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The Yellow Card scheme is a system for reporting adverse drug reactions (ADRs) from medicines or adverse incidents with medical devices in the UK, ensuring that these products are safe for both healthcare professionals and patients. Reporting these issues helps the MHRA to identify new safety concerns, review products and take action to minimise risks. Despite the role of the Yellow Card reporting system in pharmacovigilance in the UK, understanding and uptake of the scheme remains limited. The authors designed a survey to explore healthcare professionals’ awareness, usage and perceptions of the Yellow Card Scheme for reporting ADRs. It was aimed at identifying current levels of engagement, perceived barriers to reporting, confidence in identifying ADRs and opportunities for improving reporting practices within the East London NHS Foundation Trust. The survey results showed that 84% were aware of the Yellow Card scheme, with 52% selecting that they were ‘fully aware’. A total of 16% of those asked had never heard of the scheme. Despite awareness of the scheme, actual usage is very low — 76% have never reported and 12% were unsure if they had reported, suggesting underutilisation of the scheme. Reporting is infrequent: no respondents report regularly; 12% report a few times a year and 20% have only reported one or twice in total. When asked about barriers to reporting, participants selected: Lack of awareness. Uncertainty about what qualifies as reportable. Lack of time. . Belief that someone else is responsible.- Posted
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In this podcast interview series, NHS whistleblower Peter Duffy and Patient Safety Learning’s Chief Executive Helen Hughes explore how the healthcare system responds when its staff raise concerns about patient safety. In each episode, Helen and Peter interview someone who has spoken up about patient safety issues in healthcare organisations, or who works to help staff raise concerns where they see unsafe care. In this episode, emergency medicine doctor Chelcie Jewitt describes why and how she co-founded Surviving in Scrubs, a campaign that shares survivor stories of sexism, harassment and sexual assault in the healthcare workforce. She outlines the work the campaign is doing with professional regulators to set clear behavioural standards that will more effectively hold perpetrators to account. She also describes the training and support that Surviving in Scrubs offers healthcare staff and organisations on how to respond to harassment and abuse. Subscribe to our YouTube podcast to keep up to date with the latest episodes. View a transcript of this interview Read a blog from Peter and Helen about the interview series- Posted
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News Article
Pennsylvania’s patient safety database tops 300,000 reports, a first in 2024
Patient Safety Learning posted a news article in News
With more than 300,000 patient safety incidents and serious events reported, Pennsylvania’s patient safety database reached a new milestone in 2024. Analysis by the state’s Patient Safety Authority (PSA) shows that reports increased 9.5% from 2023 to 2024, with serious events up by 7.3% and high-harm events up by 1.1%. PSA Executive Director Regina M. Hoffman, M.B.A., R.N., says, “It is gratifying to see the increase in reporting; healthy reporting is associated with a culture that supports and prioritizes safety.” Pennsylvania requires all hospitals, ambulatory surgical facilities and birthing centers to report events that cause or could cause patient harm. The Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest patient safety data repository of its kind in the United States and is managed by PSA. Like the Betsy Lehman Center in Massachusetts, PSA uses data, education and collaboration to improve patient safety in Pennsylvania. PA-PSRS contains more than 5 million reports submitted since 2004, when the reporting requirement went into effect. Based on trends seen in the data, PSA is currently addressing a sharp rise in serious neonatal complications. Together with healthcare facilities and partner organisation ECRI, PSA analysed all serious event reports of neonatal injury or death in a single year and developed new recommendations to be released this summer. Read full story Source: Betsy Lehman Center, 28 May 2025- Posted
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The Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest patient safety data repository of its kind in the United States and one of the largest globally, housing over 5 million reports submitted since 2004. This article presents data from reports submitted to PA-PSRS in 2024. In 2024, 315,418 reports were submitted to PA-PSRS, marking a 9.5% increase from 2023. Reports of serious events rose by 7.3%, while high harm events increased by 1.1%. Of all reports, 96.0% came from hospitals, while 4.0% originated from nonhospital facilities (ambulatory surgical facilities (ASFs), birthing centres, and abortion facilities). The vast majority (96.0%) were incidents, while the remaining 4.0% were classified as serious events. Preliminary 2024 reporting rates show 32.2 reports per 1,000 patient days for hospitals and 11.4 reports per 1,000 surgical encounters for ASFs, with both rates increasing by 1.1 points from 2023 Error Related to Procedure/Treatment/Test (P/T/T) remained the most frequently reported event type overall, accounting for 33.4% of reports from all facilities combined and 47.6% from nonhospital facilities. Among serious events, Complication of P/T/T was the most common type, making up 57.7% of serious event reports from all facilities combined and 71.4% from nonhospital facilities.- Posted
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The COVID-19 pandemic had a profound impact on healthcare systems globally, with potential to aggravate levels of healthcare-associated harm. Due to radical changes within service provision, this period was considered likely to influence patient-reported safety concerns. This study aimed to characterise the nature of these safety concerns at different time periods after the first UK lockdown. The most frequently reported safety incidents involved access to healthcare professionals (12 months/18 months), and errors managing healthcare appointments (24 months). Prominence of themes fluctuated over time, as the context and policies that influenced the safety reports shifted. For example, geographical limitations on healthcare were evident at 12 months, mitigation from healthcare-associated harm by family members at 18 months, and concerns surrounding healthcare professional and other patient’s behaviour at 24 months. Healthcare organisations are undoubtedly still undergoing a protracted period of recovery. However, to protect health services from any further threats to functioning, organisations must review patient safety data systems and examine staff perspectives on the issues identified, notably in relation to infection control policies, social distancing, and patient access to health services. Learning from patient-reported experiences and considering how safety incidents are defined would support improvements in patient safety.- Posted
