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At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. Since launching in 2019, the hub now has over 19,000 resources, 8000 members from 98 countries, and we have had over 1.7million visits and over 3 million page views. In this blog, the hub's Editor, Samantha Warne, reflects on our most popular pieces of original content published on the hub in 2025. These are a mix of our original blogs, interviews and resources shared by patients, frontline staff and leaders in patient safety. It shows the breadth of content we have on the hub, including collaborations we have with other organisations and people, patient stories, the challenges healthcare staff face and insights from an international perspective. Keep an eye out for more end of year content from our team at Patient Safety Learning, including a policy roundup. 1 Speaking up for patient safety: A new interview series about raising concerns and whistleblowing At the beginning of 2025, we launched our video interview series Speaking up for patient safety. The series is hosted by Peter Duffy, NHS whistleblower and Chair of the Healthcare Working Group at WhistleblowersUK, and Helen Hughes, Patient Safety Learning’s Chief Executive. In each interview we hear from someone who has raised concerns about patient safety in healthcare, often at great cost to their own career and personal life, or from those who work to help staff raise concerns through their own experience and advice. Alongside the thread of bravery and tenacity that runs through each contributor, a number of common themes come up time and again as people share their experiences. One thing that we often hear is the common tactics that some organisations use when dealing with people who speak up or blow the whistle. To highlight these tactics we created 'The whistleblower playbook' infographic, illustrating how some organisations respond to staff raising concerns about patient safety. 2 Patient Safety Learning: World Patient Safety Day 2025 The theme of this year’s World Patient Safety Day was ‘Safe care for every newborn and every child’. In a blog to mark the day, Patient Safety Learning reflected on this theme, highlighting the World Health Organization goals for this event and shared a series of guest blogs from healthcare professionals, patient campaigners, organisation leaders and safety experts on the hub, each exploring a different aspect of the theme. 3 Duty of Candour: Frequently Asked Questions Through the joint efforts of the Patient Safety Management Network in collaboration with experts from the Care Quality Commission (CQC) and NHS Resolution, these FAQs were produced to address the most pressing concerns about Duty of Candour. The collaborative approach ensured that the FAQ tool reflects the insights and expertise of those actively engaged in the regulation, implementation and oversight of candour practices. This is an example of the ‘how to’ resources that Patient Safety Learning, the networks and partners are developing to guide the implementation of good practice in patient safety. 4 Working in a toxic culture: Doing the right thing is often the least popular and hardest thing to do… In this blog, Clare Wade, Patient Safety Learning's Director, draws attention to the impact toxic cultures have on staff and how, sadly, most often nothing is done about it. Clare shares her own personal reflections from past experiences in her career. There is a clear link between toxic cultures and patient safety, and while there are no easy answers these behaviours must be acknowledged, challenged and cured if the NHS is to survive. 5 Top 10 priorities for patient safety in surgery Patient Safety Learning asked the Patient Safety Group (PSG) of the Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top tips for patient safety in surgery to share on the hub. They came up with three useful resources for surgeons and surgical trainees: Top 10 priorities for patient safety in surgery Top 10 tips for surgical safety: Think Safety, think SEIPS Top 10 patient safety tips for surgical trainees These resources are an example of the effectiveness of collaborating with partners such as the RCSEd to develop resources that will help practitioners better understand patient safety and how they can access resources to help reduce avoidable harm. 6 What do Patient Safety Incident Response Plans tell us about how the NHS is approaching safety investigations? From Autumn 2023, NHS organisations in England began to change the way they investigated cases of avoidable patient harm and near misses, introducing the Patient Safety Incident Response Framework (PSIRF). As part of PSIRF, organisations are required to create and publish a Patient Safety Incident Response Plan. Drawing from a sample of 13 Patient Safety Incident Response Plans, Patient Safety Learning considers what they can tell us about the implementation of PSIRF. This is intended to support organisations who are currently reviewing their PSIRPs to ensure that their prioritisation of investigations and reviews meets national guidance and provides an evidence based rationale to inform patients, families and staff. 