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Content ArticleEdition 12 of the After Action Review (AAR) newsletter reflects on how After Action Reviews (AARs) are being used in the Patient Safety Incident Review Framework (PSIRF) and argues for a shift away from overly detailed, 'historian-style' reporting towards concise, improvement‑focused summaries that clearly capture learning and agreed actions. Drawing on recent AAR Conductor training, it explores why staff may struggle to let go of exhaustive documentation—linking this to professional identity, perfectionism and misdirected agency—and emphasises that people, not reports, drive safety improvement.
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Content Article
The challenges of navigating the healthcare system: Sue's story
Anonymous posted an article in By patients and public
We hear time and time again on the hub about the lack of joined up care and communication within and across organisations. Patients and their families and carers not knowing who to contact to chase up a referral, having to travel miles for appointments, missing appointments because the letter didn’t arrive on time, or having to repeat the patient’s history and medications to every new healthcare professional they see because the notes haven’t been shared or clinicians "don’t have time to read them all". These issues are widespread and urgently need to be addressed if we are to prevent people falling through the gaps and suffering worse health outcomes. In this blog, Sue* shares her and her husband's experiences of trying to coordinate the healthcare system and highlights the challenges and frustrations they continuously face. Difficulties getting a diagnosis My husband Neil* has a very rare chronic condition that means unfortunately he is not managed in the area we live at as it’s a regional centre some miles away. We live in North Yorkshire, one of the largest geographical areas in the country, and we feed into various health economies. It took over 4 years and three different healthcare organisations before Neil got his diagnosis. Every time we see someone new we have to go through all of Neil’s medical history again, and then they often say that it’s not their area of expertise because they only deal directly with one area or speciality; they don't think of the patient as a whole. Whilst waiting to get the diagnosis, Neil had a heart attack so he was initially treated more locally to us but it was still over 40 miles away from where we live. When we called an ambulance for a second time he was taken to a different hospital from the first one he was treated in. So he was taken to two different geographical areas not even under the same trust. To add to this, Neil is also under lots of different specialities, i.e. rheumatology, general surgery, dermatology, respiratory and lipids. So he is being treated and has appointments in numerous places. Coordinating appointments and results With all these different specialties, even if they are within the same regional centre, none of the information is joined up or accessible, including blood results from the GP. We find that things are incorrect all the time and we spend a lot of time trying to coordinate Neil’s care and following up on test results, appointments, etc. Neil receives appointments in various ways—emails, phone calls, texts, letters, messages left on his answer phone. You might get a phone call followed by a letter, or you could get a message to say ignore the letter. You may miss a call but you don’t know which department to ring back because it usually comes up as an unknown number. Recently, Neil received a text message which said he was on a waiting list, but it didn’t say what it was for or what specialist department it was from. It said in the text that if you no longer wanted the appointment and wanted to cancel it, to follow a link, but we had no idea what the appointment was referring to or where it came from! As a patient you want to have some control over your health and be able to see all blood test results, scan results and letters from the hospitals. For example, it would be so much easier to look at Neil’s medications and patient letters if they were all in one place but you can't look at the medical records to see what's been said. The only way we can get it is waiting for the letter to be seen by the GP and then, eventually, added on to their system, but it's not always quick because again it's a different geographical area and systems that are disconnected. As a patient with a new disorder, you’re not familiar with the system. Neil was referred to other specialities from rheumatology. Unfortunately, the treatment plan. including tests or length of wait for appointments, isn’t shared directly with us. We rely on my note taking to ensure everything is completed and followed up. Often we end up going to an appointment without the tests Neil needs to have done due to the length of wait for the test, or the test being triaged and cancelled but this not communicated either to us or the referring doctor. The waiting for test results at the moment are long for some of these tests but if it was in your capacity to be able to seek or understand when you might possibly get them, you wouldn't then end up wasting an appointment. You would wait until you've had the results back or know when it might be. It could take us over two hours travelling time for a wasted appointment. We don’t want to waste our time and the time of others. Lack of communication Neil has radiotherapy coming up shortly and we've had no communications regarding it. I ended up making a phone call to inquire and was given a date. But we’ve still not received a phone call, no email, no