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Professor Frank Smith's presentation to the Royal College of Surgeons of Edinburgh on confidential reporting and surgical safety.- Posted
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Ensuring Patient Safety in healthcare is essential and requires efficient methods to reduce risks and improve the quality of care. Although incident reporting tools are commonly used to identify possible and actual care failures, their efficacy differs among various environments. The aim of this study was to evaluate the effectiveness of incident reporting tools in enhancing patient safety.- Posted
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News Article
The Institute for Safe Medication Practices (ISMP), a world leader in improving medication safety, is building a medication error reporting program and portal for community pharmacies licensed by the California Board of Pharmacy. This will be the first state-mandated medication error reporting program in the nation focused specifically on community pharmacy. The creation of the California Medication Errors Reporting Program is a result of the enaction of Assembly Bill 1286 (Haney, Chapter 470, Statutes of 2023) in 2023 to improve patient safety and address staffing and workplace conditions in community pharmacies. ISMP has decades of experience collecting and analysing medication error reports to identify risks and guide safety improvements across care settings. ISMP runs the only national voluntary, practitioner-based reporting system, the ISMP National Medication Errors Reporting Program, as well as the ISMP National Vaccine Errors Reporting Program and ISMP Consumer Medication Errors Reporting Program. Building upon the experience with existing ISMP reporting programmes, analysis, and error prevention efforts, ISMP will use submitted medication error reports to identify key trends, patterns and safety issues. ISMP will also provide the California Board of Pharmacy with an annual report based on aggregate data that includes reduction strategies and other actionable recommendations for safety improvements. “The California Medication Errors Reporting Program will produce data-driven insights about preventable adverse events that can drive broad systemic change,” says Rita K. Jew, president of ISMP. “Reporting errors and near misses is essential to ensure the success of efforts to reduce risk in the community pharmacy setting. We applaud California for being a national leader in taking this forward-thinking step to safeguard patients and hope other states will implement similar programs.” Read full story Source: ECRI, 8 May 2025- Posted
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Speaking up as an agency nurse cost me my career
Patient-Safety-Learning posted an article in Whistle blowing
In this blog, Justean Winter shares her experience of working as an agency nurse in the NHS. She describes how she was told not to report patient safety issues she witnessed. After raising concerns about patient care, Justean received several accusations and was eventually blocked from working in the NHS. She outlines why she continues to try and raise awareness of the patient safety and organisational issues she witnessed. Patient safety issues and reporting I have been a nurse for 33 years, and worked for an NHS Health Board via an agency for a number of years. In the Autumn of 2022, I was working in the A&E department when we were told not to submit Datix reports without checking them with managers first. Datix is the incident reporting software widely used in the NHS for reporting patient safety issues. We weren’t able to report anything we saw, including short staffing, bullying and patients being left without treatment. When I or another member of staff asked about why we couldn’t report what we witnessed, we were told by the managers to stop asking and just get on with our job. Later that year, I was asked to work in paediatric A&E, but knew I wasn’t up to date with all the relevant training. I raised this but was told to go and do the shifts anyway. The atmosphere in the wider A&E department was one of keeping quiet about any concerns. If you raised concerns you were seen as a trouble maker. Some examples of issues I raised were patients being denied end-of-life medication, patients with diabetic ketoacidosis being left without treatment and nurses wearing name badges that didn’t belong to them. There were also some issues with staff conduct that could pose a threat to patient safety that I was told not to mention if I wanted to keep my job. At this point, I started reporting incidents anyway, as I was seeing patient safety issues that I just couldn’t ignore. Accusations and suspension In October, I was told by my agency that there had been a complaint against me, dating from that July. I asked to see the details, but they wouldn’t show me anything. I also asked why it hadn’t been raised with me sooner, but was just told there would be no statement needed and there would be no investigation. Then in March 2023, my agency contacted me to tell me about another complaint they had received against me. It turned out to be the same one they had mentioned before, but now the Health Board wanted a statement from me. I did the statement and nothing came of it again. I felt that something underhand was going on. Then in April, one of the nurse managers pulled me into an office and accused me of stealing cash from one of the patients. At this point, I felt I was being bullied because I was refusing to keep quiet about issues on the ward. There were other incidents of intimidation, such as being squared up to in the corridor by another nurse about whose care I had concerns. I was on holiday in May when I received a series of texts from my agency telling me all my shifts had been cancelled. When I came back I realised I was unable to book any shifts, and it turned out that I had been totally suspended by the Health Board. My agency then told me that I had been accused of stealing morphine back in January. Five months had passed and I was only being told about it now! I vigorously defended