7 Post-SSRI Sexual Dysfunction: After 30 years, why is the health system still failing to recognise this life-limiting adverse effect? Post-SSRI Sexual Dysfunction (PSSD) is a long-term adverse effect of Selective Serotonin Reuptake Inhibitors (SSRIs), a type of antidepressant medication. In this opinion piece, Harriet Vogt, Patient Safety Partner at NHS Sussex Integrated Care Board, outlines the need for recognition and research into PSSD to allow patients to make truly informed choices when considering SSRIs. She argues that while the health system is beginning to recognise the value of placing patients at the heart of efforts to improve safety, this focus on listening is rarely given to individual patients who express concern about the impact of their medication or treatment. 8 SEIPS in action In this blog, Patient Safety Learning’s Associate Director Claire Cox shares a video with associated training resources developed for the Patient Safety Management Network Symposium. Claire explains how they used it to facilitate an interactive workshop, bringing SEIPS (Systems Engineering Initiative for Patient Safety) to life. It's now available as a resource for you to use in your own organisation. It is simple to set up, highly engaging, and encourages teams to think beyond individuals and see the wider system in action. 9 Balancing care: The psychological impact of ensuring patient safety In this blog, Leah Bowden, a patient safety specialist working in an ambulance service, reflects on the impact her job has on her mental health and family life. She discusses why there needs to be specialised clinical supervision for staff involved in reviewing patient safety incidents and how organisations need to come together to identify ways we can support our patient safety teams. 10 Exploring the barriers that impact access to NHS care for people with ME and Long Covid For healthcare to be safe it needs to be accessible. But what does this look like for people with ME (myalgic encephalomyelitis) and Long Covid? This blog from #ThereForME explores the barriers that impact access to NHS care for people with ME and Long Covid. 11 Bridging the gap between policy and practice: A Safety-II approach to patient transfers In this anonymous blog, a patient safety lead shares how they implemented a Safety-II approach to patient transfers, highlighting the disconnect between 'work as imagined' and 'work as done', and the importance of listening to frontline voices. The author worked with subject matter experts to develop a visual, easy-to-use risk stratification tool designed to support decision making on the appropriate level of clinical escort required for safe transfer. While the tool is applicable to most adult acute settings, certain areas—such as maternity, paediatrics, and specialist theatres—require their own local adaptations. This could have wider applicability to a range of different clinical settings. 12 Evidencing the impact of culture on patient safety – a new tool from MNSI In this interview, Chris McQuitty, a clinical fellow at the Maternity and Newborn Safety Investigation (MNSI) programme, talks us through a new patient safety tool. COMPASS (Culture of Organisations and its iMpact on PAtientS’ Safety) is currently being piloted to help understand the impact organisational culture may have on patient safety in maternity settings. 13 Improving safety in healthcare—is quality improvement the answer? The healthcare landscape is evolving rapidly, with increasing complexity in patient needs, technological advancements and regulatory requirements. As this complexity grows, ensuring patient safety remains a top priority. One of the most widely adopted strategies for enhancing safety is quality improvement (QI), but is QI the right tool for navigating and improving safety in an increasingly complex health system asks Patient Safety Learning’s Associate Director Claire Cox. Claire reflects on the need for a safety management systems approach, as highlighted in Healthcare Safety Investigation Branch (HSSIB) reports, essential to embedding a proactive, system-wide perspective on patient safety. Additionally, aligning QI efforts with patient safety standards and Patient Safety Learning standards ensures a structured, evidence-based approach to mitigating risks and driving sustainable improvements. 14 Preventing patient falls in healthcare settings: The need for fall risk assessment Patient falls are a significant concern in healthcare settings, often leading to severe injuries, prolonged hospital stays and increased healthcare costs. 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. 15 Patient barcode scanning in NHS hospitals: safety, snags and workarounds. A nurse’s perspective As a nurse working in the NHS for over 25 years, Claire Cox has seen first-hand how technology has transformed patient care. One of the biggest changes in recent years has been the introduction of electronic scanning. In this blog, Claire talks about the opportunities to improve patient safety and the risks associated with the use of barcode technology in healthcare. 