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The report “To Err is Human: Building a Safer Health System” is often considered a turning point in the history of patient safety, raising alarm both about the volume of “preventable” medical errors, and the state of safety management in healthcare relative to other industries. The report called for the adoption of a wide range of practices from other industries, in particular aviation, ranging through incident reporting and investigation policies, team training methods, management systems, and structured risk assessment methodologies. ‘To Err is Human’ exemplifies a phenomenon that to me is quite remarkable. Healthcare – one the best educated, professionalised skeptical and evidence-based domains – is willing to set aside its usual standards of critical thinking when adopting practices from other industries. In this talk, Dr Drew Rae makes the argument, illustrated with examples from projects across a range of industries, that to a certain extent safety problems are universal, with patterns repeating across domains. However, he will also present some reasons to believe that the problems are exacerbated rather than improved by the uncritical adoption of safety ‘solutions’ between industries. Register

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. The tool was designed by Chris and Nicki Pusey, Maternity Investigation Team Leader at MNSI. This blog is part of our World Patient Safety Day 2025 series - Safe care for every newborn and every child. Why was COMPASS developed? COMPASS was created based on work carried out by the Patient Experience Library who conducted a literature review of over 10 years’ worth of avoidable harm enquiries, which included the reports on the maternity services at East Kent and Morecambe Bay. The work has been collated into a report called ‘Responding to Challenge’¹. The review demonstrated that poor organisational culture is a recurrent theme in avoidable harm, with significant impact on patient safety. Their work highlights how organisational culture remains challenging to quantify and articulate which hampers external bodies’ ability to provide insight to providers. Through our safety investigations it became evident that MNSI did not have a way to record and analyse cultural observations in a structured and evidence-based format. This inhibited us from feeding back our observations to organisations to help them see how their organisational culture might be impacting on patient safety. What are the aims of COMPASS? We developed COMPASS for two key reasons: To provide MNSI staff with a standardised process to record observations around organisational culture, empowering MNSI staff to articulate their observations to trusts in a structured and evidence-based manner rather than based on personal experience or individual interpretation of certain situations. To highlight to trusts areas where their organisational culture is contributing positively to patient safety, and areas where enhancing their focus will support and improve safer care to be delivered. There is already significant work being done to help trusts to improve culture and leadership within maternity services, and COMPASS is a tool designed to complement this by focussing on how organisations respond to and learn from patient safety events. How is COMPASS being used? COMPASS is currently being piloted in partnership with 12 NHS trusts in England and is due to finish at the end of May. MNSI staff are using COMPASS to gather observations about organisational culture that may have impact on patient safety, in a structured manner that reflects the findings from the ‘Responding to Challenge’ report. The findings are then collated and reviewed to determine how frequently these types of observations are occurring so we can assess the overall level of impact to patient safety that may be occurring within each of the specific areas. These findings are then shared with trust leadership teams to flag areas that may require attention or focus to improve safety and organisational culture and also highlight observations of culture that have had a positive impact on patient safety. What is next for COMPASS? After the pilot, and with the help of feedback from both MNSI staff and trusts who piloted the report, we hope to: Adapt the COMPASS tool to match the needs of both MNSI and organisations we work with to maximise the impact of the tool. Showcase the positive impact COMPASS has had on patient safety within maternity and newborn services. Share our learning through the development of COMPASS and explore how this can be utilised in other sectors to improve patient safety across healthcare. If feedback suggests that the tool is of value to both MNSI and trusts, we may seek to use COMPASS on a regular basis to help share our insights into organisational culture with trusts to help improve patient safety. How can people find out more? Introducing COMPASS: A new safety tool to help understand the impact of culture on patient safety MNSI has launched a new patient safety tool COMPASS Red Flag Tracker – a tool to help recognise the red flags for harmful healthcare cultures by the Patient Experience Library References 1. The Patient Experience Library's Responding to Challenge report April 2025 Do you have a safety tool or project to share? Are you implementing a change that has had a positive impact on patient safety? Could you share your insights, tools and knowledge to help others? Or perhaps you are at the start of the journey, seeking ways to address a patient safety issue that you've identified. Comment below (sign up for free first) or contact our editorial team at [email protected] to tell us more.