letter or anything about it, even though they've got the date and time in their books. You can’t make plans, for example if you are trying to go away for the summer. If you’re waiting for a treatment, which on the NHS may take a while, you want to know when to expect the appointment. It’s a lot easier to manage your condition or diagnosis if you have the knowledge of when something's going to happen and you can manage your own expectations. Navigating the various healthcare apps To try and help with all of this we’ve been really keen to try and find a way to get all of Neil’s medical information, from many different organisations, together in one place and to rationalise appointments. We signed up to the NHS app which then put us on to System Online and then Neil was directed to AirMid UK. We've also found the Patients Know Best app which has been set up and says that you can access all your records but it seems to be only if an organisation has signed up to it. So we’ve got four apps to supposedly access the information but not one of them has all of Neil's information. We are actively looking for an online place which has all the information but none of it ties up. None of the apps give you the same information. We’ve asked our GP but he couldn’t help and hadn’t heard of some of the apps we’d found. A system that isn't working These are just a few examples of what we’re dealing with. I’m lucky as I have some medical knowledge so I know when we're missing something or waiting for something and I will chase up, but not everyone will have this knowledge. If it’s an older patient, or someone who hasn’t got family to support them, then they are on their own to navigate a very complex system. A system that isn't working. *The names in this blog have been changed to ensure anonymity. Are you a patient, relative or carer frustrated with navigating the healthcare system? Or is your GP practice or Trust doing something innovative to make it easier for patients? We would love to hear your stories. Please add to our community forum (you will need to register with the hub, it's free and easy to sign up) or email us at [email protected]. Related reading The challenges of navigating the healthcare system: David's story The challenges of navigating the healthcare system: Margaret's story Navigating the healthcare system as a university student: My personal experience Lost in the system? NHS referrals "I love the NHS, BUT..." Preventing needless harms caused by poor communication in the NHS (DEMOS, November 2023) Robust collaborative practice must become the bedrock of modern healthcare Robbie: A homeless patient’s struggles with the system Digital-only prescription requests: An elderly woman sent round the houses Lost in the system: the need for better admin Digital-only prescription requests: An elderly woman sent round the houses- Posted
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News Article
AI outperforms surgeons in writing post-op reports
Patient Safety Learning posted a news article in News
A study has demonstrated that AI can create more accurate operative reports than surgeons. Published in the Journal of the American College of Surgeons, it is the first report on fully automated, video-based AI surgical documentation. The research highlights the potential of AI-driven solutions to reduce administrative burdens and improve surgical documentation. Surgeons frequently regard the creation of operative reports as essential yet time-consuming. These reports are inevitably subjective and may contain inaccuracies or incomplete information. The administrative task of documentation has also been recognised as a potential factor in physician burnout. Recent advancements in AI, especially in computer vision, have allowed automated systems to accurately detect surgical steps from video footage. Researchers aimed to create a platform that automates the generation of video-based AI surgical operative reports for robotic-assisted radical prostatectomy (RARP). Using an AI-powered algorithm, surgical steps were automatically identified in video recordings and mapped to pre-specified text to generate narrative AI operative reports. The accuracy of these AI-generated reports was then compared to traditional surgeon-written reports using an expert review of raw surgical video footage as the gold standard. The findings suggest that AI-driven operative reporting can enhance accuracy, reduce the documentation burden, and improve transparency in surgical procedures. Read full story Source: Surgery News, 24 March 2025 -
Content ArticleWitness statement from Professor Kevin Bampton LLB FCMI FRSA FHEA, who is also: a member of the Covid-19 Airborne Transmission Alliance (CATA) Chief Executive Officer of the British Occupational Hygiene Society (the Chartered Society for Worker Health Protection) on the Board of the Council for Work and Health Chair of the British Standards Institute Health and Safety Management Committee Chair to the Occupational Health Multidisciplinary Forum a member of the International Standards Organisation Infectious Diseases Committee. In response to the COVID-19 Inquiry Rule 9 Request in relation to Module 1, Professor Kevin Bampton responds to the Inquiry's questions under four broad headings: i) overview of who CATA is, how it was formed and why ii) discussion of the basis in principle for claiming that the failure to recognise the airborne route of transmission was a fundamental barrier in pandemic resilience, preparedness and emergency planning iii) expressing CATA's position, advocacy and engagement around issues of pandemic resilience, preparedness and emergency planning iv) CATA's proposed lines of enquiry and interim recommendations for Module 1.