16 Corridor care and patient safety Corridor care can broadly be defined as care being provided to patients in corridors, non-clinical areas or unsuitable clinical areas because of a lack of hospital bed capacity. It is increasingly being used in the NHS as demand for emergency care grows and hospital departments struggle with patient numbers. In a series of blogs for the hub, we shine a light on some of the key patient safety issues surrounding corridor care. Share your experiences on the hub I would like to take this opportunity to thank everyone who has contributed to the hub this year. the hub is a platform for everyone with a professional or personal interest in patient safety to share and learn from one another. Have you implemented a new initiative in your organisation? Have you improved patient safety where you work? Or are you a patient and would like to share your experience to improve patient safety? We would love to hear from you and share on the hub your stories. This can be done anonymously if you prefer. If you are a member, you can share directly on the hub or please contact [email protected] to discuss further. See all our 'Top picks' Our ‘Top picks’ are collections of resources, blogs and tools around a specific topic or theme. You can view them all here: Top picks.

This webinar offers a chance to explore the challenges and opportunities of the Safety-II approach with Mark Sujan, co-author of the BMJ Quality and Safety article ‘The problem with making Safety-II work in healthcare.’ In 2020 Q’s ‘Organisational Resilience & Safety-II’ Special Interest Group (SIG) ran workshops to share adaptations being made to address the emerging COVID-19 crisis. Many solutions were shared but significant challenges were identified. In this webinar we will build on the insights found and explore the arguments in the recent BMJ Quality and Safety article, ‘The problem with making Safety-II work in healthcare.’ We will be joined by the paper’s co-author Mark Sujan, as we lean into the promises and potential of Safety-II, and what gaps we need to bridge to revolutionise our understanding of what safety truly is in health care. The one hour webinar will: Outline the challenges and opportunities of a Safety-II approach Allow you to hear from peers implementing Safety-II Provide you with an opportunity to discuss your experiences of Safety-II in small groups Register for the webinar

After two years with virtual workshops due to the Covid-19 pandemic, we are pleased to announce that the fifth International Workshop on Safety-II in Practice will be organised on site in Edinburgh, Scotland on September 7-9, 2022. The Workshop is organised by FRAMsynt. The workshop will begin with an optional half-day tutorial on Safety-II in Practice in the afternoon of September 7 (1330-1730 BST), and continue with two days of meetings and discussions from September 8 (0830-1700 BST) to September 9 (0830-1500 BST). There will be a walking tour of Edinburgh old town (hosted by Steven Shorrock) and a dinner on the evening of September 8 for those who wish to join. Aim of the workshop The aim of the workshop is to share experiences from existing and/or planned applications of a Safety-II approach in various industries and practices. The workshop will give the participants an opportunity to present and discuss problems encountered and lessons learned – good as well as bad, practical as well as methodological. The workshop is a unique opportunity for safety professionals and researchers to interact with like-minded colleagues, to debate the strengths and weaknesses of a Safety-II approach, and to share ideas for further developments. The guiding principle for the workshop is “long discussions interrupted by short presentations”. In order to achieve this, the number of participants will be limited to 60 – first come, first served. Participation The workshop is open to everyone regardless of their level of experience with Safety-II. It will address the use of Safety-II in a variety of fields and for purposes ranging from investigations, performance analyses, organisational management and development, individual and organisational learning, and resilience. The workshop will provide a unique opportunity to: Discuss and exchange experiences on how a Safety-II approach can be used to analyse and manage complex socio-technical systems. Receive feedback on and support for your own Safety-II projects and ideas. Learn about the latest developments and application areas of Safety-II. Develop a perspective on the long-term potential of a Safety-II approach. Discussion topics, presentations and papers You can contribute actively to the workshop by submitting proposals for: Topics or themes for panel discussions (preferably with a presentation or introduction, but open suggestions of themes are also welcome). Presentations of ongoing or already completed work in industry and/or academia. Ideas that you would like to get a second opinion on. Questions or issues that you have been wondering about and would like to hear more about. The relevance of a Safety-II perspective for individual and organisational learning. The strategic management of Safety-II: how to introduce changes to routines and daily practice. For each type of proposal, please provide a short abstract (about 100 – 200 words, but even less if need be) with a summary of what you would like to present or discuss and how you want to be involved. All proposals will be reviewed and comments to the submitters will be provided. Please submit your proposed contribution to: [email protected] Register