myself against these accusations. In June, I was called to a Zoom meeting to discuss my suspension. I wasn’t allowed to see any of the complaints or any evidence, but the accusation was used as the reason for my suspension. I asked them to check the CCTV and was told that there was no CCTV in the department. My contact at the agency told me they would be collecting more statements and coming up with a plan for a way forward. When I asked about what the process was, I received no response. After the meeting, I wrote a long email to the Health Board detailing all my concerns, including about the inability to submit Datix reports and inadequate care standards I had witnessed . I later wrote a further letter to 18 members of the Health Boards as well as the Senedd and Healthcare Improvement Wales (HIW), sharing my patient safety concerns but heard nothing back. The Senned Minister for Health and Social Services said that the concerns I had raised were employment concerns rather than safety ones but that they would keep the letter on file for 10 years. At this stage, life was really difficult. I couldn’t get any work—there was a red flag against my name so I was basically unemployable. I asked the agency what was going on, but again got no response. My career and life were being ruined and I hadn’t done the things I was accused of. The same day I delivered the letters, my agency phoned to tell me I had been referred to the Nursing and Midwifery Council (NMC). It wasn’t until December 2023 that I heard from the NMC. The referral stated that I lacked insight to reflect and had refused to do a communication course—no missing money or morphine had ever been mentioned in the referral. I was cleared by the NMC in January 2024. I later found out through court documents relating to my employment tribunal that seven managers and an entire health board were responsible for referring me to the NMC—ostensibly on the grounds of communication issues. It just doesn’t add up. Employment tribunals When I contacted ACAS in September 2023, they told me that I was within the timeframe for an employment tribunal. But three judges since then have told me I am out of date and have refused to read my evidence bundle because it was too long. One judge told me I should “Stop criticising the NHS” and accused me of having a personal vendetta. But all I want is for the truth to come out and to be able to resume my career. I am now on my fourth appeal to try and get my case heard at tribunal. I’ll continue to do everything I can to pursue justice. Vulnerability as an agency nurse I believe that my status as agency staff made me vulnerable to repercussions. There is no support mechanism or process to follow as an agency nurse when raising concerns, and as I wasn’t employed directly by the Health Board, I was more easy to falsely accuse and get rid of. The personal cost of my experience has been huge. We have had to put our home up for sale because I’ve been unable to work since May 2023. I have developed post-traumatic stress disorder and a fear of the NHS because of what I have witnessed. I believe patients are dying because they aren’t receiving the care they need, and that it is being covered up. There are so many issues that the public need to be aware of and that NHS organisations need to deal with to keep patients safe and protect staff. Related reading My experience as an agency nurse A dropped instrument, washed in theatre and immediately reused: a story from a theatre nurse Speaking up for patient safety: A new interview series about raising concerns and whistleblowing My experience of speaking up as a healthcare assistant in a care home Share your speaking up story 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.- Posted
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Patients with vision or hearing loss frequently encounter difficulties accessing vital health information, medication instructions, and effectively using medical devices. This report for the Patient Safety Commissioner for England, commissioned from Professor Margaret Watson, highlights serious gaps and deficiencies in the way that people with visual and/or hearing impairment or loss (referred to as sensory impairment) are able to access and use medicines and medical devices safely. This report presents the results of a short-term study to explore the challenges experienced by patients with sensory impairment in relation to their safe and effective access to and use of medicines and medical devices. This study was conducted from September to December 2024. The primary data that were generated were derived from three sources: Focus groups involving individuals with visual impairment or loss, including people with diabetes. Key Informant responses to an electronic survey. Medicines and Healthcare products Regulatory Agency (MHRA) Yellow Card reports. Patients reported distressing experiences due to inaccessible packaging, unreadable patient information, inadequate communication about medication changes and a lack of suitable reporting mechanisms for issues. The report makes the following recommendations: The MHRA needs to review – working alongside patients – whether their current guidance and regulations for the licencing and packaging of medicines goes as far as is possible to enable their safe use by those with sensory impairment. The Association of the British Pharmaceutical Industry (ABPI), MHRA and Department of Health and Social Care (DHSC) should work together to restart work – alongside published milestones – to digitise paper-based patient information leaflets via the existing UK Electronic Patient Information Task Force (ePIL). As part of this restart, ePIL – working with patients – should examine how to maximise the benefits of this work for patients with sensory impairment. NHS England’s Diabetes Programme Team should launch a patient reference group to assess, understand and mitigate the barriers and enablers to the safe and effective roll-out of medical devices and other education programmes for the management of diabetes (such as DAFNE) for those with sensory impairments. DHSC and NHS England need to ensure the work announced to improve and expand the NHS App in ‘Reforming elective care for patients’ includes an assessment – conducted with the input of patients – to determine whether further accessibility improvements are required, especially for people with visual impairment. In a number of other areas, the report states that the Patient Safety Commissioner wants to make observations to a number of bodies – highlighting the outcome without specifying the solutions, in keeping with the ethos of the recent Health Services Safety Investigations Body (HSSIB) report ‘Recommendations but no action: improving the effectiveness of quality and safety recommendations in healthcare.’ The report makes the following observations: A patient’s medical record needs to include a prominent flag of accessibility needs and detailed information about these needs to ensure that the healthcare professional can provide any required reasonable adjustments. All relevant healthcare professionals – including community pharmacists – must have sufficient access to these patient records and flags. Healthcare professionals, particularly community pharmacy personnel and others involved in the direct supply of medicines and medical devices, must have sufficient funding to support the additional time and resources required by to undertake assessments of patient needs and provide the required ‘reasonable adjustments’ for medicines and medical devices. With the anticipated increase in prevalence of sensory impairment amongst the general population, further guidance is required to promote evidence-based practice by health and social care professionals in terms of the medicine journey of people with sensory impairment. It is also crucial that there is provision of training to healthcare professionals (ideally within the undergraduate curricula) regarding the needs of people with sensory impairment. People with experience of sensory impairment should be included in the design of medical devices, as well as user information and instructions to accompany their supply and use. Manufacturers need to provide more resources to facilitate the demonstration of the effective use of medical devices, especially for people with visual impairment.- Posted
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Content Article
Patient falls are a significant concern in healthcare settings, often leading to severe injuries, prolonged hospital stays and increased healthcare costs. The importance of fall prevention extends beyond patient safety—it reduces hospital liability, enhances patient outcomes and improves overall healthcare efficiency. By proactively assessing and addressing fall risks, healthcare providers can significantly lower the incidence of falls, ensuring a safer environment for patients. Given the aging population and increasing chronic disease burden, fall prevention remains a top priority in improving patient care and quality of life. This blog from Augustine Kumah, Deputy Quality Manager at The Bank Hospital, Accra, Ghana, explores the significance of fall risk assessment, its implementation and its role in reducing fall-related incidents in healthcare settings. Introduction Falls among patients, particularly in healthcare facilities, remain a pressing concern worldwide. These incidents not only lead to injuries, prolonged hospital stays and increased healthcare costs, but can also have lasting psychological impacts on patients. Preventing patient falls necessitates a multifaceted approach, with fall risk assessment at its core.[1] Understanding the impact of patient falls Patient falls are defined as unintentional descents to the ground that occur in healthcare facilities, including hospitals, nursing homes and rehabilitation centres. According to the World Health Organization (WHO), falls are the second leading cause of unintentional injury deaths globally, with older adults being most at risk.[2] In healthcare facilities, the consequences of falls extend beyond physical injuries; they also affect a patient’s confidence, independence, and quality of life. The financial burden of falls on healthcare systems is substantial. Costs include direct expenses such as treatment for fall-related injuries and indirect costs like litigation, reputation damage and loss of trust. Additionally, healthcare providers experience emotional distress and professional repercussions when preventable falls occur under their watch. Hence, fall prevention is not just a patient safety priority but also an ethical obligation and a cost-saving measure. The role of fall risk assessment Fall risk assessment is a systematic process to identify patients at risk of falling. Healthcare providers can implement targeted interventions to mitigate these risks by evaluating intrinsic and extrinsic factors. Intrinsic factors include age, medical history, mobility impairments and cognitive status, while extrinsic factors encompass environmental hazards, medication side effects and inadequate assistive devices. Risk assessment tools, such as the Morse Fall Scale, Hendrich II Fall Risk Model and STRATIFY Risk Assessment Tool have been widely used. These tools provide a structured approach to assess risk levels and guide preventative measures. However, their effectiveness depends on accurate application and regular updates based on patient conditions. Implementing effective fall risk assessments To maximise the efficacy of fall risk assessments, healthcare facilities must adopt evidence-based strategies and integrate them into their workflows. Key steps include: Standardised assessment protocols: Developing and adhering to standardised protocols ensures consistency in evaluating fall risks across different departments and shifts. Protocols should specify the frequency of assessments, criteria for reassessment and documentation requirements. Staff training: Comprehensive training programme for healthcare workers are essential to enhance their competency in conducting fall risk assessments. Training should cover assessment tools, recognition of risk factors and communication of findings to the care team. Patient and family education: Involving patients and their families in fall prevention efforts fosters a collaborative approach. Educating them about potential risks and preventive measures empowers them to contribute to safety. Technology integration: Advanced technologies such as wearable sensors, predictive analytics and electronic health records (EHRs) can augment traditional fall risk assessments. For instance, sensors can monitor patient movements and alert staff to potential falls, while EHRs can flag high-risk patients for closer observation. Challenges in implementing fall risk assessments Despite its benefits, implementing fall risk assessments is not without challenges. Common barriers include: Resource constraints: Limited staffing, time pressures and inadequate funding can hinder comprehensive risk assessments. Overburdened staff may struggle to prioritise fall prevention alongside other responsibilities. Inconsistent application: Variability in applying risk assessment tools can lead to inaccurate results. Subjective judgment, incomplete data collection and lack of protocol adherence contribute to inconsistencies. Resistance to change: Resistance from staff and