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. They share their story and their reflections on what needs to be done to improve organisational cultures so that when staff raise patient safety issues, their concerns are responded to appropriately and not dismissed because they are inconvenient to address. 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. In this blog, Helen and Peter look at some of these themes and outline their implications for people who speak up or whistleblow. We are now three months into the series, which seems like a good time to stop and reflect on what we have learned so far. Our introductory blog about ‘Speaking up for patient safety’ explains why we launched the series and what we hope it will achieve. It also explains in more detail what we mean when we talk about speaking up and whistleblowing. Briefly, speaking up in healthcare is when a member of staff raises concerns about something that is worrying them to a manager or someone else within, or outside of, their organisation. In some cases—but not all—when someone speaks up, it is also defined as ‘whistleblowing’. Whistleblowing always involves a concern that is in the public interest and might relate to a criminal offence, health and safety risks, failures to carry out legal obligations, a miscarriage of justice, or an attempt to conceal and cover up any of these things. Three key themes from the interviews so far These are the top three recurring themes we have noticed coming up in the interviews so far. Other issues we have noticed include the lack of clarity about who should take responsibility for whistleblowing and the reality of threats and bullying, and we will continue to explore these issues going forward. 1. “I didn’t realise I was speaking up, I was just doing my job!” Perhaps the comment we have heard most frequently is that people didn’t realise they were formally speaking up or whistleblowing—they just thought they were doing their job. Every healthcare profession has a set of professional standards which all practitioners are expected to keep to. For example, the General Medical Council (GMC) states that all doctors have a duty to take action by raising concerns if they believe patient care or safety are at risk.[1] In addition, each healthcare organisation has a code of conduct, which will include requirements for staff to be honest, open and accountable for their work. For the interviewees we spoke to, to not raise their concerns would be a failure to fulfil their duty to both their patients and their organisation. When people speak up, they often find themselves in the middle of a process that they had no idea they were entering. This can be very disorientating and leave them unprepared for the path ahead of them. At the end of this blog, we share some advice from our interviewees about what to do if you find yourself in this position. 2. There is a whistleblowing ‘playbook’ Most organisations have policies and support in place to listen to staff members who raise concerns, including access to a Freedom to Speak Up Guardian. We have interviewed Jayne Chidgey-Clark, the National Guardian, who described the good practice that many are developing. However, we are hearing about several common tactics that some organisations use when dealing with people who speak up or blow the whistle. The experiences of our interviewees suggest that these approaches may be deliberately designed to disadvantage the individual throughout the process—from investigation through to employment tribunals. Some of the key activities we have heard about include: Organisations not responding—or responding at the very last minute—to communications from the staff member. Interviewees said they received emails with key information at 5pm on a Friday, which left them with no opportunity to ask questions or respond until the next working week. They expressed their belief that this may be a deliberate tactic to exert pressure on the individual speaking up, which amounts to emotional bullying. The use of occupational health as a way to cast doubt on the mental state of the person. Occupational health providers are often very supportive, but we are concerned that organisations are fishing for reasons to question the believability and motives of staff who speak up. Over-focus on HR issues, rather than focusing on the patient safety issues someone has raised. Mandated isolation from colleagues while investigations take place. This can have a very damaging effect on the person’s mental health as well as restricting their ability to source evidence from other staff in support of the concerns they have raised. We have heard examples of colleagues agreeing to provide supportive testimony, but then feeling pressurised to withdraw this support. Retaliatory referrals against the person speaking up to professional regulators, such as the General Medical Council and Nursing and Midwifery Council, which can have a detrimental effect on a healthcare professional’s reputation and career. Regulators are aware of how such referrals can be used to intimidate whistleblowers and discourage them from raising concerns. Some have approaches to ensure that fitness to practice concerns are appropriately addressed without unfairly impacting doctors who have raised whistleblowing concerns. We believe it is important to identify and call out these tactics so that people raising concerns are aware of them and can seek support and advice. Organisational leaders need to look at their own practice and recognise the ethics of their approaches and whether their actions match their stated organisational values. They need to be aware of the significant damage these tactics cause to people who raise concerns and the chilling impact it might have on their organisational culture, effectively preventing others’ raising concerns. 