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Content ArticleStudy into patient attitudes and perspectives related to viewing immediately released test results through an online patient portal. In this survey study of 8139 respondents at four US academic medical centres, 96% of patients preferred receiving immediately released test results online even if their healthcare practitioner had not yet reviewed the result. However a subset of respondents experienced increased worry after receiving abnormal results.
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Content ArticleThis article by Till Bruckner of Transparimed outlines how a new UK law will affect how clinical trial results are reported. The UK Government will introduce a legal requirement to make the results of all clinical trials public within 12 months of trial completion. Any company or university breaking the law will be refused permission to start new trials.
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Content ArticleThis document describes how the Surveillance of Surgical Site Infection: Surgical Site Infection Surveillance Service aims to better patient care by asking hospitals to use data obtained from surveillance and compare rates of surgical site infections over time and against a benchmark rate. The aim is also to encourage the use of this information to help guide clinical practice.
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Content ArticleThis patient-centred report from the Regulatory Horizons Council discusses a route to more effective safety assurance through mechanisms that consider the whole product lifecycle, how adverse events are detected or a long time after use of the device and how to trace and recall patients when needed. In addition, this report also considers a number of ways in which use of data and technology can be smarter and to join up digital systems.
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Content ArticleThe coronavirus (Covid-19) pandemic will leave a deep and lasting scar on the mental health of millions in this country. The devastating loss of life, the impact of lockdown and loneliness, and the inevitable recession that lies ahead will affect all of us. New mental health problems have developed as a result of the pandemic and existing mental health problems have gotten worse. To understand how they can best support people during this uncertain time, Mind carried out research to understand the experiences of people with pre-existing mental health problems, the challenges that they are facing, the coping strategies that they are using, and the support they would like to receive. The report identified five essential learnings: More than half of adults and over two thirds of young people said that their mental health has gotten worse during the period of lockdown restrictions, from early April to mid-May. Restrictions on seeing people, being able to go outside and worries about the health of family and friends are the key factors driving poor mental health. Boredom is also a major problem for young people. Loneliness has been a key contributor to poor mental health. Feelings of loneliness have made nearly two thirds of people’s mental health worse during the past month, with 18–24 year olds the most likely to see loneliness affect their mental health. Many people do not feel entitled to seek help, and have difficulty accessing it when they do. 1 in 3 adults and more than 1 in 4 young people did not access support during lockdown because they did not think that they deserved support. A quarter of adults and young people who tried to access support were unable to do so. Not feeling comfortable using phone/video call technology has been one of the main barriers to accessing support.
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Content ArticlePatient experience measures are widely used as a means of assessing the quality of care from the perspective of users. Despite the recent proliferation of these measures, they are all too often poorly understood and fail to lead to service improvements. This session, from the European patient experience and innovation congress (EPIC), will look at the role that measuring and understanding experiences can play in ensuring that care services are person-centred, including the barriers to effective use of experience information and how these can be overcome.