administrators to adopt new practices or technologies can impede the integration of fall risk assessments into routine care. Patient non-compliance: Some patients may resist interventions such as bed alarms, mobility aids or supervision, increasing their risk of falling. Strategies to overcome the challenges To address these challenges, healthcare facilities can adopt the following strategies: Leadership support: Strong leadership commitment is crucial to allocating resources, establishing accountability and creating a safety culture. Interdisciplinary collaboration: Engaging multidisciplinary teams, including nurses, physicians, physical therapists and pharmacists, ensures a holistic approach to fall risk assessment and prevention. Continuous Quality Improvement: Regular audits, feedback sessions and performance evaluations help identify gaps in fall prevention efforts and drive improvements. Tailored interventions: Personalising interventions based on individual patient needs and preferences increases their acceptability and effectiveness. Conclusion Preventing patient falls requires a proactive and comprehensive approach, with fall risk assessment as a foundational element. Healthcare facilities can significantly reduce fall-related incidents and their associated consequences by identifying at-risk individuals and implementing tailored interventions. However, the success of fall prevention efforts hinges on overcoming implementation challenges through leadership support, interdisciplinary collaboration and continuous improvement. As healthcare systems evolve, leveraging technology and prioritising patient-centred care will be instrumental in advancing fall risk assessments. By embracing these advancements, healthcare providers can create safer environments that uphold all patients' dignity, independence, and well-being. References The Joint Commission. Fall Reduction Program - Definition and Resources, 28 August 2017 WHO. Falls Factsheet. World Health Organization, 26 April 2021.- Posted
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Patient-reported measures provide a comprehensive, real-life understanding of patients’ care, essentially “telling the story” that data sources often miss. While conventional metrics offer only snapshots of safety events, patient-reported experiences (PREs) and patient-reported outcome (PROs) capture the lived experience of patients, shedding light on patterns and opportunities for improvement that might otherwise go unnoticed. This blog looks at an innovative project which aims to redefine how patient feedback shapes patient safety and diagnostic excellence. Project PIVOT is organised by Patients for Patient Safety US, an emerging coalition of patients, patient groups and other key stakeholders committed to safer care.- Posted
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Medical errors remain a significant challenge in healthcare systems across Europe, affecting patient safety and trust. Despite advancements in medical practices, barriers to effective error reporting persist, limiting opportunities for learning and improvement. To address these critical issues, the European Patient Safety Foundation (EUPSF) together with the World Patients Alliance (WPA) are hosting a webinar. This session will bring together experts, policymakers, and patient representatives to discuss the current landscape of medical errors, explore solutions for improving reporting mechanisms, and foster a culture of transparency and learning within healthcare systems. Join us as we work toward building safer and more accountable healthcare for all. Register- Posted
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Digital technology offers the opportunity to revolutionise patient care, supporting the NHS to become more efficient, productive, cost-effective, and importantly, safer. This report published Public Policy Projects, in collaboration with Patient Safety Learning, highlights that the NHS will fail to unlock these opportunities without the prioritisation of patient safety. It sets out that although there are examples of successful technology implementation across the NHS, patients continue to be put at risk as efforts to digitalise services are not adequately considering patient safety. Key findings from this report include: 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. Commenting on the publication of this report, Patient Safety Learning's Chief Executive Helen Hughes said: “Digital health technologies will be key to delivering the forthcoming Ten Year Health Plan. However, if we are to fully realise the benefits of these changes, patient safety needs to be at the heart of these developments. When designing and implementing new technologies in health and care, we need to take a user-centred approach, with patient safety at its core. As this report highlights, there are some promising examples of where this is already happening. Though as the recommendations set out, greater action is needed with system-wide collaboration, to ensure that the opportunities of new technologies are realised and the risks to patient safety are addressed. Patient safety needs to be at the centre of everything we do.”- Posted
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Patient-Reported Indicator Surveys initiative (PaRIS) was set up by the Organisation for Economic Co-operation and Development (OECD) to allow countries to work together on developing, standardising and implementing a new generation of indicators that measure the outcomes and experiences of healthcare that matter most to people. The PaRIS survey aims to fill a critical gap in primary healthcare by asking about aspects like quality of life, physical functioning, psychological well-being and experiences of healthcare. This website explains how PaRIS works and provides access to research outputs. -
Content Article
This study aimed to develop a systematic method to identify and classify different types of communication failures leading to patient safety events. The authors developed a taxonomy code sheet for identifying communication errors and provide a framework tool to classify the communication error types.- Posted
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ICBs ‘detached’ from patient safety risks
Patient Safety Learning posted a news article in News