3. Employment tribunals are unfit, unfair and imbalanced Every person we spoke to who had attempted to pursue justice at an employment tribunal commented that the process was unfit for purpose and not the right place for whistleblowing cases to be heard. Employment tribunals take no interest in the safety issues being raised. The main issue we keep hearing is that the tribunal system is weighted in favour of whichever side has the most financial resources—which will almost always be the employer. A single individual who has lost their employment can rarely succeed against the millions of pounds that organisations are willing to spend on highly specialised lawyers who have tried and tested ways of winning. The playbook we identified above also runs into employment tribunals, with whistleblowers reporting: The employer and their legal advisers withholding key documents, and emails, minutes, notes and other vital information going missing. Key witnesses, often in senior leadership positions, being unable to recall events. Receiving last minute threats from their former employer to come after them for costs and often being given a limited time to consider signing a non-disclosure (NDA) to settle a case. If rejected, often the NHS organisation will seek the full costs from the whistleblower, including expensive external legal costs and internal staff costs, which can amount to thousands of pounds—few whistleblowers can afford to take this financial risk, even if they and their advisers think they have a strong case. Advice from our interviewees if you find yourself speaking up Reflecting on their experiences, our contributors have made some observations about how you can protect yourself when speaking up, should the issue escalate. Try to resolve issues locally first. This is not always possible, but if a concern can be raised and dealt with within a team or with a manager, in some cases this will prevent the situation from escalating to a formal process. Keep a record of concerns and events as they happen. This means you will have some facts and clear observations to refer back to, if the situation does escalate. Don’t go to meetings alone. Take a trusted colleague with you so that every conversation is witnessed. Get your union involved if you are called to meetings about your concerns or receive counter-complaints or accusations. Regulation of NHS managers Some of the interviewees highlighted that regulating NHS managers may be a potential means of tackling some of these issues. The Department of Health and Social Care recently held a public consultation on proposals that could see managers who use misconduct to silence whistleblowers barred from working in the NHS. Patient Safety Learning has formally responded to the consultation, stating that there is a clear case for the regulation of NHS managers, for the protection and benefit of both staff and patients. Everyone in healthcare should be honest and transparent when something goes wrong. Patient Safety Learning’s response expressed support for a professional register of NHS managers and the requirement for individuals in NHS leadership to have a professional duty of candour. These measures would be a positive step in increasing accountability for healthcare organisations in how they respond to staff raising patient safety concerns. But this is only one part of a much wider set of changes needed—significant cultural change also needs to take place in tandem with these reforms. Staff across many organisations are still afraid to speak up, as indicated by the most recent NHS staff survey results. Thank you to our contributors, and an invitation to get involved We’d like to take this opportunity to express our gratitude again to each person who has been willing to share their experiences and insights with us—it can be very difficult to retell traumatic events that have changed the course of your life. We are also aware that there are many other individuals who have experienced unjust treatment because they have spoken up for safety. If that’s you, thank you for your commitment to standing up for safe, ethical care. We invite everyone with experience in this area to contribute to this vital conversation. We would particularly like to hear from: Allied health professionals. Staff from Black and minority ethnic backgrounds Staff in non-clinical roles such as administration. If you would like to share your story, you can: Contribute to our community conversation (you’ll need to sign up first). Comment on any hub post (you’ll need to sign up first). You can find information about organisations that offer support and guidance for staff about speaking up and whistleblowing on the hub. Watch the interviews Helené Donnelly Martyn Pitman Jayne Chidgey-Clark Gordon Caldwell Bernie Rochford Beatrice Fraenkel References General Medical Council. Professional Standards: Raising and acting on concerns about patient safety, 13 December 2024

