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Event
This masterclass will focus on developing your role as a SIRO (Senior Information Risk Owner) in health and social care. Key Learning Objectives Understanding the role of the Senior Information Risk Owner Identifying Information Risks across the organisation Working with others to mitigate the risk to patients, staff and organization. Confidence that all reasonable technical and organisation measure are in place Giving assurance to the Board that risks have been considered, mitigated or owned Understand the requirements of external confidence that policies, procedures are in place to deal with Data Breaches Register hub members receive a 20% discount. Email [email protected] for discount code. -
Content Article
In June 2023 the Secretary of State for Health and Social Care announced that HSSIB would undertake a series of investigations focused on mental health inpatient settings. This overarching report brings together and explores cross-cutting patient safety risks across five individual investigations. The aim of this report is to examine patient safety risks identified across the following HSSIB investigations: Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of suicide risk and safety planning (12 September 2024) Creating conditions for the delivery of safe and therapeutic care to adults in mental health inpatient settings (24 October 2024) Mental health inpatient settings: out of area placements (21 November 2024) Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s mental health services to adult mental health services (12 December 2024) Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge (30 January 2025) Findings Safety, investigation, and learning culture There remains a fear of blame in mental health settings when safety events happen. This contributes to a more defensive culture despite staff actively wanting to learn. Many recommendations to support learning for improvements in mental health care do not lead to implemented actions. Reasons for this include a lack of impact assessment resulting in unintended consequences, no clear recipient involved in the development of recommendations, and duplicated recommendations across organisations. System integration and accountability The integration of health and social care within an integrated care system currently relies on relationships, with an expectation and hope that they will work well. However, where this is not the case, a lack of clear accountability can result in poor outcomes for people with mental illness and severe mental illness. The delivery of care for people with mental illness and severe mental illness is challenging because health and social care services are not always integrated and their goals are not always aligned. Physical health of patients in mental health inpatient settings There are gaps in the provision of physical health care for people with severe mental illness, including inconsistent health checks, poor emergency responses, and misattribution of physical symptoms to mental illness. The misattribution of physical symptoms to patients’ mental health was observed and had the potential to contribute to worsened patient outcomes. National reports, strategies and research have made recommendations to improve the physical health of people with severe mental illness. However, there is evidence that recommendations are delayed in implementation and people continue to die prematurely. Integrated care boards lack the required data and the necessary analytical capability to assess disparities in access, experience and outcomes related to the physical health needs of people with severe mental illness. There is variation in how the physical health checks are carried out on mental health inpatient wards, with limitations in processes for following up on patients’ physical health needs. There is variation in the knowledge, skills and experience of staff who undertake physical health checks and in the environments in which these checks take place. Patients may not always be supported in terms of health education about their physical health risks and modifiable risk factors, for example smoking, dietary advice and physical activity. Caring for people in the community Integrated care boards cannot consistently draw reliable insights from data at national, system or local level, to optimise and improve services, patient care, and outcomes across mental health pathways of care. This results in variability in service provision which does not always meet the needs of individual patients or local populations. Inpatient ‘bed days’ are taken up by people who no longer need them, because people who are clinically fit for discharge are delayed in being transferred to their home or a suitable residence (appropriate placement). Reasons for delayed discharges include issues with housing support and establishing suitable accommodation. This means patients are not always in the right place of care. Barriers to discharge affect patient flow and may result in delays in admission for people with severe mental illness. This means they have to be cared for in a community setting while waiting for an inpatient bed. There is variation across the country in how drug and alcohol services are provided. The variation does not allow for fair and equitable treatment for all patients. Community services are vital to support people to stay as well as possible and to prevent hospital admissions. However, there is variation in community service provision across the country. Staffing and resourcing Staffing and resource constraints in inpatient and community mental health settings impact their ability to provide safe and therapeutic care. In inpatient settings, constraints contribute to mental health wards aiming to staff for ‘safety’ but not always for ‘therapy’. Challenges for staff include the emotionally demanding nature of their work; this can lead to staff burnout and sickness, and further strain on services. There are gaps in mental health workforce planning, particularly in community services where there is no evidence based workforce planning tool to support a standardised staffing establishment setting model. Digital support for safe and therapeutic care A lack of interoperability or integration between digital systems affects the provision of care across mental health, acute and community providers. Challenges in securing appropriate funding impacts on the ability of hospitals to integrate and update their digital services and infrastructure. Electronic patient record functionality is often not available or does not meet staff