A new reporting system has left integrated care boards “detached” from patient safety incidents, a watchdog has found. The Health Service Safety Investigations Body (HSSIB) said some ICBs first heard of an incident when they were asked to provide a media statement. In a report published today it highlighted views that a new reporting framework had “eroded assurance activities and patient safety oversight.” The NHS has largely moved from the serious incident framework – where incidents were investigated locally but ICBs played a key role – to the patient safety incident response framework (PSIRF), which is less prescriptive about how trusts need to react to incidents and is not based on the level of harm involved. But the HSSIB report revealed widespread dissatisfaction among ICBs about the new model, with commissioners saying many PSIRF responses did not trigger a report, leading to them having less visibility of risks from incidents. This was a particular concern when risks arose when patients moved between providers. ICBs were also often uncertain how risks were being mitigated and what providers had done as a result of incidents. The safety body was also critical of the Learn from Patient Safety Events database, highlighting problems with “the useability and utility of the data”, with one ICB saying it had “3,000 incidents downloaded but no way of understanding them.” Multiple ICBs had escalated issues with this to NHSE as the data was not useful for identifying hazards and risks. Helen Hughes, chief executive of the charity Patient Safety Learning, said issues with database were “not simply a technical problem with a new digital service.” “They will result in missed opportunities to identify patient safety risks, learn from them and ultimately prevent avoidable harm to patients,” she said. “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, capacity, and a more integrated approach to digital solutions, such as LfPSE, that support patient safety.” Read full story (paywalled) Source: HSJ, 13 February 2025 You can read Patient Safety Learning’s response to this report here.- Posted
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Adverse drug events, including adverse drug reactions and medication errors, pose a significant threat to health, leading to illness and in severe cases death. This systematic review aimed to assess the effectiveness of different interventions aimed at healthcare professionals to improve the reporting of adverse drug events. The authors concluded that, compared to usual practice, the number of adverse drug reaction (ADR) reports submitted may substantially increase following an education session, paired with reminder card and ADR report form, and may slightly increase with the use of a standardised discharge form method that makes it easier for healthcare professionals to report ADRs.- Posted
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Spire Healthcare’s cultural journey through 2024 highlights how any healthcare organisation can leverage frameworks like PSIRF, coupled with supportive initiatives like Quality Improvement and Freedom to Speak Up, to drive meaningful change and create environments where safety, trust, compassion and collaboration thrive. In 2024, Spire Healthcare took a bold step towards enhancing patient safety by implementing the Patient Safety Incident Response Framework (PSIRF) across its network of hospitals. This was a legal obligation for NHS patients in England, but Spire chose to implement for every patient – private and NHS – in England, Scotland and Wales. Developed by NHS England, PSIRF redefines how healthcare organisations approach patient safety incidents, shifting the focus from blame to system-wide learning and improvement. For Spire, this was not just a compliance exercise – it represented a cornerstone of cultural transformation, fostering openness, collaboration, and continuous improvement. This work culminated in Spire being named as a finalist at the 2024 HSJ Patient Safety Awards, in the ‘Developing a Positive Safety Culture’ category. This recognised Spire’s dedication to embedding safety principles into our DNA. Central to culture were two key enablers alongside PSIRF: a robust Quality Improvement (QI) strategy and the organisation’s commitment to the Freedom to Speak Up (FTSU) initiative, both of which were deeply integrated with PSIRF to support a positive cultural shift.- Posted
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Professor Shin Ushiro is Executive Board Member at the Japan Council for Quality Health Care (JQ) and Deputy Director and Professor of Patient Safety at Kyushu University Hospital. In this guest blog for HSSIB, Professor Ushiro gives a brief overview of the history of patient safety in Japan, looks at similarities with other countries and outlines the work of the International Patient Safety Organisations Network. -
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In this blog, Patient Safety Learning’s Director Clare Wade reflects on the challenges that growing prevalence of corridor care poses to reporting and acting on patient safety concerns in the NHS. As highlighted by Lord Darzi’s independent investigation into the state of the NHS in September, the health service in the UK is currently facing unsustainable pressure accompanied by a range of critical challenges.[1] One of the most alarming indicators of this pressure is the rise and growing prevalence of 'corridor care'. Corridor care refers to patients receiving treatment in hospital corridors, cupboards and other unsuitable spaces due to bed shortages and overwhelming demand. These are referred to formally by NHS England as ‘temporary escalation spaces’.[2] While this practice aims to provide some level of care amidst resource constraints, it raises significant concerns about patient safety, dignity and quality of care. Recent reports have highlighted how corridor care is becoming increasingly common. In On the frontline of the UK’s corridor care crisis published last month, the Royal College of Nursing (RCN) highlighted from a survey of its members that nearly 70% of nursing staff deliver care in unsuitable spaces such as corridors, and over 90% believe this compromises patient safety.[3] Some hospitals, including Whittington Hospital in North London, have even advertised for 'corridor nurses' to manage patients in these overflow areas, where basic amenities like oxygen and power outlets are hastily installed.[4] Implications for patient safety As we set out in more detail in a blog published last month on the extent of corridor care in the UK,[5] this practice of corridor care poses numerous patient risks, including: Delayed treatment: Patients in corridors often face delays in receiving timely interventions as these areas lack proper infrastructure for urgent care. Inadequate monitoring: Without essential monitoring equipment and privacy, the early detection of patient deterioration is less likely. Compromised infection control: Corridors are high-traffic zones, making it harder to maintain proper hygiene and prevent hospital-acquired infections. The systemic and operational challenges posed by corridor care can also significantly undermine safety culture at an organisation, as set out in more detail in a recent blog by my colleague Claire Cox.