In the ever-evolving landscape of healthcare, patient safety and quality care remain the cornerstones of effective medical practice. Every day, healthcare professionals strive to provide treatments that not only heal but also protect patients from harm. As a passionate advocate for patient-centred care, Ssuuna Mujib, a volunteer at the Uganda Alliance of Patients' Organisations, believes that prioritising safety is not just a responsibility—it’s a moral imperative that shapes trust, outcomes and the future of healthcare. The importance of patient safety Patient safety refers to the prevention of errors and adverse effects associated with healthcare delivery. According to the World Health Organization (WHO), millions of patients worldwide suffer from preventable harm due to unsafe care each year. These incidents can range from medication errors to hospital-acquired infections, surgical complications or misdiagnoses. The consequences are profound, affecting patients’ lives, increasing healthcare costs and eroding trust in medical systems. Ensuring patient safety requires a multifaceted approach that involves healthcare providers, administrators, policymakers and patients themselves. By fostering a culture of safety, we can minimise risks and create an environment where quality care thrives. Key strategies for improving patient safety and care To deliver exceptional care while safeguarding patients, healthcare systems must adopt evidence-based practices and innovative solutions. Here are some critical strategies to enhance patient safety: 1. Effective communication Clear and open communication among healthcare teams is vital. Miscommunication can lead to errors, such as administering the wrong medication or misinterpreting a patient’s condition. Standardised tools like SBAR (Situation, Background, Assessment, Recommendation) can improve handoffs and ensure critical information is shared accurately. 2. Robust training and education Continuous professional development ensures that healthcare workers stay updated on best practices and emerging technologies. Training programmes should emphasise error prevention, infection control and patient engagement. Empowering staff with knowledge builds confidence and competence in delivering safe care. 3. Leveraging technology Technology plays a transformative role in patient safety. Electronic Health Records (EHRs) reduce documentation errors, while barcode medication administration systems help verify medications before they reach patients. Additionally, artificial intelligence tools can predict risks, such as sepsis, enabling early interventions. 4. Patient empowerment Patients are active partners in their care. Encouraging them to ask questions, understand their treatment plans and report concerns fosters shared decision making. Educating patients about their medications and procedures can prevent errors and enhance adherence. 5. Creating a culture of safety A blame-free environment encourages healthcare workers to report errors or near-misses without fear of retribution. Root Cause Analysis (RCA) and Failure Modes and Effects Analysis (FMEA) can identify systemic issues and drive improvements. Leadership must champion safety as a core value, setting the tone for the entire organisation. The role of compassion in patient care While systems and protocols are essential, the human element of care cannot be overlooked. Compassionate care builds trust and promotes healing. Listening to patients, respecting their dignity and addressing their fears create a therapeutic environment. When patients feel valued, they are more likely to engage in their treatment plans and communicate openly, reducing the risk of errors. Challenges and the path forward Despite progress, challenges like understaffing, resource constraints and burnout continue to threaten patient safety across the world. Addressing these requires investment in workforce development, equitable resource allocation and mental health support for healthcare workers. Collaboration between governments, healthcare institutions and communities is crucial to overcoming these barriers. Looking ahead, the integration of data analytics, telemedicine, and patient-reported outcomes will further revolutionise safety and care. By embracing innovation while staying grounded in empathy, we can build a healthcare system that is both safe and compassionate. A call to action Patient safety and care are shared responsibilities. As healthcare professionals, we must commit to continuous improvement, learning from mistakes and advocating for our patients. As patients, we should actively participate in our care and hold systems accountable. Together, we can create a future where every patient receives safe, high-quality care. Let’s work hand in hand to make patient safety not just a goal, but a reality.