Gavin Portier is Head of Nursing Quality at Barnsley Hospital NHS Foundation Trust. In this interview, Gavin explains how his approach to auditing has moved beyond measuring negative outcomes, instead focusing on standards of care. A year ago, you implemented a new approach to auditing at Barnsley. Can you tell us what prompted it? In healthcare, we tend to measure safety by looking at negatives. The number of falls, the number of category 2 pressure ulcers, the number of adverse events etc. Our whole system is built on it, from local auditing and Datix reporting, to CQC inspections. But counting the number of pressure ulcers for example, doesn’t really tell you about the standards of pressure ulcer care. I wanted to look at things differently; to focus more on the interventions and good practice that helps keep patients safe. Where did you start? We started with pressure ulcer reduction. Our Tissue Viability team and I looked at the learning from Root Cause Analyses and worked together to create a list of all of the things we can do to help prevent pressure ulcers. Skin assessments, pillow positioning, moving patients etc. If we ticked every box for every patient, would we prevent pressure ulcers altogether (unless the patient doesn’t follow the advice)? I took this list and worked with the digital app company, Perfect Ward to build a simple-to-use auditing tool. It allows us to measure safety by our standards of care and interventions rather than counting negative outputs. If our standards of care are high and a lot of people are still getting pressure ulcers, we have assurance on the standard of care being delivered. How did you implement the pressure ulcers audit? Once we had created the list of standards and preventative measures, we used the app to do an audit of around 35% of patients on each ward. At the start of the project, we found that teams were on average hitting 64% of the standards. The digital app provides a performance rating system, with red with red (less than 70%), amber (greater than 70% but less than 90%) and green (90% or more). The performance of the team against these ratings dictate how we would support each team moving forward. For example, if an audit showed a team to be performing at the lowest level (red), we made a commitment to support them on a weekly basis until they were performing at the highest level (green). How have staff responded? Staff have responded really well. This system provides recognition, and credit where credit is due. It can help staff to feel confident when they are providing high standards of care and to know that they are doing the right thing for the patients. Where there is room for improvement, the Perfect Ward app makes it is easy to see where the gaps in the delivery of interventions exist so they can be tackled. The tissue viability nurses are there to support, coach and to help problem solve. There may be certain interventions that are consistently missed which can sometimes be a sign that the wider organisation needs to help solve the issue. Safety is a shared responsibility, and we need to make sure we have the systems in place to support success. What support have you needed along the way? It’s really important to have passionate people who understand and believe in this approach to auditing. You need to have an Executive Team who are prepared to look at measuring outcomes differently. I’m lucky, our Director and Deputy Director of nursing are very supportive. It’s also important to acknowledge that it is not a silver bullet; change takes time. That can be frustrating for some people who want to see results quickly. It’s taken a year but teams are now hitting on average 94% of the standards set out by the auditing tool, and we are starting to see decreases in category 2 pressure ulcers (per 1000 bed days) since June 2020. What have you learnt? It has been really important to constantly engage staff and build good relationships, to make sure we understand everyone’s competing priorities. The approach has been a great enabler for quality improvement methodology, empowering teams to find their own solutions and really own the results. What’s next? This approach to auditing is not rocket science. It can be used to raise standards of care in most circumstances within health and social care – without focusing on the negatives. We have successfully applied it to both pressure ulcer and falls prevention at Barnsley and just started on nutrition and hydration. In the future I’d like to see it used in other areas, to identify what excellent dementia care in hospitals looks like for example. It could also be used to ensure that staff have a good understanding of the Mental Capacity Act and safeguarding processes. Or to make sure patients are being well-fed. It really is just a blueprint that can be used to raise standards of care, and safety in any circumstance. Final thoughts? I personally don’t like to look at my work as reducing harm. I prefer to look at it in terms of improving the standards of care we give our patients. The difference is important. Photograph of the Tissue Viability Team. Above is an example of a checklist used for pressure sores. The graph above shows the trust average on delivery of the pressure ulcer prevention interventions across adult inpatient wards over a 12 month period. The 'distribution of score' graph above shows the percentages scored across the adult inpatient wards for each month over a 12 month period. This graph shows more areas achieving 90% (or more) and fewer scoring 70% or less as time has progressed.