needs, and so it is not used. Examples include absent functions for food and fluid balance monitoring and risk assessment of venous thromboembolism (blood clots). Challenges in providing and maintaining patient-facing technology, for example televisions and payphones, impacts on the therapeutic environment and the ability of patients to maintain contact with families and loved ones. Where technology for monitoring patients had been introduced, implementation has required considerations to ensure it is used appropriately, is patient-centred, maintains therapeutic engagement, and supports patients to feel safe. Suicide risk and safety assessment ‘Doing’ tasks, like ‘ticking’ checklists, overshadow meaningful, empathetic ‘being’ interactions with patients. Open, compassionate conversations that build trust and therapeutic relationships, enabling patients to own their risk while feeling supported, can help mitigate this. Investigation processes can contribute to a fear of blame, and subsequently contribute to defensive practices such as checklists and a ‘tick box’ culture. This inhibits open and honest conversations and the ability to put the patient, as their authentic self, at the heart of them. Safety recommendations HSSIB recommends that the Department of Health and Social Care continues to work with the ‘recommendations but no action working group’ and other relevant organisations, to ensure that recommendations made by national organisations specific to mental health inpatient settings are reviewed. This work should consider the mechanisms that supported or hindered the implementation of actions from these recommendations. This may help the Department of Health and Social Care understand what has worked when implementing actions from recommendations and enable learning about why some recommendations have not achieved their intention. HSSIB recommends that the Secretary of State for Health and Social Care directs and oversees the identification and development of a patient safety responsibilities and accountabilities strategy related to health and social care integration. This is to support the management of patient safety risks and issues that span integrated care systems. Safety observation National bodies can improve patient safety in mental health inpatient settings in England by supporting provider investment in equipment, digital systems and physical environments to enable conditions within which staff are able to provide, and patients can receive, safe and therapeutic care.- Posted
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- Mental health
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Content Article
One of the most transformative changes to the US health care system in the last few decades has been the widespread adoption of electronic health record (EHR) systems and online patient portals. The patient portal has improved patient access to medical records and facilitated direct communication between patients and their health care teams, improving patient satisfaction, enhancing health care use and increasing treatment adherence. The implementation of online patient portals has altered clinical practice workflows considerably, allowing the streamlining of interappointment communication. However, direct messaging between patients and their health care team is also having a negative impact on healthcare professionals. Increasing reliance on portal messaging as a primary form of communication and more patients using portals increased the volume of messages being sent. Work associated with portal messaging has fallen primarily on doctors, and many of them end up using time outside of clinical work hours to respond. Limited access to appointments has led to more complex and time-consuming messages. This trend is causing higher levels of staff burnout and female doctors are disproportionately affected. This article looks at the issues and potential solutions.- Posted
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- Patient portal
- Communication
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Content Article
This blog describes the approach taken by researchers at the Exeter HSDR Evidence Synthesis Centre when they performed a systematic review on safety management systems in healthcare. They research practice in five English-speaking high-income countries: The Netherlands, Australia, Canada, Ireland and New Zealand. Having started their literature review, the team realised that whilst the components of a safety management system—leadership commitment and safety policy, safety risk management, safety assurance and safety promotion and culture—were present in the patient safety approaches of all of the countries we were looking at, only one of them had actually implemented safety management systems in their healthcare system. This resulted in a change of approach which looked at the differences in how key components of a safety management system were implemented. Read the research study: The implementation of Safety Management Systems in healthcare: a systematic review and international comparison (March 2025)- Posted
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- System safety
- Europe
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Content Article
To support the implementation of the National Patient Safety Plan of the Republic of North Macedonia, this handbook provides a structured framework using the Plan-Do-Check-Act (PDCA) cycle and focuses on six core intervention areas, including infection prevention, medication safety, surgical safety, safe birth practices, capacity strengthening, and error-reduction strategies. It emphasises stakeholder engagement, monitoring and evaluation, risk management, and sustainability planning. By providing a clear roadmap, this initiative aims to foster a culture of patient safety and improve health-care quality in North Macedonia.- Posted
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- Infection control
- Medication
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Content Article
Digital clinical safety is becoming increasingly embedded into organisations, and along with it, compliance with the Data Coordination Board standards DCB0129 and DCB0160, which are mandated under the Health and Social Care Act 2012. However, there exists a number of challenges that are limiting the potential impact of the process. A Digital Health Networks CSO Council survey of clinical safety officers, conducted in 2024, highlighted key areas of concern, including a lack of understanding of the clinical safety process and importance of the CSO role, insufficient capacity for digital clinical risk management and lack of senior leadership buy-in. This white paper provides actionable insights to address these concerns, foster a culture of compliance with standards and improve digital clinical safety.- Posted
