and healthy organisational culture are two sides of the same coin. A culture in which staff are valued, well supported and engaged in their work leads to safe, high-quality care." In order to improve the care delivered to our loved ones, friends and ourselves, the NHS must take action to improve its culture. Forget the financial situation and the waiting lists, this is the most pressing and wicked problem facing our health service today; it permeates throughout everything and unless it is acknowledged, challenged and cured no other interventions will work. Money doesn’t solve toxic cultures, neither does restructuring the NHS for the umpteenth time. Sadly, some colleagues have taken their own lives because of the toxicity they have endured, this needs to stop now. There are no easy answers here but if we don’t put this right the NHS won’t survive. Share your story Have you worked in a toxic culture? Have you tried to speak up? Have you examples of a good team culture? Add your comment below (you will need to be a hub member and signed in) or contact us at [email protected] and we can share your story anonymously. Related reading on the hub Speaking up for patient safety: A new interview series about raising concerns and whistleblowing Speaking up as an agency nurse cost me my career My experience of speaking up as a healthcare assistant in a care home

The 7th Global Ministerial Summit for Patient Safety, organised by the Department of Health of the Republic of the Philippines and co-sponsored by the World Health Organization (WHO), takes place on 3-4 April 2025 in Manila. This event focuses on advancing international efforts to improve healthcare quality and safeguard patients worldwide. It brings together global leaders, experts and stakeholders to discuss and shape the future of patient safety.  Global Ministerial Summits on Patient Safety aim to drive forward the global patient safety movement. Beginning in 2016, they have helped to keep patient safety high on policy makers’ agendas and helped the build the momentum needed to create the first World Health Organization (WHO) Global Patient Safety Action Plan, published in August 2021. This year’s Summit in Manilla seeks to support the implementation of the Global Patient Safety Action Plan, embracing the theme "Weaving Strengths for the Future of Patient Safety Throughout the Healthcare Continuum." The event highlights the current implementation progress, showcasing diverse approaches and strategic plans adopted by countries. The Summit will include discussions around: The role of patient engagement in bridging patient safety gaps. Diagnostic safety. Leveraging artificial intelligence (AI) and technology for patient safety. Creating psychologically safe and healthy workplaces. Investing in patient safety for sustainable healthcare. There will be sessions across the two days looking at each of these issues, within the broader context of integrating patient safety in all aspects of healthcare delivery and at all levels of care as a foundation of resilient and sustainable healthcare systems. To support the Global Ministerial Summit, Patient Safety Learning has pulled together some key resources from the hub around these key themes being discussed at the Summit. Patient engagement 1 WHO: Patient safety rights charter The Patient safety rights charter is a key resource intended to support the implementation of the Global Patient Safety Action Plan 2021–2030: Towards eliminating avoidable harm in health care. The Charter aims to outline patients’ rights in the context of safety and promotes the upholding of these rights, as established by international human rights standards, for everyone, everywhere, at all times. 2 Championing the patient voice: a recent discussion with the Patient Safety Commissioner at the Patient Safety Partners Network The role of Patient Safety Commissioner for England was created by the UK Government after a recommendation from the Independent Medicines and Medical Devices Safety Review, chaired by Baroness Julia Cumberlege. The Patient Safety Commissioner acts as a champion for patients, leading a drive to improve the safety of medicines and medical devices. This blog provides an overview of a Patient Safety Partners Network meeting where members were joined by Professor Henrietta Hughes, Patient Safety Commissioner for England. 3 Providing patient-safe care begins with asking and listening... really listening! Dan Cohen is an international consultant in patient safety and clinical risk management, and a Trustee for Patient Safety Learning. In this blog, Dan talks about how patient-safe care is all about collaborating and listening to your patients to find out what really matters to them. He illustrates this in a case study of his own personal experience whilst working as a clinician in the USA. Diagnostic safety 4 The economics of diagnostic safety Diagnosis is complex and iterative, therefore liable to error in accurately and timely identifying underlying health problems, and communicating these to patients. Up to 15% of diagnoses are estimated to be inaccurate, delayed or wrong. Diagnostic errors negatively impact patient outcomes and increase use of healthcare resources. This Health Working Paper from the Organisation for Economic Co-operation and Development (OECD) defines the scope of diagnostic error and illustrates the burden of diagnostic error in commonly diagnosed conditions. It also estimates the direct costs of diagnostic error and provides policy options to improve diagnostic safety. 5 Improving diagnostic safety in surgery: A blog by Anna Paisley Good outcomes for surgical patients require accurate, timely and well-communicated diagnoses. 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. 6 How early diagnosis saves lives: case study on aortic dissection In this blog, The Aortic Dissection Charitable Trust explains why timely and accurate diagnosis of aortic dissection is critical for saving lives. By sharing Martin’s recovery story, they illustrate the positive impact of prompt testing and treatment. The blog highlights the need to improve patient safety relating to aortic dissection, calling for increased education and awareness among healthcare professionals; improved clinical guidelines and protocols; and heightened vigilance in recognising and responding to the symptoms of aortic dissection. Artificial intelligence (AI) and technology 7 Patient Safety and Artificial Intelligence: Opportunities and Challenges for Care Delivery (IHI Lucian Leape Institute) In January 2024, the Institute for Healthcare Improvement (IHI) Lucian Leape Institute convened an expert panel to explore the promise and potential risks for patient safety from generative artificial intelligence (genAI). The report that followed summarises three user cases that highlight areas where genAI could significantly impact patient safety: in documentation support, clinical decision support and patient-facing chatbots. 8 AI in healthcare translation: balancing risk with opportunity In an increasingly global healthcare environment, with patients and professionals from many different cultural and linguistic backgrounds, precision in medical document translation is key. In this blog, Melanie Cole, Translations Coordinator at EIDO Systems International, talks about the challenges, risks and opportunities for using AI in healthcare translation. 9 Integrated human-centred AI in clinical practice: A guide for health and social care professionals This is a guide for designers, developers and users of AI in healthcare. It outlines general principles health and social care professionals should consider, a case study drawn from clinical practice and a directory of resources to find out more. It includes key questions that clinicians and AI developers need to answer together to ensure the best possible outcomes. It follows on from the CIEHF's White Paper, Human Factors in Healthcare AI, which sets out a human factors perspective on the use of AI applications in healthcare. Psychological safety 10 Speak up for Safety: A new workshop for healthcare staff about the importance of Just Culture The culture of a healthcare organisation can determine how safe its staff members feel to raise concerns about patient safety. Bella Knaapen, Surgical Support Governance & Risk Management Facilitator and Sarah Leeks, Senior Health & Wellbeing Practitioner at Norfolk and Norwich University Hospitals NHS Foundation Trust, have developed ‘Speak Up For Safety’, a Just Culture training workshop that aims to help staff, at all levels, understand the importance of creating an environment that encourages people to share concerns and feedback. 