Session Objectives • Advocate for the establishment of a culture to enhance patient safety and system reliability. • Encourage the adoption of leadership training models • Foster an environment that emphasizes learning from mistakes and redesigning healthcare systems. Register

In this blog, Patient Safety Learning’s Associate Director Claire Cox looks at how corridor care within the NHS is affecting safety culture, examining its implications for both healthcare professionals and patients. She underlines the need to understand these dynamics so that we can identify strategies to address causes of corridor care and promote a culture that prioritises safety and high-quality care for all. Corridor care is a term used to describe the practice of providing medical attention to patients in hallways or other non-designated clinical areas due to overcrowding or resource shortages. In the context of the NHS, this phenomenon has become increasingly common due to rising patient demand, workforce challenges and limited bed capacity.[1] While corridor care may seem like a necessary stopgap measure to address acute pressures on healthcare services, it raises significant concerns about patient dignity, privacy and the overall quality of care. We set out these issues in more detail in a blog published earlier this month reflecting on the extent of corridor care in the UK.[2] Corridor care reflects deeper systemic issues within the NHS, including funding constraints, staffing shortages and inefficiencies in patient flow. Its growing prevalence has led to widespread debate about its impact not only on patient outcomes but also on the morale and functioning of healthcare teams. Safety culture An organisational culture that seeks to assign blame when things go wrong makes patient harm more likely to happen again. In our report, A Blueprint for Action, we identify just culture as one of the six foundations of safer care to improve patient safety.[3] A just culture considers wider systemic issues when things go wrong, enabling professionals and those operating in the system to learn without fear of retribution. Just culture aligns with creating a safety culture, where shared values, attitudes and behaviours within an organisation prioritise safety as a fundamental component of its operations. In healthcare, a strong safety culture is critical to minimising risks, preventing harm and ensuring that patients receive the highest standard of care. Published in July 2019, the NHS Patient Safety Strategy identifies a patient safety culture as one of the two core foundations required in working towards its safety vision “to continuously improve patient safety”.[4] Safety culture directly influences how staff respond to pressures, make decisions and balance competing priorities. When safety culture is strong, staff feel empowered to speak up about concerns and systems are in place to mitigate risks. However, practices like corridor care can undermine these principles by creating environments where safety is compromised, staff morale declines and patient outcomes suffer. Corridor care and safety culture: Impact on teams Corridor care significantly affects safety culture among different healthcare teams, including ambulance staff, ward staff and emergency department (ED) staff. These groups must collaborate in high-pressure, resource-limited environments where patient safety is already at risk. However, the dynamics created by corridor care can undermine trust, communication and efficiency, all of which are critical components of a strong safety culture. Ambulance staff Ambulance staff are often the first point of contact for patients entering the healthcare system. When EDs are overcrowded and patients are treated in corridors, ambulance staff may face delays in transferring patients to hospital care. Long ambulance handover delays have been a persistent component of the problems faced by the NHS in recent winters.[5] [6] [7] Prolonged handover times can prevent ambulance crews from responding to new emergencies, creating frustration and moral distress. Corridor care also limits the ability of ambulance staff to provide a full clinical handover, leading to communication breakdowns and potential gaps in patient care. These delays can result in tension between ambulance crews and ED staff, as both teams struggle to manage their workloads under significant pressure. The lack of structured processes during corridor care undermines teamwork and fosters an environment where safety protocols may be bypassed to save time. Emergency department staff ED staff endure the most of corridor care's challenges, as they are tasked with managing patients in overcrowded spaces. The need to oversee patients in hallways stretches resources and divides attention, making it harder to maintain comprehensive monitoring and timely intervention. This environment increases the likelihood of errors and reduces the capacity to provide high-quality care. The presence of patients in corridors can also create role ambiguity and conflict between team members, as the usual boundaries between clinical responsibilities become blurred. For example, junior staff might feel unsupported when managing corridor patients, while senior staff may struggle to oversee all aspects of care effectively. The resulting stress and burnout among ED staff can weaken safety culture by diminishing morale, collaboration and the willingness to speak up about concerns. Ward staff Ward staff are often involved in the downstream effects of corridor care when patients are eventually transferred from ED corridors to inpatient wards. These staff members frequently face increased pressure to admit patients quickly to alleviate ED overcrowding, potentially without adequate preparation or information. This rushed process can compromise continuity of care and increase the risk of adverse outcomes. Many Trusts are now admitting an extra patient onto the wards to alleviate ED pressures, which also has implications for safety, privacy and dignity. Moreover, the systemic strain caused by corridor care can exacerbate existing tensions between ward staff and ED teams. Ward staff may perceive themselves as being unfairly burdened, while ED teams may feel unsupported in their efforts to manage patient flow. This misalignment can erode interdepartmental relationships and hinder the development of a cohesive safety culture. Corridor care and safety culture: Impact on inter-team collaboration Corridor care amplifies the challenges of inter-team communication, trust and collaboration, all of which are essential to maintaining a robust safety culture. When teams operate in silos or perceive themselves as competing for limited resources, it becomes harder to prioritise patient safety as a shared