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Content Article
Sepsis: A decade of change (May 2020)
Claire Cox posted an article in Deterioration and sepsis
Sepsis can develop rapidly and lead to serious illness and death. If the diagnosis is missed and treatment isn’t given swiftly, the consequences can be dramatic. About 48,000 patients lose their lives to sepsis in the UK every year. It is a national priority. The diagnostic and treatment guidance is fluid and responsive to changing best practice. This can cause issues with implementation of guidance and ensuring patients receive appropriate treatment. This Advancing Quality (AQ) report provides a summary of the progress that has been made in the North West of England over the last decade in the timely diagnosis and treatment of people with sepsis as well as improvement in outcomes. The report is also intended to outline the variation and shortfalls that still exist for patients with sepsis. -
Content ArticleThe Oxford Academic Health Science Network (AHSN) has published their 2019/2020 report highlighting their achievements, including details of key projects, key national programmes and economic growth. Achievements Reviewed more than 300 innovations and supported the adoption of 50 of them. Prevented 30 strokes per year through atrial fibrillation initiatives in primary care. Met 500 companies and established 30 industry partnerships. Leveraged £123m to improve health in our region and support economic growth. Key local projects Mental health: Relapse prevention following psychological therapy – includes launch of Paddle smartphone app providing ongoing support for patients. Heart failure: Improving treatment in primary care – working with Novartis to deliver better patient outcomes and reduce hospital admissions. Sleep improvement: Enhancing mental health and self-care at scale – real-world evaluation of the experiences of thousands of people who used the Sleepio online digital support programme. Maternity: Developing an e-learning package for fetal heart rate monitoring – helping midwifery colleagues deliver an award-winning tool developed in Reading/Oxford. Key national programmes Reducing stroke risk: Working with all clinical commissioning groups and primary care, sharing learning and spreading best practice to reduce strokes related to atrial fibrillation, diagnosing 3,000 more patient. Better outcomes following emergency surgery: Working with the five acute NHS trusts in the Oxford AHSN region which perform emergency laparotomy surgery, reducing mortality and length of stay for more than 800 patients. Preventing cerebral palsy: Promoting the adoption and spread of magnesium sulphate in pre-term labour through the ‘PReCePT’ initiative, sustaining uptake at over 85% and improving life-chances of more than 100 babies. Reducing medication errors: Working with all CCGs, pharmacists and GPs to train almost 200 practices in our region through the PINCER programme.
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Content ArticleProf Nick Bishop, VP for Science and Research at the Royal College of Paediatrics and Child Health (RCPCH), outlines some of the key developments in the College's Research and Quality Improvement Division, recognising ongoing work despite the disruptions to members' schedules. He also discusses research on the effects of COVID-19 on child health and well-being.
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Content ArticleIn this report, the Care Quality Commission (CQC) explain the information they have gathered on the pressures that services and local systems have faced during COVID-19 and the efforts that have been made to tackle them. These insight reports are designed to help everyone involved in health and social care to work together to learn from the first stages of the COVID-19 pandemic by: sharing and reflecting on what has gone well understanding and learning from the experience of what hasn't helping health and care systems prepare better in the future. This issue is divided into three main chapters: Working together across systems Focus on primary care How the care for people from different groups is being managed.
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Content ArticleAs part of its commitment to a safe healthcare system for all South Australians (SA), the SA Department of Health and Wellbeing (DHW) has used the Safety Learning System (SLS) since 2011. This is an incident management system that allows healthcare staff to report incidents and near misses. They are reviewed, escalated where appropriate, analysed and investigated in an attempt to prevent their occurrence in the future. The SLS is a “state-wide” system which allows healthcare professionals access to report incidents in all SA public health services and related agencies such as ambulance. This is an independent review of the SLS: 1. To consider recommendations made by the State Coroner and by independent reviews conducted in response to the Chemotherapy Underdosing that relate to incident reporting and management. 2. To determine and describe how the SLS is used across SA Health for patient incident reporting and management including: a. adoption and uptake; b. data extraction; c. reporting; d. incident management; and e. open disclosure to patients and feedback to staff. 3. To identify factors that are impeding or may impede the use of SLS, including; a. the culture of reporting and incident management, and b. the availability and uptake of training and education. 4. To determine if Datix Web, the software platform used for the SLS, meets the needs of SA Health and whether its functionality is comparable to alternative programs. 5. To make recommendation to the Chief Executive (CE), Department of Health and Wellbeing that will assist in assuring robust incident reporting and management and the sharing of learnings across SA Health.