11 Balancing care: The psychological impact of ensuring patient safety In this blog, Leah Bowden, a patient safety specialist, reflects on the impact her job has on her mental health and family life. She discusses why there needs to be specialised clinical supervision for staff involved in reviewing patient safety incidents and how organisations need to come together to identify ways we can support our patient safety teams. 12 Amy Edmonson: The importance of psychological safety As a leader how can you foster a work environment where people feel safe to speak up, share new ideas and work in innovative ways? In this video from the Kings Fund, Amy Edmondson, Novartis Professor of Leadership and Management at the Harvard Business School, talks about the importance of psychological safety in health and care and what leaders can do to create it. Sustainability 13 The Royal College of Surgeons of Edinburgh: Green Theatre Checklist Healthcare services globally have a large carbon footprint, accounting for 4-5% of total carbon emissions. Surgery is particularly carbon intensive, with a typical single operation estimated to generate between 150-170kgCO2e, equivalent to driving 450 miles in an average petrol car. The UK and Ireland surgical colleges have recognised that it is imperative for us to act collectively and urgently to address this issue. The Royal College of Surgeons of Edinburgh have collated a compendium of peer-reviewed evidence, guidelines and policies that inform the interventions included in the Intercollegiate Green Theatre Checklist. This compendium should support members of the surgical team to introduce changes in their own operating departments. 14 Communicating on climate change and health: Toolkit for health professionals Communicating the health risks of climate change and the health benefits of climate solutions is both necessary and helpful. Health professionals are well-placed to play a unique role in helping their communities understand climate change, protect themselves, and realize the health benefits of climate solutions. This toolkit from WHO aims to help health professionals effectively communicate about climate change and health. 15 Climate change: why it needs to be on every Trust's agenda The NHS has declared climate change a health emergency, but are trust leaders and healthcare staff talking and acting on this? Angela Hayes, Clinical Lead Sustainability at the Christie Foundation Trust and a hub Topic leader, discusses climate change and the impact it has on all of our lives and health. She believes healthcare professionals have a moral duty to act, to protect and improve public health, and should demand stronger action in tackling climate change. If you would like to write a blog or have a resource to share on any of the themes highlighted in this blog, please get in touch. Contact the hub team at [email protected] to discuss further.

Being able to effectively give feedback is fundamental to building and maintaining a high performing team, and the way we deliver that feedback can make or break psychological safety. This workshop dives into how we can work most effectively with feedback, and ensure it’s a “tool for good”, helping us meet our goals. It will cover everything from principles and approaches to practical tools, mechanisms and traps to avoid. This Power of Effective Feedback workshop is designed to be applicable for those working in all industries, domains and roles. It may be most useful for those with people responsibilities, including managers, leaders, trainers, supervisors and mentors. In this workshop, we explore: Psychological Safety Fundamentals The purpose of feedback Characteristics of great feedback Traps to avoid Psychologically safer feedback “I’m ok, you’re ok” and other models The flipside of feedback – learning to receive it well The Local Rationality Principle Non-Violent Communication Practical tools and strategies Further reading and resources You’ll leave with a new perspective on the power of feedback and a range of practical tools to help you use it most effectively in your context. Register

This course from Medled will: Introduce Human Factors For Healthcare; what is it and why does it matter? Ask we mean by ‘Systems Thinking’? Looking beyond the flawed concept of Human Error, utilising the SEIPS tool. Establish difference between simple, complicated and complex work, and how this might impact our approach to safety and performance. Look at different models of safety & risk across the spectrum of working practice; balancing the focus of rule based and adaptive working. Explore the impact of stress and cognitive load on decision making and how we can perform at our best under pressure. Discuss the key components of High Performing Teams, in particular the impact of Psychological Safety and how it can be developed. Provide a practical and tangible tool for addressing our physiological needs. Register

In this blog, Patient Safety Learning looks at the results of the NHS Staff Survey 2024, focusing on responses relating to reporting, speaking up and acting on safety concerns. We highlight that, alongside other evidence, the survey results point to a lack of progress in improving safety culture in the health service. In its major restructure of healthcare governance in England, Patient Safety Learning argues that the Government needs to prioritise decisive, practical action to create cultures in which staff feel safe to speak up. On 13 March 2024, the NHS published the results of its 2024 staff survey. 774,828 staff from 263 organisations took part and the results provide a snapshot of their experiences of working in the health service.[1] The survey included a range of questions specifically about reporting, speaking up and acting on patient safety concerns. Unfortunately, the responses show little positive progress on these areas from previous years, underlining the persistence of blame cultures and a fear of speaking up in significant parts of the NHS. Survey results Reporting of errors, near misses and incidents Two-fifths of survey respondents, over 300,000 NHS staff, were unable to say with confidence that their organisation treats them fairly if they are involved in an error, near miss or incident. This is set against a much higher number of respondents, 86.43%, who said their organisation encourages staff to report errors, near misses or incidents. Responses to both these survey questions have not significantly changed in the past three years. This demonstrates that staff see a significant disconnect between what their organisation tells them about reporting patient safety issues and how they feel they will be treated if they actually raise concerns. There is also a significant problem when it comes to what staff think about how their organisations respond to patient safety issues. 