responsibility. The relationship between safety culture and corridor care is deeply intertwined; safety culture can be significantly undermined by the systemic and operational challenges posed by corridor care. Understanding this connection is essential to addressing the negative impact of corridor care on patient safety and team dynamics. This can be seen when considering how core principles associated with safety culture compare with the realities posed by corridor care: Open communication: A strong safety culture relies on clear communication among teams to ensure patient needs are met and risks are minimised. However, in the context of corridor care, chaotic and overcrowded environments can hinder effective communication. Ambulance staff may not have the opportunity to provide thorough handovers, ED staff may miss key patient details in the rush and ward staff may receive incomplete or delayed information about incoming patients. These communication breakdowns increase the risk of errors, undermining safety culture and compromising patient safety. Teamwork and collaboration: Safety culture emphasises collaboration across all levels of healthcare. Corridor care disrupts this by placing teams under excessive strain, leading to interdepartmental tensions. For example, ambulance staff may feel unsupported during prolonged handovers, while ED staff are overwhelmed managing corridor patients. This strain and associated incivility erode trust and reduces the cohesion necessary for a positive safety culture. Proactive risk management: A proactive safety culture involves identifying and mitigating risks before they lead to harm. Corridor care creates environments where risks—such as patient deterioration, falls and inadequate monitoring—are more likely to occur. The lack of resources and time for proactive measures further weakens the ability to uphold safety standards. As well as coming into conflict with some of the core principles of a safety culture, corridor care can also erode this further by: Compromising patient safety: Corridor care forces healthcare professionals to provide care in suboptimal conditions, where monitoring equipment, privacy and basic patient needs are often lacking. This creates a pervasive sense of vulnerability among staff as they are unable to deliver the standard of care they aim to achieve. Over time, this can normalise unsafe practices and dilute an organisation’s safety culture. Increased stress and burnout: Staff operating in these environments experience heightened stress and emotional exhaustion, which can lead to burnout. Burnout can negatively impact engagement, communication and decision making—all critical components of safety culture. Blame culture: In the absence of systemic solutions to corridor care, a culture of blame may develop. Teams or individuals may be scapegoated for adverse outcomes, discouraging the reporting of safety concerns. A blame culture directly contradicts the transparency and learning focus that underpin a strong safety culture. Undermining the opportunity to learn from staff speaking up: In a pressurised environment, staff may not feel that they have the time or confidence that their concerns about unsafe care will be welcomed or listened to. It is important that both healthcare providers and system leaders understand the reality of delivering corridor care and its patient safety consequences. This requires staff to be supported to raise issues through formal reporting systems, contribute to patient safety incident reviews and investigations, and speak up when they need to do so in line with their professional responsibilities. As noted earlier, corridor care often reflects deeper systemic issues, such as funding constraints, staffing shortages and inefficiencies in patient flow due to multifactorial issues outside of the control of an individual organisation. Systemic factors that challenge the ability of healthcare organisations to maintain a robust safety culture can include: Overcrowding in emergency departments—this can be a symptom of wider systemic problems—mental health crisis, an aging population, unaddressed health inequalities, access to primary care, staffing and funding crisis, etc. Insufficient staffing levels and expertise—resulting in compromised care and reduced opportunities for collaboration, communication and oversight with systems in place to review patient acuity and appropriate escalation. Limited resources—preventing the implementation of solutions, such as expanding capacity or improving triage processes, further entrenching corridor care as a stopgap measure. When systemic problems are not addressed, staff may feel disillusioned, which may undermine their commitment to the principles of safety culture. Corridor care and safety culture: What can be done? Maintaining a safety culture is an essential component of keeping patients safe from avoidable harm. In the current circumstances where corridor care is increasingly prevalent in the NHS, this is now more important than ever. This can be supported by: Encouraging open reporting and speaking up: Creating a non-punitive environment for reporting safety concerns allows teams to identify risks associated with corridor care and work collaboratively to address them. Improving communication: Structured handover protocols and enhanced use of digital tools can ensure critical patient information is not lost, even in corridor settings. Fostering interdepartmental collaboration: Training sessions, joint meetings and shared goals can build trust and reduce tensions between ambulance, ED and ward staff. Investing in staff well-being: Providing mental health support and ensuring adequate staffing levels can alleviate burnout, enabling staff to uphold safety principles. At Patient Safety Learning we are clear that corridor care must not become the norm. The negative effects on staff, patients and families can be significant and long lasting. This requires action from healthcare leaders, not only to support real time improvements, but to identify the deep-rooted causes and commit to longer-term solutions. References 1. Royal College of Nursing. On the frontline of the UK’s corridor care crisis, 16 January 2025. 2. Patient Safety Learning. Response to RCN report: on the frontline of the UK’s corridor care crisis, 17 January 2025. 3. Patient Safety Learning. The Patient-Safe Future: A Blueprint For Action, 2019. 4. NHS England, The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019. 5. Discombe, M. Ambulance handover delays hit record high. Health Service Journal, 9 January 2025. 6. Nuffield Trust. Ambulance handover delays, 25 April 2024. 7. Health Services Safety Investigations Body. Harm caused by delays in transferring patients to the right place of care, 24 August 2023.