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- Digital health
- System safety
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Content Article
Healthcare is a dynamic and complex industry, where even minor errors can have far-reaching consequences for patients, providers, and organisations. “Beyond the Bedside” takes you on a transformative journey through the intricacies of patient safety, equipping healthcare professionals, leaders, and policymakers with the knowledge and tools needed to navigate risks, investigate incidents, and foster a safety culture. These two books goes beyond surface-level understanding to explore the hidden hazards within healthcare systems. They illuminates the interplay between human factors, system design, and environmental risks, highlighting how these elements combine to create vulnerabilities. Through real-life examples, the text sheds light on the human stories behind the statistics, creating a compelling case for why patient safety must remain at the forefront of healthcare priorities. The books delves into the foundational concepts of identifying hazards in healthcare. Readers will gain insights into cutting-edge tools like Bowtie analysis, Safety-II approaches, and STAMP (Systems-Theoretic Accident Model and Processes) that go beyond traditional methods. Adopting a proactive stance, the book empowers healthcare professionals to spot risks before they escalate into incidents. Beyond the Bedside: Unveiling Hazards, Mitigating Risks, and Mastering Patient Safety Investigations: 1 Beyond the Bedside: Unveiling Hazards, Mitigating Risks, and Mastering Patient Safety Investigations: 2- Posted
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- Patient safety incident
- Investigation
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Content Article
This guide outlines the challenges to managing risks in government and ways senior leaders and risk practitioners can overcome these challenges. The guide sets out some of the key risk management challenges facing the public sector. It then outlines 10 approaches leaders and practitioners can take to help overcome these challenges. Each approach is supported by: an explanation of why this should be a priority for government illustrative case studies and quotes practical tips for leaders and practitioners to take. -
News Article
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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- Integrated Care Board (ICB)
- Risk management
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Content Article
On the 13 February 2025, the Health Services Safety Investigations Body (HSSIB) published a report exploring how patient safety is managed across different organisational boundaries. This forms part of a series of reports looking at Safety Management System principles and their application to health and care. In this blog, Patient Safety Learning sets out its reflections on the findings of this investigation. HSSIB investigates patient safety concerns across the NHS in England, and in independent healthcare settings where safety learning could also help to improve NHS care. Their latest report looks at patient safety issues across organisational boundaries, by exploring the safety management activities of Integrated Care Boards (ICBs).[1] An ICB is a statutory NHS organisation responsible for bringing NHS and other partners together to plan and deliver services in an Integrated Care System (ICS). ICSs are partnerships that bring together organisations in specific geographical areas—there are currently 42 across England.[2] This HSSIB investigation focuses on the experiences of Ros and her husband and carer Norman, using their case to demonstrate the gaps in patient safety management when patients’ care is managed across multiple providers in an ICS. Reflecting on the findings of this report, in this blog we focus on four key subject areas: safety management systems reporting and learning from patient safety incidents ICBs and ICSs patients still having to join the dots of patient safety. Safety management systems The HSSIB report forms part of a series looking at the application of a safety management systems (SMSs) approach to health and care. HSSIB define this as: “A safety management system (SMS) is a proactive approach to managing safety that is used in other industries. It sets out the necessary organisational structures and accountabilities to manage safety risks. It requires safety management to be integrated into an organisation’s day-to-day activities.” There is a growing debate about the potential benefits of moving towards a SMS approach in healthcare, which is widely used to manage safety in different industries. HSSIB states that such an approach has four key components: Safety policy—establishes senior management's commitment to improve safety and outlines responsibilities; defining the way the organisation needs to be structured to meet safety goals. Safety risk management—which includes the identification of hazards (things that could cause harm) and risks (the likelihood of a hazard causing harm) and the assessment and mitigation of risks. Safety assurance—which involves the monitoring and measuring of safety performance (e.g., how effectively an organisation is managing risks), the continuous improvement of the SMS and evaluating the continued effectiveness of implemented risk controls. Safety promotion—which includes training, communication and other actions to support a positive safety culture within all levels of the workforce.[3] However, as the findings of their report highlight, we are currently a long way removed from such an approach in our health and care system. Emphasising this, it states: “There are no overarching principles that all healthcare providers and ICBs can use which enable a consistent and collaborative approach to the management of patient safety.” The report notes a particular gap around the role of ICBs, referencing the NHS Oversight Framework, which describes how oversight of NHS trusts, foundation trusts and ICBs operates. It highlights that this does not specify the day-to-day patient safety management activities to be undertaken by ICBs. The report’s key recommendation in this area is as follows: “HSSIB recommends that the Department of Health and Social Care, working with NHS England, uses the findings of this report to inform the development of the 10 Year Health Plan and NHS Quality Strategy. The intent of this recommendation is to encourage further exploration of how the safety management principles described in this report might be applied in health and care settings to improve patient safety.” Patient Safety Learning supports this recommendation. We think that a country-wide SMS would have the potential to provide a more structured and joined up approach to patient safety strategies, involving all the national bodies. We believe that integral to this is a standards-based framework to ensure safety, quality patient care, consistently delivered.