68.21% of staff said that when errors, near misses or incidents are reported, their organisation takes action to ensure that they do not happen again. It is a major concern that over 240,000 NHS staff feel unable to agree with this statement. Connected to this, nearly two-fifths of respondents, 38.71%, did not agree that they are given feedback about changes made in response to reported errors, near misses and incidents. When staff are unable to clearly see their organisation’s approach to learning and acting on safety concerns, it is understandable that they might not have confidence these are being acted on. This issue is likely to be amplified further for patients and the public who do not have an inside view of the NHS. We need to see action for improvement being shared transparently within organisations and with the wider public. Concerns about clinical safety and speaking up The percentage of staff who say they would feel secure raising concerns about unsafe clinical practice has changed very little in the past five years, hovering at just above 70%. The response rate in 2024 means that over 200,000 NHS employees, 28.47% of survey respondents, could not say that they would feel secure raising concerns about unsafe clinical practice. When asked if they were confident that their organisation would address these concerns, only 56.83% of staff responded positively, a figure very similar to last year’s results and down nearly 4% from 2020 (56.87% in 2023, 60.57% in 2020). When it comes to speaking up about broader issues, 38.18% of respondents, nearly 300,000 NHS staff, could not say that they felt safe to speak up about anything that concerns them in their organisation. When asked about their confidence in their organisation acting on any concerns, the picture looks worse, with half of all respondents not having confidence that their concerns would be addressed (50.48%). Published in July 2019, the NHS Patient Safety Strategy identifies a patient safety culture as one of the two foundations required in working towards its safety vision “to continuously improve patient safety”.[2] This ambition clearly remains a long way out of reach when, for four consecutive years, nearly two-fifths of NHS staff surveyed have said they do not feel safe to speak up about concerns. No signs of culture change The 2024 staff survey results show no significant change from recent years in responses to questions on reporting incidents, clinical safety and speaking up about patient safety issues. While the survey only provides an annual snapshot of what it is like to work in the NHS, its findings are reinforced by evidence elsewhere. Blame cultures are a recurring theme echoed across many different inquiries into major patient safety scandals.[3] [4] [5] By creating an environment in which staff fear retribution if they are involved in a patient safety incident, blame cultures encourage staff to cover up the causes of avoidable harm rather than reporting them. The shocking experiences and testimonies of whistleblowers in healthcare are further evidence of staff not feeling safe to speak up and suffering severe repercussions when they do. Too often, staff raising patient safety concerns to their organisation are met with a hostile and aggressive response, rather than one that welcomes challenge and scrutiny. Staff who speak up for patient safety often receive personal threats, vexatious referrals to regulatory bodies, pay cuts and demotions, disciplinary action and contractual changes. We are highlighting these issues as part of a new interview series, Speaking up for patient safety, in partnership with Peter Duffy, an NHS whistleblower and Chair of the Healthcare Working Group at WhistleblowersUK.[6] The series looks at how people who speak up in healthcare are treated by organisations, leaders and regulators, and how this acts as a barrier to staff raising patient safety concerns. In each interview, Peter and Patient Safety Learning’s Chief Executive Helen Hughes, talk to with someone who has spoken up about patient safety in healthcare or who works to help staff raise concerns. We need to move from ambition to action At Patient Safety Learning, we believe it is vital that we create a culture in healthcare that supports raising, discussing and addressing the risks of unsafe care. It is difficult to imagine that this type of evidence of an unsafe culture in other safety-critical industries—where the consequences of incidents may also be serious injury or loss of life—would be considered acceptable. Responses to patient safety questions in this year’s NHS Staff Survey were very similar to the 2023 results, which we analysed in our report, We are not getting safer: Patient safety and the NHS staff survey results.[7] This year’s survey results indicate that in too many parts of the health service, staff don’t feel safe to speak up and don’t have confidence that their concerns are being listened to and acted upon. These results support our view that the health service needs a more transformative effort and greater commitment to creating a safety culture. As detailed in ‘We are not getting safer’, NHS England has made some positive progress by introducing new guidance and information that aims to help develop a safety culture in the NHS.[7] However, there is little detail about how to effectively implement safety culture guidance and best practice across NHS-commissioned health and social care providers. There is also a lack of clarity about how improvements in culture will be monitored, evaluated and shared for wider adoption. The way that the NHS will operate in future years is currently subject to significant change. The forthcoming 10-Year Health Plan and the recent announcement that NHS England will be incorporated back into the Department of Health and Social Care are signs of significant structural change.[8] Patient safety must be at the centre of this new operating model, with organisations supported and held to account in creating a culture where staff feel safe to speak up. We need to move beyond rhetoric and into practical action. References NHS Staff Survey. Results, Last Accessed 13 March 2025. NHS England. The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019. Department of Health and Social Care. Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust. Ockenden Report: Findings, conclusions and essential actions from the independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust, 30 March 2022. Department of Health and Social Care. Independent Investigation into East Kent Maternity Services. Maternity and neonatal services in East Kent – the Report of the Independent Investigation, 19 October 2022. The Mid Staffordshire NHS Foundation Trust Public Inquiry. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, 6 February 2013. Patient Safety Learning. Speaking up for patient safety: An interview series with Peter Duffy & Helen Hughes, 15 January 2025. Patient Safety Learning. We are not getting safer: Patient safety and the NHS staff survey results, 26 March 2024. Department of Health and Social Care. World’s largest quango scrapped under reforms to put patients first, 13 March 2025

Last month Public Policy Projects, in partnership with Patient Safety Learning, held their Patient Safety Forum 2025, as part of a new patient safety policy programme between the two organisations. Taking place at the Royal College of Physicians in London, in attendance were senior healthcare leaders, patient safety experts, representatives from the HealthTech industry, frontline healthcare professionals, patients, policy makers and the media. In this article, Patient Safety Learning’s Chief Executive, Helen Hughes, and Director, Clare Wade, look back at the day and share their reflections on the event. Digital health technologies are likely to be central to the successful delivery of the UK’s forthcoming 10-Year Health Plan. However, if we are to fully realise the benefits of new devices and innovations, patient safety needs to be at the heart of their development, implementation and use. In working towards this, it is vital that we bring together people from across the health and social care system who have the right knowledge, skills and experiences to contribute to this. We have therefore been delighted to partner with Public Policy Projects (PPP) over the past six months on a patient safety programme that culminated in our Patient Safety Forum on Thursday 27 February 2025. Leading up to this event, between October and December 2024, we hosted with PPP three roundtable sessions discussing patient safety through the lens of technology, digital innovation and data-driven transformation. The outcomes of these events are summarised in a new report, Patient safety in the digital NHS: user-centric approaches to technology and transformation.