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Content ArticlePatient safety event reporting systems are a mainstay in non-punitive reporting of near misses and adverse events. The authors of this study, published in the American Journal of Surgery, hypothesised that an upgraded reporting system that included the ability to report positive behaviours would increase behavioural reports in the perioperative environment. After implementation of an upgraded reporting system that includes an option for positive reporting, the number and length of reports increased. The authors believe that a robust reporting system has contributed to a culture of safety at their institution.
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Content ArticleThe appointment of a Freedom to Speak Up (FTSU) Guardian is a requirement of the NHS Standard Contract in England. The National Guardian’s Office (NGO) provides leadership, support and guidance to FTSU Guardians. Guidance on recording data was originally issued in January 2017 and guardians in trusts and foundation trusts have been asked to provide quarterly reports on the number of cases they have received since April 2017. These quarterly reports have been published on the NGO’s webpages. This end of year report represents a summary and analysis of the second year’s return and compares across the two years for which data is available. Key findings Between 1 April 2017 and 31 March 2019, 19,331 cases were raised to FTSU Guardians in trusts and foundation trusts. 12,244 cases were raised to FTSU Guardians in trusts and foundation trusts between 1 April 2018 and 31 March 2019. The total number of cases raised in 2018/19 was 73% higher than that raised in the 2017/18 reporting period. The number of cases raised in Q4 of 2018/19 was 38% higher than that raised in Q1 of the same year. In 2018/19: The average number of cases per trust was largest among combined acute and community trusts (an average of 75 cases per trust reported over the year). This is the same trend as was observed in 2017/18. More cases (3,728, 30% of the total) were raised by nurses than other professional groups. 1,491 cases (12%) were raised anonymously, compared to 18% of cases the previous year. 3,523 cases (29%) included an element of patient safety / quality. 4,969 cases (41%) included an element of bullying / harassment. 564 cases (5%) indicated that detriment as a result of speaking up may have been experienced The highest number of cases in a single trust reported over the year was 270. The lowest number of cases reported was 1.
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Content ArticleAnalysis of the patient safety incidents reported in England to the National Reporting and Learning System (NRLS) up to June 2019. NHS Improvement publish two sets of National patient safety incident reports (NaPSIRs) simultaneously. This publication includes reports covering incidents to June 2019 and to March 2019; the commentary analyses data to March 2019. NaPSIRs were previously called Quarterly Data Summaries (QDS).
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Content ArticleThe Care Quality Commission (CGC) is the independent regulator of health and adult social care in England. They make sure that health and social care services provide people with safe, effective, compassionate, high-quality care and encourage care services to improve. Independent acute hospitals play an important role in delivering healthcare services in England, providing a range of services, including surgery, diagnostics and medical care. As the independent regulator, the CQC, hold all providers of healthcare to the same standards, regardless of how they are funded. In this report the CQC have seen much good and outstanding care, in particular around: responsiveness staff interactions with patients effective treatment leadership and engagement with staff and patients. However, there were a number of areas where services needed to make substantial improvements: governance clinical audit safety culture.