[4] A patient safety standards framework helps organisations understand ‘what good looks like’ for patient safety and where more action is needed for improvement with clearly defined safety aims and goals. Such a framework will enable organisations and regulators to demonstrate a risk-based approach to patient safety and evidence achievement. It can provide assurance that patient safety sits at the organisation’s core, improves performance through increased effectiveness, and enables patients and families, staff, funders and communities to identify and differentiate good safety providers. This is a point we recently highlighted in our submission to the independent review of patient safety across the health and care landscape being led by Dr Penny Dash.[5] Reporting and learning from patient safety incidents In the last couple of years, the NHS has been transitioning to a new system for recording and analysing patient safety incidents. The former National Reporting and Learning System (NRLS) has been gradually phased out, with organisations moving onto the new Learn from Patient Safety Events (LfPSE) service.[6] This HSSIB investigation highlights a number of concerning issues relating to how effectively the LfPSE service supports the identification and management of patient safety risks across organisational boundaries. The report notes difficulties accessing and using data from the system with less analysis tools available compared to the previous NRLS. Worryingly, it states: “ICBs suggested that they needed to be building a picture of ICS risks, including those which involved cross-organisational boundaries, but they could not currently do this because of the usability of the LFPSE service and data.” The report does note that in response to these concerns some ICBs have developed local adaptations to compensate for this lack of visibility of patient safety risks within providers. It also says that NHS England has indicated it is developing a new Recorded Data Dashboard for LfPSE that will allow for greater analysis of incident records than was possible with NRLS. Considering these concerns, HSSIB makes the following safety observation: “Health and care organisations can improve patient safety by working together to identify the challenges with the practical use of the Learn from Patient Safety Events service to enable the identification of risks that span multiple providers. This is intended to identify the requirements and support needed to improve risk management.” On these issues, we feel more robust action is required. Sharing learning from patient safety incidents is a fundamental component of improving patient safety and delivering safe care. That LfPSE is not currently providing the means to analyse and share cross-organisational learning represents a significant missed opportunity. As the findings of the report demonstrate, local fixes, which may not be applied consistently across the NHS, are now required because of ICBs lack of visibility of patient safety risks within providers. At Patient Safety Learning we also have related concerns about the availability of LfPSE data beyond ICBs. Currently, individual trusts can see reports of their own data 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. We are also troubled that the outputs of local learning responses and safety incident investigations under the new Patient Safety Incident Response Framework (PSIRF) are not widely shared either within or across ICBs. We understand that the new initiatives, PSIRF and LfPSE, are intended to align so that there is a comprehensive and system-wide analysis with reports on the causes and contributory factors of avoidable harm and action needed to make improvement. However, this alignment is not currently reflected in practice. This is not an acceptable situation. The existing gaps in the LfPSE service are not simply a technical issue 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. We believe the Department of Health and Social Care and NHS England must now prioritise the development and improvement of LfPSE and its integration with PSIRF. Integrated Care Boards and Integrated Care Systems A theme that runs throughout the HSSIB report is the lack of clarity around the roles of ICBs and ICSs in patient safety. Its key findings highlight this, noting: “There is a difference in the perception of how patient safety is managed between ICBs and national health and care stakeholders, including the lines of safety accountability.” This lack of clarity can also be seen in a number of other examples in the report: Inconsistency in how ICBs have reported processes and responses when escalating safety risks to NHS England. If these do not fall within existing programmes of work, responses were described as “hit and miss”. Uncertainty about whether ICBs have oversight of provider collaboratives in relation to patient safety. This was described by an NHS England respondent as a “big black hole”. Varying approaches to safety management activities by ICBs. The report notes that while some undertake assurance visits, “these are limited by capacity and ICBs described a reliance on more reactive activities such as responding to incidents which had already occurred”. In a further example of this lack of clarity, at one point the report notes: “… a senior manager at NHS England told the investigation that while there is an expectation that ICBs will manage cross-organisational safety risks, NHS England “have not told ICBs they have to” do this or “flagged this” in planning or operational guidance. The investigation acknowledges that PSIRF guidance refers to management of cross-organisational safety risks. However, this does not direct how cross-organisational safety risks should be managed more generally outside of PSIRF.” Patient Safety Learning believes action is required to create clarity about the role of ICBs and ICSs in patient safety. We set this out previously in in our report, The elephant in the room: Patient safety and Integrated Care Systems.