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While traditional methods such as Failure Mode and Effects Analysis (FMEA) are well-established, they often reach their limits in clinical practice. This is due in particular to the subjectivity of fault identification. I would like to propose the Hazard and Operability Study (HAZOP) as a complementary risk analysis method. HAZOP offers a structured, systematic approach to risk identification and assessment, particularly suited to analysing process risks and human factors. Unlike FMEA, HAZOP uses guide words (e.g. NO, MORE, LATE, LESS, OTHER THAN) to explicitly identify and analyse potential deviations from tasks and procedures.  A systematic approach to identifying and assessing clinical risks Despite the implementation of risk management systems, practice often falls short of expectations. This is due, among other factors, to the complexity of clinical processes, the dynamics of the work environment, and interprofessional interfaces, which make a holistic risk assessment difficult. Although traditional methods are widely used, they reach their limits in clinical practice: Subjectivity: When using traditional methods such as FMEA, which rely on the team’s spontaneous fault detection and experience, critical risks are easily overlooked as they are not recognised as ‘failure modes’. Monocausality: Traditional failure-mode-based approaches lead to a monocausal derivation of causes and effects. Human factors as ‘operator error’: Human errors are easily classified as ‘user problems’ without questioning the systemic causes (e.g. time pressure, unclear responsibilities, inadequate communication). Against this background, I propose the Hazard and Operability Study (HAZOP) as a complementary risk analysis method. The HAZOP method was originally developed in the aviation industry and has established itself there as the gold standard for analysing risks in highly complex, safety-critical environments. HAZOP enables the approach required by ISO 31000 as a structured, step-by-step approach: Risk identification Risk analysis Risk evaluation Risk identification using guide words The method uses guide words as a heuristic to systematically identify potential process deviations as a starting point for the risk analysis. These guide words are adapted to clinical reality and enable a comprehensive risk analysis: Guide Word: Possible deviation. No: Failure to perform a task. More: Excessive performance of a task. Less: Inconsistent performance of a task. Late: Delayed performance of a task. Other than: Incorrect execution of a task. Using guide words as a starting point for risk identification also helps to involve those with little experience in risk management in the process. A list of guide words can and should be adapted to the specific requirements of the specialist department. Practical application: Example 'documentation of vital signs' Task: Recording and documenting vital signs in the intensive care unit. Guide word: Possible deviation No: Blood pressure is forgotten. Late: Documentation is delayed, delaying further diagnosis. Less: Not all vital signs are measured. Other than: A mix-up of patients in the documentation. Risk analysis The identified risks can be assessed using a two-dimensional risk matrix, like in other risk tools: Probability of occurrence (scale: ‘almost impossible’ to ‘almost certain’). Impact (scale: ‘no health consequences’ to ‘life-threatening consequences’). This commonly used and well-known assessment method enables measures to be prioritised and helps hospitals to proceed in a resource-efficient way. Risk evaluation and identification of measures Preventive and corrective measures are developed during interprofessional workshops, in which representatives from all relevant professional groups (doctors, nursing staff, administration, IT) work together to evaluate risks and propose solutions. Typical measures include: Process optimisations (e.g. standardisation of documentation procedures). Training to raise awareness of human factors. Technical adjustments (e.g. introduction of digital checklists). Clarification of responsibilities (e.g. through clear SOPs). Discussion The HAZOP method offers several key advantages that are particularly relevant to clinical patient safety: The use of guide words enables risks that are often overlooked to be systematically identified. This reduces subjectivity in error detection and enables more objective prioritisation of measures. The method allows for the analysis of human and organisational factors. This enables a holistic view of incident causes and supports hospitals in developing systemic solutions. HAZOP can be seamlessly integrated into the SEIPS 2.0 approach, which enables a coherent risk assessment that accounts for all relevant factors. The approach promotes collaboration among professionals from different disciplines. This strengthens the learning culture and helps to close governance gaps. Thanks to the structured approach and the use of guide words, risk analysis can be carried out more quickly and efficiently. Conclusion The HAZOP method, with its guide words, is a proven, systematic and evidence-based tool for improving clinical patient safety. It enables a comprehensive risk analysis that takes into account technical, procedural and human factors. Do you use the HAZOP method? We would love to hear from you if you're using HAZOP in a clinical setting so we can share real-life examples of its use. Email us at [email protected] or comment below (you need to be signed into the hub; sign up here, it is free and easy to do).