[1] The key findings of this report were reflected throughout the discussions at our Patient Safety Forum: 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. Introduction to the Forum To begin the event, Helen Hughes, Chief Executive of Patient Safety Learning, welcomed participants, sponsors and panellists to the Patient Safety Forum. The goals of the event and our partnership with PPP were to: Ensure that technology introduced to service delivery is patient centred and safe. Embed a culture of patient safety within UK healthcare. Support patient safety being a core purpose of Integrated Care Systems (ICSs) and to ensure the patient voice is core to the design of safety at system level. The initial keynote speech at the Patient Safety Forum was then provided by Jeremy Hunt MP, Chair of the All-Party Parliamentary Group on Patient Safety. He reflected on his first experiences of patient safety in his previous role as Secretary of State for Health and the scale of avoidable harm in the healthcare system. Jeremy spoke about a report published in December by Imperial Institute of Global Health Innovation and the charity Patent Safety Watch, which had highlighted the gap in healthcare between the UK and best performing OECD countries.[2] The report showed that if the UK matched the top 10% of OECD countries, this would equate to 13,495 fewer deaths per year. The report also underlined the cost of unsafe care in England, estimated at £14.7 billion per year. He also talked about the areas that he believes should be key patient safety priorities, identifying the following four areas: Creating a centralised system to collate and prioritise patient safety recommendations. To improving and revitalise the Care Quality Commission. To tackle cultural issues in the NHS, with reform of the clinical negligence system an important element of this. Not normalising avoidable deaths. Patient safety and Integrated Care Systems Following the morning keynote address, the first panel session of the Forum focused on the need to position patient safety as a core purpose across ICSs. This featured the following participants: Helen Hughes – Chief Executive, Patient Safety Learning Sir Liam Donaldson – Chair of North East and North Cumbria Integrated Care Board (ICB), Special Envoy for Patient Safety, World Health Organization Kate Provan – Associate Director Clinical Effectiveness and Improvement, NHS Greater Manchester Matthew Mansbridge – Senior Safety Investigator, Health Services Safety Investigations Body (HSSIB) Tim James – Clinical Director and Nursing Executive, Oracle Health UK Sir Liam Donaldson opened the first panel by explaining that when approaching patient safety as an ICB, it must be viewed through the lens of avoidable harm. Some of the issues discussed with the panellists were: The need to reduce variation across healthcare in how patient safety incidents and avoidable harm are both responded to and acted on. The difficulties of reducing avoidable harm while working against the backdrop of persistent blame cultures in parts of the NHS, which undermine efforts to learn and improve. The difficulties that organisations can face in attempting to respond to mismatched reporting requirements across various bodies in a complex operating environment. Errors occurring in weak systems, where services are performing at suboptimal level and with poor practitioner performance. We need to tackle the normalisation of deviation from good practice At Patient Safety Learning, we believe that greater action is required to create clarity about the role of ICBs and ICSs in patient safety. We set this out previously in in our 2023 report, The elephant in the room: Patient safety and Integrated Care Systems.[3] A HSSIB investigation report published this year echoed these points, highlighting the lack of overarching principles for ICBs and ICSs to take a consistent approach to safety management. [4] [5] With greater clarity around the roles, ICBs and ICSs have the potential to drive systemic improvements in patient safety. However, to do so effectively, they require enhanced tools, commitment and capacity that support patient safety. Culture and regulation The second panel session at the Forum focused on how patient safety improvement could be driven forward and supported through culture and regulation. This featured the following participants: Sue Holden – Executive Chair, Advancing Quality Alliance Dr Alan Clamp – CEO, Professional Standards Authority for Health and Social Care Norman MacLeod – Patient Safety Partner Moyra Amess – Director - Assurance and Accreditation, CHKS A key element of this panel discussion was how to create a psychologically safe culture in healthcare. This extended not just to creating a culture of incident reporting, but also ensuring staff and patients see clear examples of those reports being acted on for improvement. Psychological safety is when someone feels they are safe to speak up with ideas, questions, concerns or mistakes without fear of being punished or humiliated. We have a number of different resources available on this topic on the hub, our platform to share learning for patient safety. To overcome blame cultures in the NHS, the panellists all emphasised the importance of kind leadership: “Leaders have an active choice to be kind in healthcare, and it makes such a difference, it is hard in a pressurised system, but it is a choice we can all make.” Panel members also discussed some of the challenges for regulators and regulation, highlighting the following points: Regulators must prioritise safety over regulations. The need for the regulatory environment to continually evolve to meet new patient safety opportunities and challenges, such as the growing use of artificial intelligence (AI) in healthcare. Being clear on how to understand ‘what good looks like’, what organisations are doing to work towards this and how this is measured. Not subsuming safety within quality. Being alert to system failure in healthcare like the frogs in a saucepan analogy—the water heating slowly to the point of catastrophic harm because we have tolerated normalised deviance. Insight through triangulation of data—patient and, staff perspectives and experience and data. Harnessing information and sharing for patient safety The next panel session at the Forum was on the opportunities and challenges presented by the development of new systems for sharing and utilising patient data to improve outcomes. This featured the following participants: Professor Sam Shah – Professor of Digital Health, College of Medicine and Dentistry, Ulster University Jonathan Webb – Head of Safety & Learning, NHS Wales Professor Maureen Baker CBE – Former Chair, Professional Record Standards Body Mark Linggood – Director of Product Management, RLDatix A key area of discussion in this session was on the use of AI and the need to understand the advantages and limitations of this in improving the sharing and use of healthcare data. This included the use of AI in diagnostics, sentiment analysis and how it can support deeper organisational learning. Panel members also highlighted the following points: The need to improve interoperability—the ability of different systems, devices, applications or platforms to work together and exchange information effectively. This still presents significant barriers to sharing data in real-time. Difficulties that patients and families face in navigating the NHS and having control over their own care. This has recently been the subject of a new blog series we have published on the hub. The importance of clinical engagement in the design and procurement of digital systems. That the digital safety standards are essential and need to embraced, supported and championed by system regulators such as CQC, which unfortunately isn’t the case. Improving how we can share and use patient data, and the implications of this for patient safety, is an area we have previously looked at in detail around electronic patient record (EPR) systems. While EPR systems have the potential to improve patient treatment, increase efficiency and reduce the costs of healthcare, their implementation also comes with serious patient safety risks. In July last year, we published a new report on this topic, Electronic patient record systems: Putting patient safety at the heart of implementation.