[6] Patient safety incident reporting in the NHS In the face of such risks, it is essential that we have robust systems for reporting events or situations that potentially harm, or could harm, patients while they are receiving care. NHS England has recently introduced a new service for recording and analysing patient safety incidents in England. The Learn from Patient Safety Events (LfPSE) service replaces the previous National Reporting and Learning System and is intended to improve patient safety incident reporting in the NHS. Stating how it will do this, NHS England says that when it is fully functional it will: Make it easier for staff across all healthcare settings to record safety events, with automated uploads from local systems to save time and effort, and introduce new tools for non-hospital care where reporting levels have historically been lower. Collect information that is better suited to learning for improvement than what is currently gathered by existing systems. Make data on safety events easier to access, to support local and specialty-specific improvement work. Utilise new technology to support higher quality and more timely data, machine learning, and provide better feedback for staff and organisations.[7] LfPSE has now been rolled out across most of the NHS. However, the way in which this system works, coupled with the conditions created by corridor care, can present significant challenges to reporting and learning from patient safety risks associated with corridor care. Reporting rates At Patient Safety Learning we have heard concerns from frontline staff that significant time pressures can deter them from submitting incident reports. When working in less than ideal conditions such as delivering corridor care, this is further exacerbated. Staff who face significant additional time pressures that accompany monitoring and caring for patients in non-standard spaces can simply have less time and capacity to report incidents. Focus on digital systems LfPSE depends heavily on digital tools for incident reporting. For some organisations this can still be a barrier to their use as they continue to work with outdated IT infrastructure. These infrastructure limitations impact in a range of areas, one of which can be the accessibility and ability to capture incidents comprehensively using the new LfPSE service. This is another issue amplified when working in overcrowded and chaotic environments like corridors, where staff may not have easy access to appropriate IT. Lack of timely feedback Some healthcare staff told us that feedback from LfPSE can be delayed or absent altogether. Without timely insights, the potential for learning and improvement diminishes, and staff may be less likely to report issues if they don’t see evidence of concerns being acted on. Sharing learning Sharing learning from patient safety incidents is a fundamental component of improving patient safety and delivering safe care. However, at Patient Safety Learning we have concerns that LfPSE lacks effective mechanisms for disseminating the learning derived from reported incidents. Currently, LfPSE data is not made readily available for analysis. Trusts can see reports of their own data (which they already have access to) but not system-wide information to help them assess risk or engage with others. This can create a siloed approach where individual trusts or departments may benefit from their data but fail to contribute to a wider culture of safety improvement. For example, in the context of corridor care, incidents such as missed deteriorations or infection outbreaks may provide valuable lessons but, without NHS-wide sharing of this information, other organisations are unable to implement preventive measures. Underrepresentation of corridor care data Many corridor care incidents may be unreported or under-reported, as they often occur in makeshift spaces outside formal wards or departments. This creates a gap in the data and limits the system’s ability to address specific risks associated with such practices. At present, there appears to be no formalised mechanism to capture data from healthcare providers specifically highlighting ‘corridor care’ as a contributory factor to an increased risk of or actual patient harm. NHS England have recently announced that they will now require trusts to report on the number of patients who receive care in ‘temporary escalation spaces’.[4] To date, this data has not been made available so we are unaware of the true frequency of corridor care, where the ‘hot spots’ are or how long patients are being cared for in a corridor/escalation area. Cultural barriers There is a significant body of evidence, ranging from staff survey results to whistleblower testimonies, highlighting the wider problem of the persistence of blame cultures and a fear of speaking up in parts of the NHS.[8] [9] This is particularly true in high-pressure settings like corridors, where staff may feel they are being judged for circumstances beyond their control. Given the significant media focus on this issue, staff may feel reluctant to speak up, fearing a negative response from the trust worried about the reputational impact of reported concerns. Addressing the challenges There are clearly a number of challenges associated with reporting, learning from and acting on patient safety risks and incidents associated with corridor care. Reporting corridor care incidents needs to improve, which could involve introducing specific reporting categories to help identify and address systemic issues more effectively. Also, actively encouraging staff to share their insights to enable trusts and the wider healthcare system to better understand the nature and scale of risk to patient’s safety would be beneficial. There are also a number of wider system issues that need to be considered: Improved sharing of learning: The NHS must establish robust mechanisms for sharing insights from LfPSE data, ensuring that safety lessons from one trust are accessible more widely across the organisation. National safety alerts or learning forums could support this initiative. Support for staff and patients/families: Equipping staff/patients/families with the skills and confidence to report incidents without fear of blame is essential. Investment in IT infrastructure: Upgrading digital systems across NHS trusts will ensure the LfPSE is accessible and efficient, allowing staff providing corridor care to easily use the IT to report to LfPSE. Real-time feedback mechanisms: Providing