This online session will look at the essential role of robust data and learning from audit in helping identify risks, prevent harm, and build safer systems of care. Drawing on practical examples, the session will explore how data from audits and registries can be used to detect safety signals, understand where harm is occurring, and support action to reduce risk and improve patient safety. This session includes: Welcome from the Chair: Dr Jacqueline Andrews, Executive Medical Director, Harrogate and District NHS Foundation Trust and HQIP Trustee Using data for safety – A perspective from the Patient Safety Commissioner: Professor Henrietta Hughes OBE, Patient Safety Commissioner The role of the National Joint Registry in patient safety: Chris Boulton, Director of Operations, National Joint Registry Using national maternity data to drive patient safety improvement: Faith Sheils, Director of Midwifery, Northern Care Alliance NHS Foundation Trust From incident to improvement: using Epilepsy12 data to commission a safer first seizure pathway: Dr Colin Dunkley, Consultant Paediatrician, Sherwood Forest Hospitals, Epillepsy12 Clinical Lead Update from Patient Safety Learning: Clare Wade, Director, Patient Safety Learning Register here.

In February, Public Policy Projects (PPP) hosted their annual Patient Safety Forum in partnership with Patient Safety Learning. Held at the Royal College of Surgeons of England in London, it was attended by senior healthcare leaders, patient safety experts, representatives from the HealthTech industry, frontline healthcare professionals and patients. A wide-ranging conversation between Penny Dash, Chair of NHS England, and the PPP Chair, the Rt Hon. Stephen Dorrell, offered a rare, candid look at the thinking behind the forthcoming National Quality Strategy and the complex trade-offs shaping it. The session was a live debate on the priorities, pressures and realities of improving care across the NHS. In this blog, Patient Safety Learning reflects on the key takeaways from this keynote session. A strategy nearing the finish line Penny Dash confirmed that the National Quality Strategy is in its final stages, with publication anticipated in April 2026. The process has involved extensive input from across the system, with the National Quality Board—co-chaired with the Care Quality Commission—playing a central role in refining the final draft. While the timeline reflects urgency, it also highlights the challenge of aligning political, clinical, and operational perspectives in a single framework. However, there was a concerning lack of focus on the NHS Patient Safety Strategy. Will it be updated or subsumed into the National Quality Strategy? This interview made it clear that while patient safety may have become less of a focus for NHS leadership, for the delegates in the room it was front and centre. During a panel session earlier in the day, Bola Owolabi (CQC Chief Inspector of Primary Care and Community Services) had a clear focus on patient safety, saying that we are all patient safety practitioners and that interfaces between episodes of care are the biggest patient safety risk, with many patients falling between the cracks. Did we witness a complete difference of opinion and priority between key senior NHS leaders and, if so, what hope is there for coherent strategies that will align to bring safer care and improvements? No surprises—but a sharper focus At its core, the strategy reaffirms three familiar pillars of quality: Effectiveness (outcomes). Safety. Patient and user experience. But what matters is how these are prioritised. Penny Dash was clear that improving life expectancy and healthy life expectancy is the overarching goal. That means focusing on major drivers of population health, particularly cardiovascular disease and cancer, while aligning with broader NHS reforms around prevention, community care and digital transformation. The big insight: effectiveness versus safety One of the most striking moments came when Dash revisited a controversial finding from her earlier review: Improving effectiveness could save ~100,000 lives per year. Improving safety could save between 1,000 and 10,000. Her message was clear: this is not a choice, but it does challenge how the system has historically prioritised safety over other aspects of quality and the outcomes from that; aspects of patient safety have not improved over the past 25 years. Audience members pushed back on this framing, arguing that safety and effectiveness are often intertwined in practice. Penny Dash agreed, acknowledging that quality cannot be meaningfully separated into silos and should instead be addressed as a whole. A system out of balance Penny Dash also pointed to a deeper structural issue: how resources have been allocated across the NHS. Over the past decade: Hospital spending has risen significantly. Primary care has seen modest growth. Community care funding has declined. At the same time, life expectancy and healthy life expectancy have fallen. The implication is stark: the system may be investing heavily, but not always in the areas that deliver the greatest long-term health impact, reinforcing the need to prioritise prevention, neighbourhood care and earlier intervention. The role of Integrated Care Boards Integrated Care Boards (ICBs) were highlighted as critical to delivering change. Their role is to: Plan services for local populations. Improve outcomes and reduce inequalities. Ensure value for money. Penny Dash emphasised that ICBs must take responsibility for entire populations, including underserved groups such as prisoners and the homeless, while being supported by national guidance and shared best practice. As ICBs implement more strategic commissioning, the performance management of the outcomes will fall to the regions. Given the current situation with resource reductions and redundancies, will anyone be focussing on ensuring the right staff are in place with the right skills to understand safety indicators and analyse the data? A lack of appropriate people in place who understand this agenda will leave a void, meaning we will see no progress in how the available data is used to review implementations, learn lessons and make improvements. Patient