[6] This outlined the key patient safety risks associated with choosing and introducing new EPR systems and identifies 10 principles to consider for safer implementation. Health inequalities and patient safety The focus of the final panel session of the Forum was on the connection between health inequalities and patient safety. This featured the following participants: Jono Broad – President Elect - Patient Safety, Royal Society of Medicine Sandra Igwe – Chief Executive, The Motherhood Group Professor Habib Naqvi MBE – Chief Executive, NHS Race and Health Observatory Jacob Lant – Chief Executive, National Voices Health inequalities often result in poorer outcomes for some patient groups, including impacting on their safety during care and treatment. Discussing these issues, panel members made the following points: Research has found that, in too many cases, black mothers are treated in an inhumane way by maternity healthcare professionals, including examples of the barriers in providing pain relief and a lack of empathy. The need to do more to ensure appropriate minority representation in healthcare organisation staffing and leadership. Addressing racial biases in medical devices, such as the accuracy of pulse oximetry, and recommendations of the Government’s review of unfair biases in their design and development more broadly. Vulnerable groups have longer wait times—as services do not cater for their needs, a ‘one size fits all’ strategy doesn’t work in healthcare. Health inequalities can lead to a breakdown in trust by communities, which leads to further patient safety issues if patients are reluctant or fearful of accessing services. Closing remarks At the end of the Patient Safety Forum, Dr Penny Dash, Chair of NHS North West London and the incoming Chair of NHS England, gave a keynote address.[7] Penny set out how she had approached her independent review into the patient safety landscape, commissioned by the Government to be published ahead of the 10-Year Health Plan.[8] [9] She noted the overcrowded and fragmented patient safety landscape, highlighting that her team had identified over 127 organisations in England involved in patient safety to some degree. Penny emphasised that quality should encompass productivity and efficiency as well as safety and effectiveness. She said: “We know that well-managed services lead to more efficient use of resources–that in itself is a big quality opportunity. We can actually do things for less that frees up money for more care.” Looking forward, she said she hoped the NHS would be given a “balanced scorecard” to measure quality, alongside the priorities in its annual planning guidance. She said there were many metrics available, but they could be “presented and brought into board papers” better than they were.[10] Reflections from Patient Safety Learning This was the first face-to-face event as part of our new patient safety policy programme with PPP. We had a magnificent line up of speakers with expert chairing of panels and a great turn out on the day. The Forum was significantly oversubscribed and we had a long waiting list that we had to close. We are sorry that not everyone was able to attend, next year we plan to make the event even bigger and better. We have received enthusiastic feedback from panellists, sponsors and participants, many saying that this was the best event on that topic that they’d ever attended. There was huge energy in the auditorium with conversations during the breaks that were equally inspiring, with people keen to push ahead on improving patient safety in their own organisations. There was also a supportive theme that ran throughout the discussions, with a number of panellists and participants stressing the need for greater kindness and empathy in the health service. Helen’s thoughts One personal story shared at the Forum that really resonated with me was shared by Sue Holden, Executive Chair, Advancing Quality Alliance. She recalled a time early in her career as a midwife when she had met with parents to share information as to why their newly born baby had suffered severe avoidable harm during the birth. At the end of the meeting, which she said had been at times challenging and emotionally hard for all, the father of the baby showed Sue two envelopes that he’d previously prepared. On opening the one passed to her, Sue found a financial donation to the hospital’s fundraising appeal. When she asked what was in the other one, the father explained that he was a solicitor and it was a prepared letter outlining the clinical negligence action he would have taken if faced with a lack of information and defensiveness. Sue described how this has always stayed with her, and I felt that this is a strong metaphor for the choices we all make for patient safety. It made me think, how often do we, as clinicians, patient safety experts or organisational leaders, look the other way? Do we just follow process? Or do we embrace honesty, integrity and justice, putting patients and families at the heart of the work we need to do to take action for improvement. Many of the Forum participants shared their challenges in doing the right thing, raising questions about organisational culture and behaviours that don’t prioritise patient and staff safety. As Penny Dash said, we must role model the behaviour we want to see in others. We must listen and act with kindness. And as Sir Liam said, “'find harm', go looking for it, use data and analysis to understand it and address it.” Clare’s thoughts At a time when the NHS is grappling with the toughest challenges in its history, it was heartening to have so many enthusiastic, positive delegates join us last Thursday. Connections were made and reignited, and conversations about issues and how to combat them were shared. Although everyone is in no doubt of the hill we all have to climb, there was a collective voice keen to find solutions and make change happen. I met new people, listened to different perspectives and drew energy from being in such a positive space. Our keynote speakers offered their insights, and panel members brought opinions from their own experiences encouraging us to challenge beliefs. It's important that we all take these opportunities to refresh, engage and reenergise. Thank you to everyone who joined us, we hope to see you again soon. References Public Policy Projects. Patient safety in the digital NHS: user-centric approaches to technology and transformation, 28 February 2025. Imperial Institute of Global Health Innovation & Patent Safety Watch. National State of Patient Safety 2024: Prioritising improvement efforts in a system under stress, 12 December 2024. Patient Safety Learning. The elephant in the room: Patient safety and integrated care systems, 11 July 2023. HSSIB. Safety management systems: accountability across organisational boundaries, 13 February 2025. Patient Safety Learning. Patient safety across organisational boundaries: Patient Safety Learning’s response to HSSIB investigation, 13 February 2025. Patient Safety Learning. Electronic patient record systems: Putting patient safety at the heart of implementation, 31 July 2024. Department of Health and Social Care. Dr Penelope Dash confirmed as new chair of NHS England, 3 March 2025. Department of Health and Social Care. Review of patient safety across the health and care landscape: terms of reference, 15 October 2024. Patient Safety Learning welcomes a new review of patient safety across the health and care landscape, 15 October 2024. Health Service Journal. New NHSE Chair seeks ‘clear accountability and responsibility’, 4 March 2025.