[7] One means of addressing this gap could be through implementing a SMS approach in health and care, with ICBs and ICSs tasked with a clear leadership role for system safety. This is another point we recently highlighted in our submission to the independent review of patient safety across the health and care landscape.[5] We believe that there is potential at an ICS level to develop an integrated and coordinated approach to safety, reflecting patient care pathways across systems and ensuring consistency and collaboration. Patients still having to join the dots of patient safety At Patient Safety Learning, we believe that patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account. We identify this as one of our six foundations of safer care in our report, A Blueprint for Action.[8] The importance of patient feedback is reflected in the HSSIB report, which notes that: “Patients and carers are an important source of feedback to ICBs about patient safety risks across organisational boundaries. However, this can create inequities as some people are more able than others to make their voice heard.” There is no doubt that insights and feedback from patients and carers can provide ICBs with valuable information on patient safety risks, within organisations and across organisational boundaries. However, this must be accompanied by a structured and resourced framework for gathering these insights otherwise the visibility of these insights are likely to favour those patients and carers who are more adept and confident at making their voices heard. As noted by Norman in his own reflections on his carer role for Ros: "Norman told the investigation that he was getting the care Ros needed through his actions and that he was aware of other patients whose families did not have as strong an advocate as him. He said this affected their ability to get the care they needed, and that 'there are a lot of us out here trying to look after patients'.” While points around safety management systems, LfPSE and ICB/ICS roles and responsibilities can appear detached from day-to-day care, ultimately their impact comes back to the patient. As noted by the First Do No Harm report of the Independent Medicines and Medical Devices Safety Review, patients impacted by avoidable harm and unsafe care often have to ‘join the dots of patient safety’ in response to systemic failures.[9] If we fail to address these systemic failures, they will result in patient safety risks that come with a very real human cost. References HSSIB. Safety management systems: accountability across organisational boundaries, 13 February 2025. NHS England. What are integrated care systems? Last accessed 10 February 2025. HSSIB. Safety management systems: an introduction for healthcare, 18 October 2023. Patient Safety Learning, Standards: What Good Looks Like, Last accessed 10 February 2025. Department of Health and Social Care, Review of patient safety across the health and care landscape: terms of reference, 15 October 2024. NHS England. Learn from patient safety events (LFPSE) service, Last accessed 10 February 2025. Patent Safety Learning. The elephant in the room: Patient safety and integrated care systems, 11 July 2023. Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019. The IMMDS Review, First Do No Harm: The report of the Independent Medicines and Medical Devices Safety Review, 8 July 2020.- Posted
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- Investigation
- System safety
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Content Article
This is one of a series of Health Services Safety Investigations Body (HSSIB) investigations exploring safety management and whether the principles adopted in other industries may assist in the management of safety in health and care. The aim of the investigations is to help improve patient safety in relation to the management of patient safety risks across organisational boundaries. This has been explored through an understanding of the pathways of care for patients whose care involves engaging with providers in primary, secondary and community care and with integrated care systems (ICSs). This report makes reference to processes which exist within the health and care system relating to the management of safety. You can read Patient Safety Learning’s response to this report here. This investigation explored the experiences of Ros, and her husband and carer Norman, to demonstrate the gaps in patient safety management when patients’ care is managed across multiple providers in an ICS. The investigation engaged with patient safety and quality teams within Integrated Care Boards (ICBs) to understand how patient safety risks were managed at this level of the health and care system. The investigation also engaged with NHS England regional and national teams to understand the risks that were escalated to them and how they were managed. Findings There are no overarching principles that all healthcare providers and ICBs can use which enable a consistent and collaborative approach to the management of patient safety. There is a difference in the perception of how patient safety is managed between ICBs and national health and care stakeholders, including the lines of safety accountability. National organisations’ expectations of how ICBs manage patient safety are not in line with what ICBs can currently achieve due to challenges with resourcing and the usability of safety data. Patient safety risks may be escalated from the regional to the national level but there is variability in how these risks are managed at a national level and how responses to escalations are fed back. Cross-organisational safety risks are not always being escalated to ICBs and there may be limited resources and capability to identify, define and investigate such risks. Learn from Patient Safety Events (LFPSE) is the national learning service for the NHS; however, challenges in the usability of LFPSE data means that system level risks may not be visible to ICBs and the wider health and care system. Existing informal ‘good relationships’ between individual providers and an ICB facilitate the effective sharing and management of risks. Where these ‘good relationships’ do not exist or change, formal governance processes do not always ensure information sharing continues. Patients and carers are an important source of feedback to ICBs about patient safety risks across organisational boundaries. However, this can create inequities as some people are more able than others to make their voice heard. Recommendations, observations and suggestions HSSIB makes the following