experience: leadership without mandates A major proposal within the strategy is the creation of a National Director of Patient Experience, aimed at strengthening how patient feedback informs decision making. However, this sparked debate around a broader theme: the approach of not mandating process and practice across the NHS. The perspective from Penny Dash was that too many mandates can stifle innovation and local responsiveness; however, too few can lead to inconsistency and inaction. Rather than imposing roles or structures from the centre, the strategy will lean towards defining best practice and encouraging adoption locally—a move that drew both support and scepticism from the audience. Patient Safety Learning has recently highlighted through our blogs the concerns that the patient voice is being dissipated given the structural changes resultant from the implementation of the Dash review. We will look to support initiatives strengthening the patient voice that might come from the new National Director of Patient Experience. Technology as a game changer Another key theme from the keynote was the role of technology, particularly through Modern Service Frameworks. Unlike traditional guidelines, these are envisioned as live, digital tools that will integrate with patient records with the ability to provide real-time prompts to clinicians. Early focus areas include cardiovascular disease and sepsis, with ambitions to expand into mental health, frailty and children’s services. If successful, this could mark a shift from static policy documents to dynamic, data-driven care pathways. Beyond healthcare: the wider determinants The discussion also touched on the limits of the NHS alone in improving health outcomes. Penny Dash highlighted the importance of social prescribing, housing and legal support, and community and mental health services. These 'non-biomedical' interventions are increasingly recognised as essential but require closer collaboration between the NHS, local authorities and public health systems. The mandate dilemma—still unresolved Perhaps the most persistent theme throughout the session was the unresolved tension between national consistency and local autonomy. As the chair noted, this is “as old as the health service” itself. Dash’s position was pragmatic: neither extreme work. The challenge is to find a balance that ensures high standards across the country while allowing local systems the flexibility to innovate and respond to their populations. Audience Q&A Members of the audience were given the opportunity to pose questions to Penny. Following a comment from her, that our collective focus should have been on quality rather than patient safety, there was a noticeable edge to delegate’s questions. People were surprised that patient safety appeared to have been downgraded in importance and others seemed to question whether NHS senior leaders are in tune with the reality of frontline work. Some felt this was not a positive demonstration of leadership in a time of significant change within the NHS. A system in transition The conversation made one thing clear: the National Quality Strategy is not just a document, it’s an attempt to reshape how the NHS thinks about quality, signalling a shift from safety alone → to broader outcomes, from central control → to guided collaboration and from static policies → to dynamic, tech-enabled systems. But it also exposes the scale of the challenge. Balancing priorities, reallocating resources, integrating services and maintaining public trust all while improving outcomes will require more than strategy alone. It will require sustained alignment across one of the most complex healthcare systems in the world. And as this session showed, that conversation is only just getting started. At Patient Safety Learning, we look forward to the publication of the National Quality Strategy. We will reflect and engage with our network members before publishing on the implications for patient safety. Find out more about the Patient Safety Forum 2026 You can read more about different discussions and panel sessions at this year’s event in the below: Safe systems, safe cultures: reflections from the Patient Safety Forum 2026 Patient voice, safety and the NHS 10 Year Plan: Reflections from the Patient Safety Forum 2026 Designing AI with patient safety at its core: Reflections from the Patient Safety Forum 2026

A good night’s sleep is essential for healing, yet, for many patients, it can feel almost impossible to be able to sleep or get rest during an inpatient stay. The Noise at night sleep pack project at Nottingham University Hospitals was a finalist at the Picker Experience Network 2025 Awards. In this blog, project lead Kelly Morley tells us why this initiative and a renewed focus on reducing noise at night was so important. Despite the dedication of staff and the comfort measures provided on our wards, night‑time noise remains one of the most common concerns raised through patient feedback and it was quickly identified as one of the top three patient experience priorities within our trust. At Nottingham University Hospitals (NUH), we know that sleep isn’t a luxury it’s a vital part of the fundamentals of patient care. Why night-time noise matters Hospitals are naturally busy environments. Even after lights dim, clinical activity continues as staff carry out observations, respond to emergencies, check medications and support patients who are awake or unwell. For patients, though, these unavoidable sounds can lead to: Interrupted sleep or the inability to fall asleep. Increased anxiety and stress. Decreased mental awareness. Higher pain sensitivity. Slower recovery times. Lower patient satisfaction. Complaints. Decreased uptake in rehabilitation exercises. Deconditioning. Longer patient stays. Many patients tell us that a noise is one of the most challenging aspects of their stay. Sleep is not just a comfort—it’s a critical part of recovery. Even as far back as in 1859, Florence Nightingale published her book 'Notes on Nursing', which contains lots of good advice about sleep in patients and these are still actions we would do well to take into consideration in modern nursing. “Unnecessary noise, then is the most cruel absence of care