In this blog, Leah Bowden, a patient safety specialist, reflects on the impact her job has on her mental health and family life. She discusses why there needs to be specialised clinical supervision for staff involved in reviewing patient safety incidents and how organisations need to come together to identify ways we can support our patient safety teams. It was 2am and I found myself on my third trip to my one-year-old son’s bedroom, just to check if he was still breathing. He had a cough and a fever, which we were managing with paracetamol and ibuprofen, but I couldn’t settle. My mind raced with worst-case scenarios—is this sepsis? strep A? pneumonia? I crept into his room, relieved to find him still breathing. His head felt cooler. I tried to calm myself, texting my husband who was on a night shift. “I’m so worried about Ruairi, I can’t sleep.” He replied, “He’s fine, Leah. His temperature is coming down. You need some rest.” But as I lay in bed, staring at the baby monitor, I knew sleep wouldn’t come. It was December 2022 and I was leading the Learning From Deaths Agenda for West Midlands Ambulance Service (WMAS). That winter, child mortality rates spiked. What used to be occasional reviews of child deaths turned into several. The Coroner requested photos of the deceased to aid investigations. I found myself opening file after file, seeing photos of dead children. One case hit too close to home—a little boy in the same pyjamas my son wore, cuddling the same Makka Pakka toy. The room seemed to close in on me. I felt palpitations, tears welling up, and I struggled to breathe. I worked remotely, my husband was at work, so I went downstairs, made tea, and sobbed uncontrollably on my own. I felt ridiculous—this wasn’t my child, my grief, and I wasn’t the paramedic on scene. How could I be so upset? Before joining the patient safety team, I was a frontline paramedic, witnessing my share of traumatic cases, including child deaths. I moved into patient safety in early 2022 and loved it. But my role shifted from caring for the living to reviewing deaths and I hadn’t realised the toll it took. My husband, also a paramedic, faces these cases head-on. I felt silly sharing my distress over reviews, thinking I shouldn’t be this affected. So, how do we cope? How do we manage? Patient safety teams are often small, fostering close relationships. I spoke to my boss daily; she would call checking in with “How are you? The numbers have increased, haven’t they? Are you coping? Do you need anything?” Countless times, I called her in tears, “I’ve just reviewed this awful case.” But working remotely can be isolating. Reviewing cases at home, especially if you live alone or your partner is at work, can feel very lonely. I’m no longer the Learning From Deaths Lead for WMAS. Now, as patient safety specialist leading the Patient Safety Incident Response Framework (PSIRF), I oversee a team of 11, including 10 learning leads and the learning from deaths lead. Although I no longer review cases of those who died, or who’s care contributed to their death, I now support those who do. I’m the boss at the end of the phone asking, “How are you? How are you coping? Do you need anything?” One of my learning leads, experienced, who has been in the team years, recently struggled with the impact of her cases. She wants a baby but has seen too many cases where care went wrong and babies died. A situation I had contributed to as I had assigned her these cases because under the Serious Incident Framework we were staffed mostly with alternative duties staff, who were often pregnant, and they couldn’t investigate cases like that. She’s in a better place now, I am thankful to say, but the impact of those cases will stay with her forever. We need more support for our patient safety teams. These teams show up every day, striving to improve care and make a difference. We need specialised clinical supervision for those involved in reviewing patient safety incidents. Engagement with families, especially bereaved families, is emotive, heartbreaking and incredibly difficult to do day in and day out. Our organisations need to come together to identify ways we can support our teams and I am excited to be working with Patient Safety Learning to collaborate on what this may look like. We know the 'second victim' of patient safety incidents is thought to be the staff directly involved in care; is the 'third victim' patient safety staff? But, for now, I’ll keep being there, asking, “How are you? How are you coping?” I’ll make face-to-face catch-ups mandatory to see them in person. I’ll keep checking my three-year-old is still breathing when he’s unwell, and things he might choke on—grapes, sausage rolls and bouncy balls—will never be allowed in my house. We would love to hear from you Do you work in patient safety? How does it affect you? How do you cope with what you see and hear? How do you support your team members? Please share your experiences and suggestions by commenting below. You will need to be a member of the hub and signed in. It's free and easy to do. Further reading on the hub: Top picks for staff psychological safety “The alarming rate of suicide among healthcare workers should be a wake-up call in the urgent need to support them” (a blog by Claire Goodwin-Fee, CEO of Frontline 19) Staff Support Guide - Patient Safety Learning Vicarious trauma: The invisible epidemic Bitter pill – A paramedic's tale How fostering empathy and psychological safety makes healthcare safer: An interview with Carolyn Cleveland

Session Objectives • Advocate for the establishment of a culture to enhance patient safety and system reliability. • Encourage the adoption of leadership training models • Foster an environment that emphasizes learning from mistakes and redesigning healthcare systems. Register

Patient Safety Learning and retired urology consultant Peter Duffy have launched a new interview series, ‘Speaking up for patient safety’. Peter is an NHS whistleblower and Chair of the Healthcare Working Group at WhistleblowersUK. The series looks at how people who speak up in healthcare are treated by organisations, leaders and regulators, and how this acts as a barrier to staff raising patient safety concerns. In each interview, Peter and Patient Safety Learning’s Chief Executive Helen Hughes talk to someone who has spoken up about patient safety in healthcare, or who works to help staff raise concerns. In this blog, Peter and Helen explain the concepts of speaking up and whistleblowing and outline why creating a safe environment for speaking up is vital for patient safety. They share why they decided to produce the interview series and outline the impact they hope giving people who have spoken up a platform to share their experiences and insights will have. You can follow the interview series on the hub and by subscribing to the series YouTube podcast. "After I lost my own career as a direct consequence of whistleblowing, I found myself unemployed and prematurely claiming my NHS pension many years before I had ever anticipated stepping away from full-time work. As well as the personal cost, it meant that the unsafe care I reported went unchanged and opportunities to make care safer for patients were lost. It left me determined to prevent the same kind of catastrophic consequences and cover-ups happening to the next generation of patients and healthcare professionals, a cause that Patient Safety Learning is also committed to." Peter Duffy "I hear stories like Peter’s so often, it’s a pattern that is repeated across healthcare all the time. We need to expose the unfairness of doctors, nurses and other healthcare professionals being required to raise concerns, and then being vilified when they do so. The horrendous impact on their lives and careers when the system closes in on them is something we desperately need to address. Staff need to feel safe to share their genuine concerns and insights—and these must be listened to and acted upon to improve patient and staff safety. It’s vital we explore how we can make changes to legislation, leadership and management and culture so that we can stop this awful cycle repeating itself." Helen Hughes We decided to collaborate on a series of interviews that would draw together the voices of some of the people who have spoken up for safety and found themselves treated poorly by the organisations and systems they were trying to make safer. Speaking up, whistleblowing and patient safety People working in healthcare will sometimes see things at work that cause them concern. They might notice a situation or action that is causing or could cause harm to a patient, staff member or the public. For example, they might see a patient safety incident that isn’t dealt with properly or a risk that is not being taken seriously. They may witness dishonest behaviour, bullying, harassment or discrimination. When someone reports their concerns with the aim of making things better or stopping something from going wrong, they are ‘speaking up’. In some cases—but not all—when someone speaks up, it is also defined as ‘whistleblowing’. Although the two terms are often used interchangeably, whistleblowing refers to the sharing of ‘protected disclosures’ which have a specific legal definition, as outlined in the Public Interest Disclosure Act 1998 (PIDA).