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Content ArticleThe Academic Health Science Network’s (AHSN) plan 'Patient safety in partnership' has been developed to support the NHS Patient Safety Strategy and sets out how England’s 15 AHSNs, and the Patient Safety Collaboratives (PSCs) they host, will work more closely with their local health and care organisations to improve safety both in hospitals and community-based services such as care homes. The paper sets out how the AHSN alongside the PSCs have improved patient safety and their goals for the future: We will support the foundations of the national strategy: a patient safety culture and a patient safety system, across all settings of care. The PSCs will deliver the patient safety strategy improvements and seek the next tranche of national programmes for national adoption and spread. We will work with our members, Sustainability and Transformation Partnerships (STPs) and Integrated Care Systems (ICSs) to roll out and embed these national initiatives in the local areas, ensuring ownership and sustainability. We will work alongside the Regional Patient Safety Teams focusing on their system-wide objectives to support STPs and ICSs to identify and implement transformational change. Each region will have differing local needs depending on their starting point, but there will be cross-cutting themes that every PSC can support in a standardised way. Following the adoption and spread of the national initiatives, the AHSN network can support the seven regions with the national programme of capacity and capability building, utilising our local academies and delivery mechanisms for integrated quality improvement, Health Foundation training and innovation training. We will support the capacity and capability and leadership development programmes particularly helping our local system leaders and partners to build knowledge and understanding of the innovation landscape and the opportunities this affords their own organisation’s and wider system’s safety agendas. We will build on the operational and strategic relationships we have with other national bodies also interested and engaged in the world of patient safety. In particular, we will strengthen our partnership with: The Health Foundation (HF), which has supported the development of the early phases of a number of projects that have developed into national patient safety initiatives; Health Education England (HEE) to deliver the safety mandate, building on our existing relationship which sees us working together on joint programmes of work such as learning from deaths and the response to the Topol Review, focusing on the opportunities for safety from genomics, artificial intelligence (AI) and the digital revolution.
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Content ArticleRhidian Bramley is a consultant radiologist and associate medical director at the Christie NHS FoundationTrust. In this blog he discusses how unintended consequences from implementation of digital solutions can have an impact on patient safety.
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Content ArticleThe Royal College of General Practitioners (RCGP) have developed this toolkit to disseminate learning highlighted from acute kidney injury (AKI) case notes reviews, part of the RCGP AKI Quality Improvement project. Working with GP practices, they have put together resources, alongside national Think Kidneys guidance, to support the implementation of quality improvement methods into routine clinical practice. Who is this aimed at? This tool kit is aimed at everyone. There are different sections for each target group What will I learn? Kidney health Recognition and response to AKI Primary care management post AKI episode Embedding a holistic approach to AKI
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Content Article
Acute Kidney Injury - Podcast
Patient Safety Learning posted an article in By health and care staff
A podcast discussing blogs from Dr Josh Farkas of the PulmCrit blog on the importance of renal protection in sepsis. FOAMcast reviews Dr Josh Farkas's PulmCrit blog posts on 'Renal microvascular haemodynamics in sepsis: a new paradigm' and 'Renoresuscitation: Sepsis resuscitation designed to avoid long-term complications', in which he posits that renal protection in sepsis may prove beneficial for patients. -
Content ArticleThis qualitative study looked at whether oncologists should ask children with cancer and their parents about their communication preferences before telling them about their prognosis. The results suggest that patients, parents and oncologists recommend asking patient and parent communication preferences in advance. Research participants provided advice for achieving this goal, relating to the questions that should be asked, giving multiple options and considering delivery and tone.
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Content ArticleIncidental imaging findings (IIFs) are things that show up on a diagnostic image that are not related to the reason a healthcare professional ordered the test. Inadequate follow-up of IIFs can result in poor patient outcomes, patient dissatisfaction and provider malpractice. In an effort to improve awareness of IIFs, this study aimed to investigate communication of IIFs on inpatient discharge summaries after implementation of a new electronic health record (EHR) notification system. The results showed that IIFs were included in 51% of discharge summaries. The authors identified that lack of inclusion of IIFs on discharge summaries could be related to transitions of care within hospitalisation, provider alert fatigue and many diagnostic testing results to distil. The findings demonstrate the need to improve communication of IIFs and the need for care coordinators to follow up on IIFs. This year’s World Patient Safety Day on 17 September 2024 (WPSD 2024) is focused on the theme “Improving diagnosis for patient safety”. Find out more.