safety recommendation: Safety recommendation R/2025/057: HSSIB recommends that the Department of Health and Social Care, working with NHS England, uses the findings of this report to inform the development of the 10 Year Health Plan and NHS Quality Strategy. The intent of this recommendation is to encourage further exploration of how the safety management principles described in this report might be applied in health and care settings to improve patient safety. HSSIB makes the following safety observations: Safety observation O/2025/061: Health and care organisations can improve patient safety by working together to identify the challenges with the practical use of the Learn from Patient Safety Events service to enable the identification of risks that span multiple providers. This is intended to identify the requirements and support needed to improve risk management. Safety observation O/2025/062: Health and care organisations can improve patient safety by having clear lines of safety accountability and assurance of risk management processes. Currently patient safety risks are not managed in line with established UK government risk management principles. HSSIB makes the following safety suggestions: Safety learning for Integrated Care Boards ICB/2025/011: HSSIB suggests that integrated care boards seek assurance of how health and care providers will work together when commissioning services, so that patient safety can be managed across health and care providers. This is to help support the visibility and management of patient safety risks across an integrated care system. Safety learning for Integrated Care Boards ICB/2025/012: HSSIB suggests that integrated care boards develop their patient safety capability and expertise to ensure they can effectively analyse safety data and intelligence about patient safety risks. This would help to identify and understand patient safety risks that exist across multiple providers in order to proactively investigate and manage these risks.- Posted
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- Investigation
- System safety
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Event
This masterclass will focus on developing your role as a SIRO (Senior Information Risk Owner) in health and social care. Key Learning Objectives Understanding the role of the Senior Information Risk Owner Identifying Information Risks across the organisation Working with others to mitigate the risk to patients, staff and organization. Confidence that all reasonable technical and organisation measure are in place Giving assurance to the Board that risks have been considered, mitigated or owned Understand the requirements of external confidence that policies, procedures are in place to deal with Data Breaches Register hub members receive a 20% discount. Email [email protected] for discount code. -
News Article
Dozens of safety probes kept secret by trusts
Patient Safety Learning posted a news article in News
Trusts are still keeping reports that reveal serious patient safety concerns secret, HSJ has discovered. So-called “invited reviews” are often commissioned by trusts’ management from a medical royal college, when they are trying to deal with concerns about safety, quality or staffing in a particular service — or, in some cases, about individual doctors. The providers are meant to publish a summary of the findings where they uncover safety or quality issues, but HSJ has established this is still routinely not happening. Using the Freedom of Information Act, HSJ traced at least 49 reviews commissioned since April 2020. Only six had been published by the trust in a meaningful way, despite many others surfacing concerns about care. Morecambe Bay inquiry chair Bill Kirkup told HSJ: “It is disappointing to see so many trusts continuing to treat invited reviews as confidential, despite clear recommendations. These are public services, and there should be transparency. Some detail may need to be redacted to maintain individual confidentiality, but I can see no justification for wholesale failure to disclose information that is in the public interest.” Patient Safety Learning chief executive Helen Hughes added: “These reviews have the potential to unearth patient safety insights that are applicable far beyond the organisations they are focused on. Currently however, this learning is not shared widely in a consistent way to inform our understanding of patient safety risks and the need for improvements across the system.” She said “privacy, personal sensitivity, and legal reasons… should not present an insurmountable barrier to extracting system-wide learning”. Read full story (paywalled) Source: HSJ, 4 February 2025- Posted
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- Patient safety incident
- Patient harmed
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Content Article
In a dynamic healthcare environment, patient safety is crucial. A "Conscious Actions Reduce Errors" (C.A.R.E) approach is needed to safeguard safety and reduce medical errors. The dual process theory highlights two thinking modes: intuitive (fast, automatic) and analytical (slow, deliberate). Intuitive thinking, though quick and often effective, can lead to cognitive biases like anchoring and availability heuristics. A C.A.R.E approach incorporating tools like the TWED checklist (Threat, What if I'm wrong? What else?, Evidence, Dispositional factors) and Shisa Kanko (Japanese method of pointing and calling) can help to improve decision-making and action precision in clinical settings.- Posted
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- Behaviour
- Diagnostic error
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News Article
The hospitals so rundown they are 'outright dangerous', NHS chiefs say
Patient_Safety_Learning posted a news article in News
Multiple NHS hospitals are now so rundown they pose a serious risk to patient and staff safety, internal health service documents reveal. Named and shamed facilities include Stepping Hill hospital in Stockport, three hospitals in Doncaster and Bassetlaw, Croydon hospital in south London, and multiple hospitals run by Barts Health trust, also in the capital. Hazards include fires, floods from ageing pipes and tanks, electrical issues and even potentially dangerous bacterial infection from decaying infrastructure. Some of the patients deemed at risk include cancer patients, those receiving life-saving care and even some specialist services caring for vulnerable babies. Read full story Source: Daily Mail, 30 December 2024 -
News Article
NHS patients at risk as hospital urgent repair costs triple in decade