that can be inflicted on either the sick or well” (Florence Nightingale) What our patients were saying Through patient surveys, ward feedback and conversations with patients and staff, we regularly heard that noise from equipment, conversations, staff, bins, alarms and other patients would significantly affect their sleep. When asked the question: Do you have any suggestions as to how we can improve the quality of sleep for in-patients or any comments you would like to make? Patients responded: “Would be willing to try anything.” “I think the sleep pack should be mandatory and given to inpatients.” “Ask staff to speak quietly and answer the buzzers quicker—it sounded like they were moving furniture last night.” When we asked staff what they thought prevented patients from sleeping they reported: “Noise from other patients.” “Lighting.” “Observations/medications/investigations/turns.” "Noise from staff.” This feedback drove our improvement work. Sleep packs: small items, big impact To help patients rest better, many wards at NUH now offer sleep packs. These typically include: A sleeping well in hospital leaflet—this was designed by clinical staff with an interest in sleep and why it matters. The leaflet pulls together all literature that has been written in the Trust to date in regard to sleep and amalgamates this into one simple evidence-based leaflet. Earplugs—to soften unavoidable environmental noise. These are in singular packs and can be replaced as and when needed. Eye masks—to reduce disruption from lighting on the wards, particularly when nurses tend to other patients. Slipper socks—these ensure patients are not looking around for slippers in the night, opening lockers, looking under beds and, best of all, they are a simple measure that can also reduce slips, trips and falls. Sleep packs may seem like a small intervention, but patients consistently tell us they make a real difference—especially for those who struggle to settle in unfamiliar surroundings. The items are always used with the aid of clinical judgement, and it is reiterated that these items are not always suitable for everyone. Our aim is to ensure these packs are readily available and consistently offered, particularly to patients most likely to benefit. Post implementation, the feedback was very different: “Thank you for supplying the sleep pack. They have definitely made a difference.” “The mask was comfy and helped.” “Sleep packs, very beneficial. Sleep interrupted a lot as observations being taken regularly, but this is to be expected and not a criticism.” How our staff are supporting quieter nights Staff play a crucial role in creating a calmer night‑time environment. Across NUH a quieter hospitals group was formed to work on the problems that were identified during this project, including: Reducing unnecessary noise on wards: Lowering voices during night rounds. Limiting equipment noise where safe to do so. Closing doors softly. Using soft close bins/ doors. Having top tips poster for staff—reiterating the sleep leaflet guidance and making staff more aware. Planning care to avoid multiple disturbances during the night: Grouping non‑urgent tasks together (cluster care). Using soft‑close bins and quieter equipment where possible. Responding to patient needs: Offering sleep packs. Adjusting lighting levels where safe to do so. Addressing concerns quickly. This work is guided by patient experience feedback and in collaboration with ward teams who see first‑hand how important sleep is for recovery. Below is the feedback from the ward manager of one of our pilot wards, and they continue to see the benefits of these packs. “The ward can be noisy at night, and I think we had all just accepted that disturbed sleep is to be expected when you are in hospital, but this trial has changed that outlook. The sleep packs are really simple but very effective, they contain an eye mask, slipper socks, ear plugs and a leaflet with hints and tips of how to get a good night’s rest. Staff have been offering them to patients in the evening, feedback has been great with a few patients claiming ‘it’s the best night’s sleep they have had in years'. We will carry on with them after the study finishes.” (Amy, ward manager on sample ward for pilot – PDSA 2) How the community can help Support from families and visitors also plays a part in creating a restful environment. Simple actions can make a difference: Being mindful of noise during visiting times and remembering people are often sicker than they look and often need more rest. Avoiding phone calls late at night. Encouraging relatives to use call bells instead of raised voices. Bringing in comfort items that help patients relax. Sharing feedback so we can continue improving. Together, we can support better sleep in our hospitals for everyone. So what’s next? Improving sleep in hospital isn’t solved by one intervention alone—it’s a combination of thoughtful design, staff awareness, helpful tools like sleep packs, and ongoing feedback from patients and families. Our commitment at NUH is to continue: Listening to patient experiences. Reacting to feedback. Supporting clinical teams. Introducing practical solutions. Creating calming, quiet environments. Because a quieter night isn’t just about comfort—it’s about better care and better patient outcomes. Noise at night sleep pack presentation: Poster in wards:

The Cheshire and Merseyside Cancer Alliance (CMCA) were finalists in the 'Partnership Working to Improve the Experience' category at the Patient Experience Network 2025 Awards. In this blog, CMCA explain how patient stories are deliberately integrated into their governance, learning and pathway redesign, and how this approach transforms storytelling from passive listening into active improvement. Beyond data—listening to lived experience Modern healthcare systems are built on measurement. We track waiting times, referral-to-treatment targets, survival rates and performance indicators. These metrics are essential and tell us whether services are efficient, timely and clinically effective. Yet some of the most powerful drivers of improvement do not originate from a dashboard—they begin with a story. Cancer care is one of the most complex, emotionally charged and high-risk areas of healthcare delivery. A single cancer journey may span primary care, diagnostic services, multidisciplinary team (MDT) discussions, surgery, treatment, supportive services and palliative or end-of-life care. Along the way, patients navigate multiple appointments, handovers between teams and often life-altering decisions. Delays in diagnosis, unclear communication, fragmented pathways and missed escalation opportunities can have profound consequences. A cancer patient’s story does more than recount a sequence of clinical events. It reveals what mattered most to them in moments of uncertainty. It highlights where systems worked well—and where they did not. It brings into focus inequalities, access barriers and communication gaps. The question is no longer whether patient stories matter. It is how we use them responsibly, consistently and systematically to improve care. From patient story to structured improvement To create measurable impact, storytelling must move beyond powerful listening sessions. It must be embedded into structured quality improvement and safety culture. At CMCA, patient stories are deliberately integrated into governance, learning and pathway redesign. Stories are shared across meetings, events, training sessions and improvement programmes. Rather than treating stories as standalone testimonies, they are used to strengthen systems thinking. Each story prompts structured reflection: where were the faults in the pathway? what safety nets failed or were absent? how did workload pressures or process design contribute? were there missed opportunities to escalate concerns and could this scenario happen in our service today? This approach transforms storytelling from passive listening into active improvement. When patients see that their lived experience leads to tangible change, storytelling becomes partnership—not performance. On 23 May 2022, CMCA invited its first patient storyteller to a team away day. Hearing a personal cancer journey directly from someone with lived experience had a profound effect. It shifted conversations from abstract targets to real human impact. Since then, colleagues across the Alliance have increasingly invited patients to share their experiences to inform pathway redesign and programme development. Between 2022 and 2025, 73 patient stories have been shared. As a result, six significant changes have been implemented. These include improvements to the accessibility of diagnostic testing and the development of a patient engagement checklist for the pathology transformation programme. Other impacts are less immediately measurable but equally meaningful. Stories often leave a lasting impression, influencing how leaders think about service design long after the meeting ends. Empowerment through partnership For many patients, sharing their story is both courageous and empowering. Storytellers remain fully in control of what they share and how they share it. CMCA offers multiple formats—written narratives, audio recordings, video submissions or in-person presentations—ensuring that individuals can choose what feels safest and most authentic. One storyteller reflected: “Oh my word, it's always so amazing to know people hear what I say and take it in.” Another, a CMCA Patient Representative, shared: “Sharing a patient journey can feel daunting at first, but the team at CMCA have been empathetic, kind and supported me every step of the way. Knowing that my words can help others in some way gives me hope and helps me to heal.” Storytelling has also opened further opportunities for patient involvement. Some storytellers have joined project groups, contributed to service redesign or been connected to additional support services. What begins as a story can evolve into ongoing collaboration. Embedding the patient voice in leadership and education The influence of storytelling at CMCA has expanded beyond frontline teams. Patient stories are now a standing agenda item at Board and Diagnostics Board meetings, ensuring that strategic decisions remain grounded in lived reality. At one recent Board meeting, a storyteller who is both a wheelchair user and a cancer patient described the physical and systemic barriers they encountered across their pathway. The account was powerful and specific. It prompted Board members to commission a system-wide accessibility review—a direct example of lived experience shaping strategic action. Patient stories have also informed education. They became the foundation of the 123 Health Inequalities training programme, a CPD-accredited e-learning course developed by the CMCA Health Inequalities and Patient Experience team. Built from both staff and patient voice, the programme uses real experiences to illustrate how inequality manifests in everyday practice—and what professionals can do differently. As Jenny Brazier, Patient Engagement Senior Project Officer at CMCA, explains: “Listening to and acting on lived experience teaches us how to deliver better care and improve services for others. When we truly understand what matters most to patients and their loved ones, we create more equitable, person-centred care.” Conclusion: listening as a safety intervention In cancer care, success is often measured through survival rates, treatment standards and clinical outcomes. These are vital—but they do not tell the whole story. Safety is also about how patients experience their care. Did they feel heard? Were things explained clearly? Were they treated with dignity and supported during an incredibly vulnerable time? Patient stories are not just emotional accounts. They are practical tools for improvement. They help uncover risks that data may miss, reveal gaps in communication or coordination, and highlight where systems create barriers or inequalities. When listening is built into leadership and improvement work, it becomes a powerful safety intervention—helping ensure cancer care is not only effective, but truly centred on those who receive it. The Cheshire and Merseyside Cancer Alliance (CMCA) team. Further reading on the hub: How authentic patient stories can shift systems thinking and improve care Digital storytelling: Learning opportunity or reputational risk? Catching cancer early: what more can we do as GPs?