In this blog, Farrah Pradhan, Project Manager for Clinical Quality, Education and Projects at RCOG, describes her work with maternity professionals, namely obstetricians, and through undertaking an MSc in Patient safety. Farrah’s focus was on their 'work as done' to see if the concepts of Safety-II (capability mindfulness and resilience engineering) helped them to work more safely. ‘Work as done’ Because healthcare is constantly evolving and complex, by looking more closely at everyday work and finding out what actually happens, it allows an understanding of what it is, that frontline clinicians do to ensure successful outcomes. This is termed as looking at 'work as done' and informs us about the nuances, the adjustments, the compromises, the workarounds, the actions and the decision making that is taken to meet the needs of the patients they are caring for. ‘Work as done’ is a combination of expertise, clinical decisions, experience and tacit knowledge. It is because clinicians are flexible and can vary their performance that allows the system to function albeit with acceptable or adverse outcomes. As healthcare is intractable (not easily controlled), performance adjustments are vital. Things often go well because obstetricians make sensible adjustments in response to the situations to ensure safety, often within a highly pressurised environment. These adaptations and performance variables, under complex circumstances, are not well understood. Combining the concepts of capability mindfulness, positive deviance and resilience engineering as the principles of safety-II and understanding the 'work as done' and the performance variability of obstetricians’ (that results in good or successful outcomes), may bring insights that can be used to help build adaptive capacities and capabilities in obstetricians when working in unpredictable and unanticipated stressful clinical environments. Compassion against a backdrop of complexity My first encounter with an obstetrician was over 21 years ago when I was pregnant with my first baby. The attention and kindness that I received by the obstetrician and his team were incredible; I was cared for with gentleness and understanding. He spoke to me with compassion, and in moments of delivering uncertain news, he placed his hand on my shoulder, showing his empathy for my circumstances. I saw him regularly until it was time for my baby to be born, twelve weeks early. This experience, although very traumatic, opened my eyes to a caring profession that surpassed any expectation that I could ever have imagined. When I came to work at the Royal College of Obstetricians and Gynaecologists nearly seven years ago, I had the privilege of witnessing more of these encounters. I visited maternity units, listening and watching obstetricians and their colleagues work tirelessly for women and their babies against a backdrop of complexity and variation. Intrigued by this, I decided to pursue a Master’s degree in Patient Safety. I wanted to understand what it was that gave obstetricians this skill; to work effectively while maintaining a constant awareness of situations, identifying and managing emergencies and providing day-to-day care, all at the same time. Proactive safety management My dissertation (under the supervision of Professor Suzette Woodward) focused on obstetricians’ use of proactive safety management concepts (termed Safety-II). Taking a safety-II approach includes looking at 'work as done’ [1]. These are the adjustments, compromises, workarounds, actions and decisions that obstetricians make, to meet the needsof the women they care for. Obstetricians have to make prompt decisions, organise multiple activities and co-ordinate care rapidly, all within an already complex system. ‘Work as done’ is achieved because of a combination of expertise, clinical decisions, experience and tacit knowledge and because obstetricians vary their performance, depending upon changing circumstances, that allows the system to function. Reliability, adjustment, and safety Studying ‘work as done’ brought insights into how obstetricians build adaptive capacities when working in complex settings. This adaptation is an essential factor in the interaction between complex infrastructures and human behaviour. Because healthcare is intractable, clinicians are relied on to adjust to situations (emergency cases, staff