In this podcast interview series, NHS whistleblower Peter Duffy and Patient Safety Learning’s Chief Executive Helen Hughes explore how the healthcare system responds when its staff raise concerns about patient safety. In each episode, Helen and Peter interview someone who has spoken up about patient safety issues in healthcare organisations, or who works to help staff raise concerns where they see unsafe care. In this episode, Helen and Peter speak to Dr Jayne Chidgey-Clark, the National Guardian for the NHS about how to create organisational cultures where staff are safe, and feel safe, to speak up about concerns. They reflect on the results of the latest NHS Staff Survey and discuss some of the issues relating to NHS manager regulation. They also talk about how regulatory bodies and other national organisations can work together to streamline safety and improvement recommendations so that they are simpler for organisations to implement. Reflecting on the gap that exists between organisations identifying cultural problems and finding solutions that make a difference, Jayne describes the need for a multi-layered approach that places safety and quality on an equal footing with financial and productivity targets.  Subscribe to our YouTube podcast to keep up to date with the latest episodes. View a transcript of this interview Read a blog from Peter and Helen about the interview series

In this blog, author, consultant and patient safety expert Tom Bell shares his story of being approached by an NHS Trust to take up a role as a Patient Safety Partner. He describes how his initial enthusiasm to make a difference was crushed by the Trust’s failure to value his experience and time. Tom describes the Trust’s approach to working with Patient Safety Partners and implementing PSIRF as tokenistic and disjointed. He highlights the gap between the Trust’s stated view about the importance of working with Patient Safety Partners and its disorganised internal systems and unwillingness to manage and compensate Patient Safety Partners for their work. In the summer of 2022, I was approached by the NHS Leadership Academy to see if I would be willing to make myself available to become a Patient Safety Partner for an NHS Trust that might be seeking one. Shortly thereafter I was asked and encouraged by an NHS Foundation Trust to become one of two Patient Safety Partners they wanted to appoint. My lived experience, former NHS management role, and knowledge of delivering healthcare services in rural areas were deemed useful. My role as a Patient Safety Partner started in early autumn 2022. From the beginning I was open in sharing my concerns that not every NHS leader is comfortable hearing what they don’t want to hear. I explained I would not be offended if the Trust felt I was not right for them. I was assured by the Assistant Director for Safety and Quality that my ability to present an alternative perspective would be welcomed. I was delighted. I accepted that the pay was menial in relation to my experience and qualifications, but the improving of patient safety matters deeply to me, as many will know from working with me or hearing me speak at the Annual Patient Safety Congress. Having lost a sister to suicide after a period of sexual abuse and cover up in an NHS mental health hospital and then losing my job as a middle manager in the NHS after whistleblowing in an unrelated incident over two decades later, I have been on a journey I would not wish on others. I understand to the very depths of my gut the need for significant culture change in the NHS in a way few could ever comprehend. I think the Patient Safety Incident Response Framework (PSIRF) is a genuinely well-intentioned initiative. The principles it embodies and the cultural shift it seeks to be the lever for, are massively important. The role of the Patient Safety Partner as outlined by NHS England in helping NHS Trusts successfully and meaningfully implement PSIRF, in form and spirit, is quite rightly held aloft as a significant one. For those like me who are fortunate enough to recover from the rage injustice flushes through our veins and make it through the red mists of righteous anger, the truths our experiences reveal are gifts. The hard-earned insights and knowledge we inadvertently find ourselves possessing, are precious and valuable to those willing to hear and hold them with us. I am continually emerging, if never fully, from my journey with a far greater understanding of the many forces that drive and shape individual and organisational behaviour than my academic qualifications and professional experiences could ever give me. And I remain one of the NHS’s greatest supporters. I understand very few people are inherently bad, whatever that may mean, but I also remain acutely aware that many good NHS employees at every level, feel they are working within sub-optimal systems. As W Edwards Deming rightly