Thriving through compassion and community: Sharing stories for the future of health systems Join 1,400+ professionals from 80 countries at the world’s most energising healthcare conference on quality, safety, and patient-centred innovation. Register

The Green Nursing Challenge Showcase was held on 20 October 2025 celebrating the outstanding work of teams from hospital and social care settings—an award-winning leadership and engagement programme dedicated to transforming healthcare. One of the teams that competed in the Green Nursing Challenge was the Bladder, Bowel and Pelvic Health community team in Lewisham, London, with their project: ‘Trial without catheter (TWOC) using a structured approach’. The team have shared their project with the hub. The Centre for Sustainable Healthcare supported the Bladder, Bowel and Pelvic Health community team in Lewisham by undertaking a sustainable quality improvement project: a ‘Trial without catheter (TWOC) using a structured approach’. The team (consisting of the clinical lead, catheter lead nurse and a graduate management trainee) worked with the district nursing teams and urgent care service as part of the Green Nursing Challenge to improve care for patients, whilst saving money and carbon emissions. The challenge Indwelling urinary catheters are among the most used invasive medical devices in the UK, and an estimated 90,000 people in community settings require long-term catheter use. Evidence suggests that the longer a catheter remains in place, the higher the risk of infection, and around 2,100 deaths per year are directly attributed to catheter-related infections. The financial burden of catheter-associated urinary tract infections (CaUTIs) is approximately £2,000 per episode and the total annual cost of Foley catheter use estimated between £1 billion and £2.5 billion. A TWOC is conducted when a catheter, which is a tube inserted into the bladder to drain urine, is removed to determine if the patient can urinate normally without it. This procedure is essential for evaluating bladder function and ensuring that the patient can manage without ongoing catheterisation The team found that there was a lack of knowledge around standardised TWOC protocol, and a lack of clear evidence on how to manage the process. They identified problems with repeated catheter use, unnecessary district nurse visits, ambulance callouts and avoidable hospital stays. These inefficiencies not only compromise patient care, comfort and quality of life, but also generate considerable plastic waste from catheters, gloves, aprons and maintenance solutions. Removing catheters as soon as possible has many advantages, but it is vital that removals are planned and effective to prevent adverse events, unnecessary emergency call outs or attendances to the emergency department. Avoiding the cycle of failed TWOC and repeated catheter insertion is key. The Green Nursing Challenge helped the team in the successful implementation and evaluation of a project to develop a structured TWOC process, and measure the impact from a social, financial and environmental perspective. They implemented a classification system for TWOC suitability, together with corresponding TWOC strategies. The project saw the team training staff and evaluating their results across the community of Lewisham and the wider Trust. Results Monthly figures were collected before and after the project and showed clear improvements in the following: Reductions in: Catheter-related ambulance call outs by 25%, suggesting more timely community interventions. Catheter-related hospital stays (bed days) by 32%. Catheter-related hospital admissions by 12.5%, indicating fewer acute deterioration events. No catheter associated urinary tract infections were reported. Environmental sustainability The projected annual saving is 42,156.40 CO2e, equivalent to driving 124,026 miles in an average car. Economic sustainability On average, the initiative contributed to projected net annual savings of £441,708. Social sustainability The reduction in bed days meant that patients spent less time in hospital and more time at home which linked to improved emotional wellbeing. Reduction in staff pressures due to TWOC attempts and urgent visits for catheter-related complications. Increased staff confidence in catheter management contributing to a working environment that was less reactive and more focused on delivering high quality, consistent care. Improved integration, communication and patient pathways helped to ensure accurate referrals, faster and more effective communication. Next steps The team are continuing to develop their project hoping to see further improvements in emergency attendance, hospital stays, CaUTI rates, use of catheter materials and speed of catheter removals. They hope developing more comprehensive guidelines will lead to faster assessment and TWOC, or referral elsewhere, with the net result being a significant reduction in catheter usage overall. For more information please see Green Nursing Challenge Trial without catheter - a structured approach. Do you have a project you would like to share on the hub? We'd love to hear from you. Please email [email protected].

This year will mark the publication of the first comprehensive Quality Strategy for the NHS in over fifteen years. In this blog, Patient Safety Learning and the Advancing Quality Alliance (Aqua) set out the need for safety to serve as a golden thread woven throughout the Strategy. The 10-Year Health Plan for England presents a significant opportunity to improve patient care, experiences, and outcomes. It is expected that the forthcoming NHS Quality Strategy will seek to deliver these improvements by placing a system wide focus on quality. We believe that improving patient safety is inextricably linked to this aim. Level of avoidable harm Prior to the Covid-19 pandemic, NHS England stated in its Patient Safety Strategy that there were around 11,000 avoidable deaths annually due to safety concerns, with thousands more patients seriously harmed.[1] Separately, a 2026 report from the Institute of Global Health Innovation has suggested that 22,789 lives could be saved if the UK matched the rate of treatable mortality of Switzerland.[2] In practice, both these sets of figures are likely to significantly underestimate the scale of harm given the ongoing enormous strain faced by the healthcare system in recent years. Particularly when also considering the pressures in service provision in primary care, emergency and urgent care and discharge planning with social care. This is an unnecessary tragedy for patients, families, and healthcare professionals. Cost of unsafe care This level of avoidable harm is also accompanied by a huge financial cost. The Organisation for Economic Co-Operation and Development (OECD) has estimated that the direct cost of treating patients who have been harmed during their care in high-income countries approaches 13% of health spending.