shortages, high patient numbers etc.) to create safe outcomes, as well as recover from unexpected events. Reliability is a necessary requirement of safety and is concerned with the likelihood of occurrence of failure [2]. Clinicians are vital to creating high reliability and a resilient system. Through my research with obstetricians, I found that they successfully demonstrated their adaptive capabilities to respond to unforeseen, unpredictable and unexpected demands and recover from high-risk situations, also known as resilience engineering [3]. The ability of obstetricians and their teams to be in a state of constant alertness, sensitive to changes in women’s conditions, continually re-evaluate their safety supposition, and respond as appropriate, is a key resilient strength that was evident. It also requires an organisational culture that nurtures a climate of trust and respect. The importance of culture and relationships During interviews, obstetricians described the importance of trusting relationships, which fostered excellence in team working, and the ability to be collectively and consciously alert to risks and mitigations. Overall, they demonstrated excellent leadership attributes, valued safe care centred on the woman and her baby, good working relationships and the feeling that they made a positive difference. "It was having the willingness to step in and take that level of responsibility in that situation. … it was also familiarity with the team and communication with the team, and drawing in the expertise of cardiologists and the anaesthetist so that we did have a cohesive joined up plan that we'd all agreed on and we'd communicated out to everyone." (Consultant Obstetrician, Manchester) “It’s about staying calm, understanding what the whole situation is, … it's about gaining the trust of the woman and the staff, gaining the trust of the staff is much easier if it's a team that you know, who you've worked closely with, who know you as well, because they know what your skill set is.” (Consultant Obstetrician, London) Improving maternity safety – some final thoughts My research concluded that a systems approach to maternity safety including human factors and safety management must be adopted to understand 'work as done'. Safety can be improved through ‘learning from excellence’ as a way of cultivating habits in focussing on the activities that promote good outcomes, hence strengthening resilience as well as continuing to learn from the inevitable errors. I suggested using human reliability analysis, a technique looking at a process of care and systematically examining the process, to pinpoint and foresee possible failure points to proactively manage safety within a unit. Excitingly, the NHS Patient Safety Strategy [4] is striving to embed safety-II principles, and healthcare regulators are considering how proactive safety management can be measured and developed as part of their inspection frameworks. Indicators for resilience engineering [5] are also emerging which will assist with assessing a resilient work environment and provide metrics for safety measurement. You can read Farrah's full dissertation paper in the document attached towards the end of this webpage. References 1. Hollnagel E, Braithwaite J. From Safety-I to Safety-II: A White Paper. The Resilient Health Care Net; 2015. 19 2. Vincent C. The measuring and monitoring of safety. UK: The Health Foundation; 2013. 3. E. Hollnagel JB, R Wears. Resilient Health Care: Ashgate Publishing Limited; 2013. 225 p. 4. NHS Improvement. The NHS Patient Safety Strategy Safer culture, safer systems, safer patients. July 2019. Available from https://www.england.nhs.uk/wp-content/uploads/2020/08/190708_Patient_Safety_Strategy_for_website_v4.pdf 5. Ranasinghe U, Jefferies M, Davis P, Pillay M. Resilience Engineering Indicators and Safety Management: A Systematic Review. Saf Health Work. 2020;11(2):127-35.

Ben Watson is a Strategy Implementation and Quality Improvement (SIQI) Manager in the Scottish Ambulance Service. He is currently responsible for supporting operational services in the West of Scotland, to see how they can improve patient care, existing processes and develop new ways of working that benefit both staff and patients. In this interview, Ben explains why they’ve started collecting positive feedback through a peer-to-peer system called GREATix.