timely analysis and feedback to staff will reinforce the value of reporting and enable immediate improvements. Using the safety science tools being promoted in PSIRF: Undertaking thematic analysis and observations of corridor care to identify the reality of ‘work as done’, including: – the risks of unsafe care – the contributory factors to these risks (task, environment, process factors, etc) – the potential opportunities for immediate improvement – sharing these insights across the healthcare system as a matter of urgency. Trusts should be made aware of colleagues who are developing good practice to mitigate risks to patients and to enable them to implement in their environments. Focus on systemic solutions: Policy reforms must address resource allocation, especially around primary care, bed management and alternative care pathways to reduce reliance on corridor care. The combination of corridor care and the limitations of the LfPSE underscores the urgent need for systemic change within the NHS. While the LfPSE is a promising tool for learning from safety events, its full potential will only be realised if these shortcomings are addressed. By prioritising the sharing of learning, fostering a culture of transparency, investing in resources and refining reporting systems, the NHS can take a vital step towards safeguarding patient safety and dignity in even the most challenging circumstances. References The Rt Hon. Professor the Lord Darzi of Denham. Independent Investigation of the National Health Service in England, 12 September 2024. NHS England. Principles for providing safe and good quality care in temporary escalation spaces, 17 September 2024. Royal College of Nursing. On the frontline of the UK’s corridor care crisis, 16 January 2025. Lintern S, Wheeler C. Hospital advertises for ‘corridor care’ nurses to ease NHS crisis. The Times, 11 January 2025. Patient Safety Learning. Response to RCN report: on the frontline of the UK’s corridor care crisis, 17 January 2025. Claire Cox. How corridor care in the NHS is affecting safety culture: A blog by Claire Cox. Patient Safety Learning, 27 January 2025. NHS England. Learn from patient safety events (LFPSE) service, Last accessed 27 January 2025. Patient Safety Learning. We are not getting safer: Patient safety and the NHS staff survey results, 26 March 2024. Peter Duffy and Helen Hughes. Speaking up for patient safety: A new interview series about raising concerns and whistleblowing. Patient Safety Learning, 15 January 2025.- Posted
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NHSN is a secure, web-based surveillance application that is the nation’s most widely used healthcare-associated infection (HAI) tracking system. The application is managed and maintained by the Division of Healthcare Quality Promotion (DHQP) at the Centers for Disease Control and Prevention (CDC). While ensuring data security, integrity, and confidentiality, NHSN gives healthcare facilities the ability to see their data in real-time and share that information with clinicians and facility leadership, as well as with other facilities (e.g., a multihospital system) and partners such as health departments or quality improvement organizations. CDC provides the standard national measures for HAIs as well as analytic tools that enable each facility to assess its progress and identify where additional efforts are needed. In addition, NHSN is the conduit for facilities to comply with Centers for Medicare and Medicaid Services (CMS) infection reporting requirements. NHSN provides medical facilities, states, regions, and the nation with data collection and reporting capabilities needed to: identify infection prevention problems by facility, state, or specific quality improvement project benchmark progress of infection prevention efforts comply with state and federal public reporting mandates drive national progress toward elimination of HAIs. NHSN includes the following components: Patient Safety, Long-term Care Facility, Outpatient Dialysis, Healthcare Personnel Safety, Biovigilance, Outpatient Procedure, and Neonatal.- Posted
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The Saudi Patient Safety Center (SPSC) is mandated to establish a mechanism for reporting sentinel events. This policy outlines the ground rules for the healthcare facilities across the Kingdom of Saudi Arabia with a standardised framework to ensure robust reporting and analysing sentinel events, including a detailed list of reportable sentinel events to assure consistency and accountability to improve patient safety.- Posted
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This was a debate in the House of Commons on the 16 January 2025 discussing the performance of the Medicines and Healthcare products Regulatory Agency (MHRA), the body responsible for the regulation of medicines and medical devices in the UK. The motion debated focused on the MHRA’s performance in relation to patient safety matters, including: the agency’s work on the hormone pregnancy tests, the Yellow Card System and safety monitoring, funding and the influence of the pharmaceutical industry and the implementation of recommendations made by the Independent Medicines and Medical Devices Safety review.- Posted
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500 CQC reports ‘stuck in IT system’
Patient-Safety-Learning posted a news article in News
Around 500 draft inspection reports are “stuck” in the Care Quality Commission’s IT system and cannot currently be retrieved, its leaders admitted today. Outgoing chair Ian Dilks told the Commons health and social care committee hearing: “We have reports that go back for some months that are stuck in the system. People can’t get them back out… [The inspectors] have started their work, they have started their draft report… There is probably more information required, it has to go for quality assurance, [but] they can’t get it back out of the system. I can’t actually tell you exactly how that happened, I’m just giving you an illustration of the difficulties.” CQC chief executive Sir Julian Hartley—who took up the post last month—told the MPs around 500 reports were involved. HSJ asked the CQC for more details of which providers’ reports have been lost. It indicated the “majority” were of adult social care providers, but has not yet given further details. The regulator said the delays caused “falls far short of what people using services and providers should be able to expect and we have apologised for this”, but that “any immediate action [we] needed to take to protect people… has not been affected”. Read full story (paywalled) Source: HSJ, 15 January 2025- Posted
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