[3] Excluding cases of avoidable harm that may not be preventable, this figure is 8.7% of health expenditure. NHS Resolution estimated that the “annual cost of harm” of clinical negligence claims alone in England in 2024/25 was £4.6 billion.[4] The problems created by unsafe care also undermine efforts to improve quality by increasing productivity. Avoidable harm and its consequences are inherently inefficient, leading to longer inpatient stays, higher staff turnover, reputational damage and reduced trust by patients and the public in the NHS. Improving safety to deliver improvement Patient Safety Learning and Aqua believe that improving patient safety should be a key cornerstone for creating a more effective and productive health system. This means that we should be designing for safety, to ensure safe outcomes, processes, and behaviours. We should know ‘what good looks like’ for safe care and apply this knowledge rigorously and transparently.[5] This should include: Improving the quality of patient safety reviews and investigations. Sharing learning widely and translating this into tangible improvements. Nurturing an open and restorative culture in the NHS. Listening to patients, families, and staff, to better understand risk, take action to prevent harm and give redress and support to people harmed. Board level oversight and reporting of safety incidents, reviews and learning applied. Greater use of technology, data and analytics to significantly improve the safety, effectiveness and responsiveness of care delivery.[6] We also believe it is important to embrace safety science and not oversimplify complex issues. We must respond to delivering safer ‘work as done’ and not be comforted by revising unrealistic and unachievable ‘work as imagined’.[7] Moving towards a safer healthcare system Leadership will be essential to driving these safety improvements. The creation of a new Quality Strategy presents a valuable opportunity for organisational and system leaders to embrace an integrated approach to patient safety. They should encourage a culture of openness and transparency among staff and patients regarding safety issues and related recommendations, while ensuring that safety and quality remain balanced priorities. We need to find better ways of working within organisations and across patient pathways and systems to design and deliver safer outcomes. We too often remain siloed in our response to avoidable harm and must share and work together to design system-wide solutions. There is a huge opportunity for Integrated Care Boards (ICBs) to drive a systemic approach to patient safety through their strategic commissioning responsibilities.[8] [9] There is however currently significant variation in ICBs involvement in safety management activities.[10] We believe they could take on a clear leadership role for system safety. This could have the potential to develop an integrated and coordinated approach to safety, reflecting patient care pathways across systems and ensuring consistency and collaboration. Patient Safety Learning and Aqua look forward to reviewing the Quality Strategy and contributing to its implementation, ensuring that patient safety is integral to how we design and deliver a transformed health care system. Get in touch For organisations wanting to engage in our work and networks, please contact us at: Aqua: [email protected] & 0161 206 8938 Patient Safety Learning: [email protected] References NHS England. The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients. July 2019. Institute of Global Health Innovation & Patient Safety Watch. National State of Patient Safety 2025: Prioritising improvement efforts in a system under stress. 29 January 2026. OECD and Saudi Patient Safety Centre. The Economics of Patient Safety. From analysis to action. 21 October 2020. NHS Resolution. NHS Resolution annual report and accounts 2024 to 2025. 17 July 2025. Patient Safety Learning. ‘What Good Looks Like’ in patient safety. Last accessed 23 February 2026. Alex Kafetz. Why data on quality of care is now more important than ever. 17 February 2026. Claire Cox. Putting the writing on the wall: Explaining work as imagined vs work as done. 1 August 2023. Aqua. What Should Safety Look Like at a System Level. 6 April 2023. Patient Safety Learning. The elephant in the room: Patient safety and integrated care systems. 11 July 2023. Health Services Safety Investigations Body. Safety management: accountability across organisational boundaries. 13 February 2025.

‘Neo’, an Allied Health Professional working on the frontline, reflects on the role of Royal College reviews in the NHS, why they matter and the unintentional consequences that can occur when shared in the public domain. Patient safety sits at the heart of the NHS’s founding principles. Every policy, pathway and performance metric ultimately exists to serve one core purpose: to deliver safe, effective care to patients. Yet ensuring patient safety in a complex, high-pressure healthcare system is not a static achievement. It requires continual reflection, learning and the courage to confront uncomfortable truths. One of the most important—and often misunderstood—mechanisms for doing this within NHS Trusts is the commissioning of Royal College reviews. These reviews offer expert, independent insight into clinical services, workforce challenges, governance arrangements and patient pathways. At their best, they are a powerful method for organisations to speak up, surface risk and identify areas for improvement before harm occurs. However, when these reviews enter the public domain, the resulting media scrutiny and public reaction can create unintended consequences that threaten their future use. What are Royal College reviews and why do they matter? Royal College reviews are typically commissioned by NHS Trusts, Integrated Care Boards or national bodies when there are concerns about service delivery, staffing, outcomes or sustainability. They are conducted by experienced clinicians and system leaders with deep specialty expertise, bringing an external and credible perspective. Crucially, these reviews are not disciplinary processes. They are diagnostic tools. They aim to identify systemic issues—such as workforce shortages, governance gaps, training pressures or service configuration challenges—rather than assign individual blame. In this way, they align closely with the NHS’s stated commitment to a “just culture”, where learning and improvement