[1] Whistleblowing always involves a concern that is in the public interest to raise and might relate to a criminal offence, health and safety risks, failures to carry out legal obligations, a miscarriage of justice, or an attempt to conceal and cover up any of these things. PIDA was designed to offer some protection from retaliatory action for whistleblowers. However, many whistleblowers report that the reality of their experience was that there was little to protect them from retaliatory grievances and disciplinary action by their organisation’s management. The repercussions of speaking up act as a significant barrier to people sharing concerns about patient safety. Healthcare staff often fear that they will lose their career and that it will affect their work and personal lives if they step out and speak up. Many people decide it just isn’t worth the risk. But speaking up and whistleblowing are vital to improving patient and staff safety and standards of care. By raising concerns, staff offer their organisations opportunities to learn from things that could go or are going wrong, and mitigate risks. In addition, all registered healthcare professionals have a professional duty of care to raise concerns. Many people we interview in this series make the same comment; that in speaking up, they were just doing their job. For these reasons, it is vital to create a culture where staff feel safe and supported to fulfil their obligations to raise concerns without fear that it will affect their career prospects, working life and personal wellbeing. Creating this kind of environment contributes to what is sometimes referred to as ‘psychological safety’. While there are currently measures in place to encourage and support staff to speak up, they clearly aren’t working effectively—despite so many regulators, potential targets and available sanctions in the NHS, individual and organisational scandals in healthcare just keep happening. Candour, ethical behaviour and honesty are key things we need in place to maximise patient safety in the healthcare system. The importance of first-hand experience and insights Peter’s experience of speaking up is one of many that clearly demonstrates that the current system of regulation and safeguarding is not effective. We decided to start this interview series because we believe it’s time to identify and deal with the cultural and organisational issues that make it difficult for people to raise concerns about patient safety issues. The national NHS Staff Survey results tell us that too many healthcare staff are nervous to speak up when they see unsafe care or inappropriate behaviour. In spite of slight progress in some areas, 37% of all staff who responded still feel unsafe to speak up about concerns—that’s about 260,000 people. Almost 50% said they were not confident that their organisation would address concerns raised.[2] It’s so important that we hear the voices of people who have gone through the difficulty of speaking up or whistleblowing as they have unique and highly valuable insights. Their experiences of internal investigations, complaints processes and employment tribunals demonstrate that the systems that are supposed to support people who speak up often neglect their needs. The reasons for this include pressure from organisational leaders, a culture of not wanting to hear bad news and prioritising organisational reputation above patient and staff safety. It’s vital that we understand the cost individuals have paid for taking action that they believe to be right and that their professional standards require. During the series we speak to experienced and committed healthcare professionals who have received threats, abuse and gaslighting from their employers. Some have lost their careers as a result and many describe the significant impact on their work life, private life and health. The interviews are informal and although the interviewees will have a rough idea of where the discussions are likely to lead, we challenge and explore their opinions. Our aim is to draw out the details that might help us better understand the nature and extent of specific issues—from threats and retaliation from other staff to human resources practices and employment tribunals. We start each conversation by inviting our guest to share their own experience of whistleblowing or speaking up, or of working with people in that space. We discuss the consequences for whistleblowers, as well as for patients and families, when organisations fail to respond well to staff who raise concerns. We then invite each guest to reflect on any areas for learning that can be drawn from their experience and make suggestions of ways to better protect both NHS staff and patients. In some interviews we look at whether healthcare regulators and the legal system are appropriately designed or equipped to protect whistleblowers and staff who speak up, as well as the public interest. Amplifying voices for change If enough healthcare staff, patients, families and motivated members of the public take notice of the issues we’re raising, then the pressure for change can only increase. Our hope is that we can convince leaders across the sectors that real, profound and lasting progress will be in the best interests of all of us. We’d like to see changes to the way that safeguarding and whistleblowing are viewed within our political, judicial and regulatory systems. But to achieve this, we need to see more urgency from those who have the power to make real change. We are seeing some examples of positive movement, but this remains slow and patchy and there is resistance to change from parts of the legal profession and healthcare leaders. Towards the end of last year, the Secretary of State for Health and Social Care, Wes Streeting MP, launched a new consultation on government proposals to regulate health service managers, ensuring they follow professional standards and are held to account. As part of this announcement, he stressed the Government’s commitment to protect whistleblowers by introducing regulation for managers and enforcement measures to tackle managers who “silence whistleblowers or endanger patients through misconduct.”[3] We welcome this commitment, and Patient Safety Learning will be responding to the consultation. However, these words need to be accompanied by prompt and decisive action, or the gap between what many NHS organisations say to employees about speaking up and whistleblowing and what happens in practice will remain. The statistics that estimate the worrying extent of avoidable harm in the UK [5] need action right now, not in a year, or five, or ten. We believe any drive to bring these awful figures down needs to include a relentless focus on safeguarding, speaking up and accountability. Get involved If you have spoken up about unsafe care or have been a whistleblower in healthcare or social care, we would love to hear from you about your experience. You can: contribute to our community conversation (you’ll need to sign up first) comment on any hub post (you’ll need to sign up first) contact us at [email protected] and we can share your story anonymously. You can find information about organisations that offer support and guidance for staff about speaking up and whistleblowing on the hub. Listen to the interviews Helené Donnelly in conversation with Peter Duffy and Helen Hughes Martyn Pitman in conversation with Peter Duffy and Helen Hughes Jayne Chidgey-Clark in conversation with Peter Duffy and Helen Hughes Gordon Caldwell in conversation with Peter Duffy and Helen Hughes Bernie Rochford MBE in conversation with Peter Duffy and Helen Hughes Beatrice Fraenkel in conversation with Peter Duffy and Helen Hughes References 1 UK Government. Public Interest Disclosure Act 1998. Accessed 11 December 2024 2 NHS Staff Survey. NHS Staff Survey National Results 2023. Accessed 11 December 2024 3 Department of Health and Social Care, UK Government. New protections for whistleblowers under NHS manager proposals. 24 November 2024 4 J Elgot and D Campbell. Managers who silence whistleblowers ‘will never work in NHS again’, vows Streeting. The Guardian. 27 June 2024 4 J Illingworth, A Shaw, R Fernandez Crespo et al. National State of Patient Safety 2022: What we know about avoidable harm in England. Institute of Global Health Innovation, Imperial College London, 2022