Patient_Safety_Learning posted a news article in News
A decade-long failure to address urgent repairs in hospitals across England has led to a dramatic rise in issues posing a “high risk” to patients and staff, ministers are being warned. The cost of dealing with this backlog has almost tripled since 2015 in real terms, to £2.7bn this year. High-risk repairs have been the fastest growing part of the lengthy maintenance list over that time. It includes issues that could lead to serious injury to both staff and patients, or to major disruption of services or “catastrophic failure”. The NHS lost more than 600 days – or 14,500 hours – of clinical time because of infrastructure failures in the last year, according to a new analysis seen by the Observer. The total maintenance backlog has now ballooned to £13.8bn in 2023-24, an 18% increase from last year. The figure is more than the NHS’s entire capital budget for the year. Read full story Source: Guardian, 28 December 2024- Posted
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Content Article
Artificial intelligence (AI), the next health technology disruptor, is upon us and could greatly improve patient safety. Examples include detection and prediction of sepsis, pressure ulcers, postpartum haemorrhage, adverse drug events and patient decompensation, to name a few. However, if it is not designed, developed, implemented and used appropriately, AI in clinical settings may contribute to patient harm. This JAMA Health Forum viewpoint article looks at how potential harm caused by AI can be mitigated in healthcare, including through the introduction of implementation guidelines, monitoring systems and traceability.- Posted
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The Patient Information Forum (PIF TICK) criteria have been updated after consultation with the PIF TICK Steering Group. The update takes in new developments including artificial intelligence and health information translation. This webinar explains the changes in the criteria, the timetable for implementation and how PIF will support members through the change. To support members with the responsible use of AI, a Framework for Policy Creation on the Use of AI in Health Information was also launched at the event. Speakers from PIF and Prostate Cancer Research introduced the new criteria and showcased examples of how AI can be used for good in health information. Related reading: Balancing the risks and benefits of AI in the production of health information- Posted
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In February 2024, Change Healthcare, a data processing firm, was the target of a cyberattack by the ransomware group ALPHV Black Cat. An active ransomware operation, ALPHV Black Cat is thought to also be behind a 2021 attack on Colonial Pipeline that disrupted the nationwide fuel supply chain. In the wake of the attack on Change Healthcare, hundreds of thousands of healthcare organisation were unable to submit claims or receive payments. With the weeks-long paralysis and ponderous shift to alternative protocols, many facilities found themselves unable to deliver care and facing financial collapse. This article in JAMA Health Forum looks at what healthcare organisations can learn from the incident to protect against future ransomware attacks and mitigate their impact.- Posted
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NHS England plans cyber risk rating platform
Patient Safety Learning posted a news article in News
NHS England is planning to develop a platform for assessing and managing the cyber risk in healthcare organisations. It has indicated that it is preparing to publish a tender document for a cyber risk rating platform, and has ran a market engagement event with potential suppliers on its plans. It said the platform would enable NHS organisations to better understand their security posture and how to mitigate potential threats that could impact on their operational activities, including the availability and management of patient data. The move reflects the increasing focus on cyber security in the NHS. In September NHS England announced a plan to adopt the Cyber Assessment Framework as its main mechanism for assuring relevant standards, and in October the Government’s Budget provided £2 billion for technology in the health service with an indication that this should include spending on cyber security. NHS England also publishes cyber alerts for organisations in the sector. Read full story Source: UK Authority, 27 November 2024- Posted
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Cyber risk, response and claims
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untilJoin a conversation with industry experts on cyber risk, response and claims. With increasing and high profile cyber-attacks on both health and care organisations we discuss the issues that organisations face, what can be done prevent and minimise attacks, what to do if your organisation falls victim to an attack and the steps that should be taken to minimise the impact on your organisation which can far ranging in terms of patient safety, work force, and finance. Your panel of expert speakers: Richard Hearn - Divisional Director, Howden Dave Allen - CEO, Cysiam Vicki Bowles - Partner, Bevan Brittan Julie Charlton - Partner, Bevan Brittan Register- Posted
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A set of 5 infographics describing the the factors that influence the risk of nosocomial transmission of infections (such as Covid19), and how health and care staff can take action to manage the risks and reduce the infection rate. The factors explained are: People Equipment Task Environment Organisation These infographics are from the summary HSIB report (22 October 2020) entitled "COVID-19 transmission in hospitals: management of the risk – a prospective safety investigation". The exec report can be found here. They explain the five main aspects related to the nosocomial transmission of infection, and how the risks of this happening can be properly managed.- Posted