are prioritised over punishment. For many Trusts, commissioning a Royal College review is an act of organisational maturity. It signals a willingness to ask difficult questions, to listen to expert advice and to address risks proactively. Often, the issues identified will already be known internally but require external validation to unlock support, resources or system-wide change. Transparency versus trust: when reviews go public The challenge arises when Royal College reviews are published or leaked into the public sphere. Transparency is a core NHS value, and patients and the public have a legitimate interest in understanding how services are performing. However, the way these reports are reported and received can significantly distort their purpose. Media coverage frequently focuses on the most alarming language within a report—phrases such as "unsafe”, “not sustainable” or “significant risk”. Stripped of context, these terms can understandably cause public concern and distress. Headlines may imply negligence or crisis, even where a service continues to deliver care safely under immense pressure. For staff working within those services, this can feel deeply demoralising. Clinicians and managers who have actively sought external review in the interests of patient safety may find themselves portrayed as presiding over failure. In some cases, public narratives overlook the structural factors underpinning the findings—national workforce shortages, funding constraints or system-wide demand—and, instead, focus on perceived local shortcomings. The chilling effect on commissioning and publishing reviews Perhaps the most worrying consequence of this dynamic is its potential to deter Trusts from commissioning or publishing reviews at all. If seeking external advice is consistently followed by reputational damage, regulatory escalation or hostile media scrutiny, organisations may understandably become more risk averse. This creates a paradox. The very tools designed to surface risk early and prevent harm can become perceived as liabilities. In extreme cases, this may encourage a culture of silence, where concerns are managed internally or issues are allowed to persist unexamined for fear of public outcry. History has shown the cost of such silence. Major patient safety failures across the NHS have repeatedly been associated with ignored warnings, suppressed concerns and a reluctance to challenge the status quo. Reviews and inspections only become 'bad news stories' when systems fail to listen and act early. Reframing reviews as a sign of strength, not failure If Royal College reviews are to continue playing a meaningful role in patient safety, a shift in narrative is needed—not only within the NHS, but across media, regulators and public discourse. Commissioning a review should be understood as a sign of organisational openness and responsibility. Publishing a review, even when its findings are uncomfortable, should be seen as an act of transparency and commitment to improvement. Reports should be read as starting points for action, not verdicts on competence or care quality. There is also a role for NHS leaders to provide clearer context when reviews are released. This includes explaining why the review was commissioned, what immediate actions have already been taken and how recommendations will be supported at system and national level. Without this framing, reports risk being interpreted in isolation, detached from the wider pressures facing the service. Supporting staff while protecting patients At the centre of this issue are NHS staff—clinicians, nurses, allied health professionals and managers—who are often working at or beyond capacity. Reviews frequently highlight risks arising from workforce shortages or unsustainable rotas, yet public reactions can inadvertently place blame on the very people raising those concerns. Protecting patient safety and supporting staff are not competing priorities. In fact, they are inseparable. A system that punishes honesty, discourages speaking up or treats external review as failure, ultimately undermines both. Royal College reviews offer a rare opportunity: expert insight combined with professional credibility, focused on learning rather than blame. To lose or weaken that mechanism because of fear would be a significant setback for patient safety. Moving forward The NHS is at a critical juncture. Demand continues to rise, resources remain constrained and the margin for error is slim. In this context, the ability to speak openly about risk, invite external challenge and learn from expert review has never been more important. Rather than asking whether Royal College reviews are damaging to public confidence, we should ask a different question: what does it say about a system if organisations are afraid to look honestly at themselves? Patient safety is not protected by silence. It is protected by courage, transparency and a shared commitment to improvement—even when that improvement begins with uncomfortable truths. What are your thoughts and experiences of Royal College Reviews? We'd be interested to hear your views. Add your comments below—you'll need to be a hub member and signed in (sign up here). Further reading on the hub: Read more blogs from staff on the frontline in our Florence in the Machine series.

Across the healthcare sector, evidence of patient involvement leading to positive outcomes is ever-growing; however, little movement seems to have been made. Oxleas NHS Foundation Trust have been working to increase involvement across all aspects of their Trust, not only in patient facing services but also within Corporate services. Find out more from the presentation slides and poster presentation attached. Oxleas were finalists in the 2025 Picker Experience Network Awards (PEN Awards). In 2021, Oxleas’ Quality Management Team (QMT) implemented the 'Improving Lives' internal assurance programme, which included training staff to use frameworks and tools to support the assessment of services and prepare clinical teams for CQC inspections. In 2023, the Quality team identified that feedback from patients and families was not being prioritised for collection during reviews. Following discussion with the Involvement Team and reviewing current involvement opportunities, Quality Team recognised how lived experience can improve outcomes and user satisfaction across services. They decided to develop and introduce the concept of 'Lived Experience Reviewers' into quality systems. This method was not based on principles or research but has been based on feedback and population need. This is an innovative approach to enabling those with lived experience to have a say in how their services are running.