Psychological safety is when someone feels they are safe to speak up with ideas, questions, concerns or mistakes without fear of being punished or humiliated. In healthcare, developing a culture of psychological safety is essential to ensuring patient safety. It helps to create and maintain an environment where patient safety issues can be raised, discussed and resolved. A psychologically safe environment supports incidents of avoidable harm being responded to with empathy, respect, rigour and action for improvement. Whilst the first priority after any incident of avoidable harm will be to support patients and their families, staff directly and indirectly involved should also be provided with the support they need following an incident. Organisations should have a support structure in place to look after their staff’s mental health and wellbeing. At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples.  In this ‘Top picks’, we have pulled together resources, blogs and tools from the hub to support staff and organisations in developing a culture where everyone feels psychologically safe. 1 Paul O’Neill: A psychological safety success story We often talk about failures of psychological safety – what happens when, in an absence of psychological safety, concerns are not raised, questions remain unasked, mistakes are hidden and no one shares their improvement ideas. Unsurprisingly, the consequences can be catastrophic. But what happens when leaders prioritise psychological safety, and how can it transform their organisations? Paul O’Neill at Alcoa was one such example and highlights that cultures can change, with leadership and commitment to psychological safety and addressing the ‘work as done'. 2 Speak Up for Safety: A new workshop for healthcare staff about the importance of Just Culture The culture of a healthcare organisation can determine how safe its staff members feel to raise concerns about patient safety. Bella Knaapen, Surgical Support Governance & Risk Management Facilitator and Sarah Leeks, Senior Health & Wellbeing Practitioner at Norfolk and Norwich University Hospitals NHS Foundation Trust, have developed ‘Speak Up For Safety’, a Just Culture training workshop that aims to help staff, at all levels, understand the importance of creating an environment that encourages people to share concerns and feedback. 3 Amy Edmondson: The importance of psychological safety As a leader how can you foster a work environment where people feel safe to speak up, share new ideas and work in innovative ways? In this video from the Kings Fund, Amy Edmondson, Novartis Professor of Leadership and Management at the Harvard Business School, talks about the importance of psychological safety in health and care and what leaders can do to create it. 4 Staff Support Guide: a good practice resource following serious patient harm This guide from Patient Safety Learning and the Safer Healthcare Biosafety Network, as part of the Safety for All campaing, outlines what good practice support looks like for a staff member following a serious safety incident, and through the subsequent investigation and aftermath. 5 System-level changes are essential to improve the psychological wellbeing of NHS staff In this study, researchers reviewed literature on the causes of stress and anxiety among nurses, midwives and paramedics. They recommended that senior leaders, managers and clinicians improve working conditions and shift from individual interventions only (such as mindfulness or resilience training) to include a focus on system-level culture change. 6 Royal Society of Medicine: Aware to Care resource pack Psychological safety resource pack for all staff on a wide range of topics, including improving team communication and dynamics, tools to build awareness of current state of mind and behaviour, moving from reacting to responding, building and balancing compassion between others and self. 7 Trust talk! The language of leaders who create psychologically safe teams Language is powerful. Our words are important. Few things are likely to have a more frequent or profound impact on the trust (or mistrust) levels of our teams than the words we speak on a daily basis. Our words can influence our teams to frame events in positive or negative, helpful or hindering, and trusting or fearful ways. Psychologist Clive Lloyd looks at how the language we use can create psychologically safe teams. 8 Vicarious trauma: The invisible epidemic In healthcare, an insidious epidemic lurks beneath the surface, affecting the very individuals tasked with providing care: vicarious trauma by empathy. Despite its profound impact, this phenomenon remains largely unrecognised and under-discussed within the sector. As leaders, it is imperative that we shed light on this invisible trauma and acknowledge it as one of the greatest challenges facing our industry, as Margarida Pacheco explains in her blog. 9 How can our team move past a traumatic event? After an extreme traumatic event there are things that you can do to help yourself, and your colleagues, to move on. Fiona Day, medical and public health leadership coach and chartered coaching psychologist, Stacey Killick, consultant paediatrician at Glan Clwyd Hospital, and Lucy Easthope, professor in practice at Durham University’s Institute of Hazard, Risk, and Resilience and adviser on disaster recovery give their tips in this BMJ article. 10 Strategies for improving clinician psychological safety in reporting and discussing diagnostic error One of the best ways to collect information about diagnostic errors is through self-reporting by patients and healthcare professionals. This issue brief from the Agency for Healthcare Research and Quality looks at how to foster psychological safety and organisational safety culture in order to reduce harm from diagnostic error. 11 Safety Incident Supporting Our Staff (SISOS): A second victim support initiative at Chase Farm Hospital Suicide rates for doctors, nurses and allied healthcare workers are rising and being involved in a safety incident increases this risk. The need to support staff when things go wrong is evident. We come to work to do the very best we can for our patients, often ignoring and at the cost of our own health. Most adverse incidents happen, not because we are bad at what we do, but because of system failure. As professionals who care passionately about our work, we blame ourselves when things go wrong. In a series of blogs. Carol Menashy shares her experiences of setting up and developing Safety Incident Supporting Our Staff (SISOS). 12 Pyschological safety videos This channel is dedicated to useful, entertaining and informative content about psychological safety, human organisational performance, and organisational learning. 13 What can the NHS do to help staff speak up about concerns? How do you ensure staff’s concerns are voiced and heard in a complex system like the NHS? A recent decline in doctor’s confidence to raise concerns about patient safety has led to renewed calls for stronger regulation of managers – but a broader approach is likely to be vital to encouraging staff to speak up writes Professor Graham Martin, Director of Research at THIS. 14 Balancing care: The psychological impact of ensuring patient safety In this blog, Leah Bowden, a patient safety specialist, reflects on the impact her job has on her mental health and family life. She discusses why there needs to be specialised clinical supervision for staff involved in reviewing patient safety incidents and how organisations need to come together to identify ways we can support our patient safety teams. 15 “The alarming rate of suicide among healthcare workers should be a wake-up call in the urgent need to support them” Frontline19 was established at the start of the Covid pandemic as an urgent response to support frontline workers who were under extreme pressure and experiencing significant mental health challenges. In this blog, psychotherapist Claire Goodwin-Fee, founder and CEO of Frontline19, explains how systemic pressures and stigma around mental health are continuing to leave healthcare staff extremely vulnerable. 16 How fostering empathy and psychological safety makes healthcare safer: An interview with Carolyn Cleveland Carolyn Cleveland has delivered training on empathy and compassion to healthcare organisations for many years. In this interview, she describes how she came to develop her training approach and outlines how creating a psychologically space environment for individuals to engage with the practice of empathy contributes to safer organisational cultures. Do you have a resource or an example of how your organisation supports staff psychological safety to share? We’d love to hear about it – leave a comment below or join the hub to share your own post.