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The National Audit of Inpatient Falls (NAIF) is a continuous audit of all inpatients who have a fall that results in a femoral fracture. This report looks at clinical data on falls collected in 2023. Based on 1,609 cases, it states that falls prevention activity should not focus solely on older people’s wards, finding that nearly half of all inpatient femoral fractures (IFFs) occur on general medical wards. To address the potential for harm caused by hospital-acquired deconditioning, this report presents a new approach to risk factor assessment that focuses on promoting activity to ensure each patient is fit to move as safely as possible. This covers factors such as vision, medication review, delirium, mobility and continence, and provides information on the proportion of patients affected by each in 2023, compared to 2022 and 2021. It contains five key recommendations, four of which state that Trusts and health boards should: Review their policies and practice to ensure that older hospital inpatients are enabled to be as active as possible Ensure that there are robust governance processes in place to understand when post-fall checks fail to correctly identify a fall related injury’ Have processes in place to hasten time to administration of analgesia after an injurious fall Prepare for the audit expansion in January 2025. The fifth recommendation states that NHS England and the Welsh Government should implement national drivers to ensure that all older people are screened for delirium upon hospital admission and reviewed for changes suggestive of a new onset of delirium for the duration of their admission.- Posted
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This article, published in Patient Safety, includes the following sections: What is Transfusion-Associated Circulatory Overload (TACO)? Occurrence of TACO and Impact on Patients. Strategies to Mitigate the Risk of TACO. -
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Top picks: Venous thromboembolism
Patient Safety Learning posted an article in High risk areas
Blood clots, particularly deep vein thrombosis (DVT) and pulmonary embolism (PE), together venous thromboembolism (VTE), pose a significant health threat to patients. These potentially life-threatening conditions can manifest silently and without warning, making vigilance and knowledge crucial. In this Top picks, we’ve pulled together resources, blogs and reports from the hub for patients and healthcare professionals, which focus on how to recognise venous thromboembolism and how to improve patient safety. 1. Deep vein thrombosis: understanding and managing your risk In this blog, Jo Jerrome, CEO of Thrombosis UK, explains the dangers of DVT and why it is important for patients and staff to be aware of the risk factors. Jo offers advice on how we can all manage our risk of DVT. 2. HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments This investigation by the Healthcare Safety Investigation Branch (HSIB) explores the timely recognition and treatment of suspected pulmonary embolism in emergency departments. 3. Jenny, and why we must learn from her misdiagnosis of pulmonary embolism Jenny Edwards died in February 2022 from pulmonary embolism, following misdiagnosis. In this blog, her son Tim introduces us to Jenny, illustrating the deep loss felt following her premature passing. He talks about the care she received and argues that there were multiple points at which pulmonary embolism should have been suspected. 4. Venous thromboembolism (VTE): deep vein thrombosis and pulmonary embolism VTE is a significant cause of mortality, long-term disability and long-lasting ill-health problems – many of which are avoidable. 1 in 20 people will have a VTE at some time in their life and the risk increases with age. This NHS Resolution guide provides more information about the risks of VTE and how to spot the common signs and symptoms. 5. HSIB - The assessment of venous thromboembolism risks associated with pregnancy and the postnatal period final report This investigation by the HSIB explores the issues associated with the assessment of risk factors for venous thrombosis in pregnancy and the first six weeks after birth. 6. NHS Resolution: Working to prevent avoidable venous thromboembolism VTE is an international patient safety issue and a clinical priority for the NHS. Around half of all cases of VTE are associated with hospitalisation, with many events occurring up to 90 days after admission. It is a leading and preventable cause of death in an estimated 25,000 of hospitalised patients each year. This information leaflet highlights the cost of VTE claims and what you can do in your organisation to prevent VTE. 7. Pulmonary embolism misdiagnosis – a systemic problem Tim Edwards is a risk management expert and son of Jenny, who passed away in February 2022 from pulmonary embolism, following a misdiagnosis. Frustrated by the quality of the initial investigation that followed her death and the lack of assurance that learning would take place, Tim conducted an independent review. In this opinion piece, Tim draws on his research to highlight the key patient safety issues, and to encourage further dialogue around the topic. 8. Let's Talk Clots! Help reduce your risk of DVT and PE in hospital with this simple app Download the free Let’s Talk Clots patient information app from Thrombosis UK, and help reduce your risk of DVT and pulmonary embolism in hospital. 9. Patient Safety Spotlight Interview with Beverley Hunt, Professor of Thrombosis and Haemostasis and founder of Thrombosis UK In this interview, Beverley Hunt talks about setting up Thrombosis UK and how it has grown to have a national impact on patient safety in hospitals. She also describes the value of combining policy work with seeing patients face-to-face, and explores the need to find new ways of working to deal with the pressures facing the healthcare system. 10. Risk assessment models for venous thromboembolism in medical inpatients This cohort study in JAMA Network Open aimed to determine the prognostic performance of the simplified Geneva score and other validated risk assessment models (RAMs) to predict VTE in medical inpatients. The study provided a head-to-head comparison of validated RAMs among 1352 medical inpatients. It found that sensitivity of RAMs to predict 90-day VTE ranged from 39.3% to 82.1% and specificity of RAMs ranged from 34.3% to 70.4%. The authors concluded that the clinical usefulness of existing RAMs is questionable, highlighting the need for more accurate VTE prediction strategies. 11. HSIB: Investigation into management of venous thromboembolism risk in patients following thrombolysis for an acute stroke This HSIB investigation focused on the management of VTE risk in inpatients following thrombolysis for an acute stroke detection of medical problems (that impact on VTE risk) occurring in inpatients following thrombolysis for an acute stroke. Do you have a resource or story to share? We’d love to hear about it - leave a comment below or join the hub to share your own post.- Posted
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