observed, “The origin of issues can be largely traced back to the system, not blamed on the people within them.” It will come as no surprise to those who know me that I launched myself proactively into my role as a Patient Safety Partner. I endeavoured to be a well-informed asset to a Trust I thought had placed faith in me. I carried out research and spent a great deal of my own time looking at relevant issues and exploring areas of interest that would add value to my role. Yet instead of the Trust valuing my expertise and input or welcoming the views and information I brought to the table, as well as the positive informed challenge I offered, I found myself being treated incredibly shoddily. Despite being told the work I was involved with was important, more than half the scheduled PSIRF meetings planned for the coming year were cancelled, often at short notice. Those meetings that were held were far too short to accommodate the number of agenda items included in them. Meaty and complex topics such as organisational culture, that required in-depth discussion in their own right, were given minor billing on agendas and skipped briskly over in a matter of minutes. The hour-long meetings that did go ahead were held during staff lunchtimes at which many people were distracted, eating while checking emails. The meetings were classically hierarchically dominated by a director. The majority of attendees offered little if any input. Some of those present never spoke other than to introduce themselves at the first meeting. There was no space or appetite for discussion during meetings. Progress and actions were presented through the usual RAG rating lenses of red, amber or green. I recall during one meeting I asked about progress on a particular issue, to which the chair of the meeting replied that, “Oodles of work has been done in that area.” They seemed surprised when I asked what “oodles” looked like in practice. I was greeted with a confused silence. I explained politely that were anyone to create a report for a regulator or their colleagues stating that “oodles of work had been done,” they might not be taken seriously. My point was acknowledged, I was promised evidence of the “oodles” and the meeting moved on. Of course, I never received what I had been promised during the meeting, despite my follow up emails asking for it. What I find fascinating is that nobody else in the meeting appeared to understand or support my challenge. Why did none of the well-paid presumably well-qualified NHS managers and directors in the room say anything or question the unevidenced assertion their colleague had made? The irony is that I was by many degrees the least well-paid person in the room. To me it seemed the Trust was viewing PSIRF as just another top-down, flavour of the month, centrally-mandated initiative that they needed to demonstrate they were taking seriously by ticking all the right boxes. As anyone with a degree of public sector experience knows, demonstrating you are doing something well is very different to actually doing something well. In my view and based on my experience, the Trust and its directors were simply not making the time to talk about and implement PSIRF meaningfully. As Forrest Gump might say, important is as important does. As the meetings were frequently cancelled and opportunities for face-to-face (albeit virtual) conversation became more limited, I found myself trying to communicate via emails and phone calls. However, trying to get to speak to people on the phone was a nightmare and over three quarters of the emails (yes, I’ve done the maths) that I sent in relation to my role went unanswered. Worryingly, after many months I had not received most of the reimbursement I was owed. I was being bounced around between the NHS Leadership Academy’s and the Trust’s confused and unresponsive admin departments. My requests for an update in relation to the growing amount I was owed, were ignored. I became so frustrated at the lack of responsiveness that I emailed the Trust’s senior leadership team, at which point the Trust actively blocked my email address to stop me contacting them. My access to the Trust was only reinstated when I bypassed the block using another email address and copied in numerous local MPs with whom I shared my concerns. Some of the amounts I was owed related to activity undertaken over nine months previously. I was appalled that an NHS Trust that had approached me for help and assured me my work was important and my input would be valued, was treating me so poorly. It was not the amounts in question that mattered, the reimbursement was essentially tokenistic. It was the principle. Trying to correspond and deal with the administrative mess the Trust was creating was getting me nowhere. The Trust’s own admin and finance teams acknowledged to me that the situation was “shambolic.” I eventually contacted the Trust’s newly appointed Chief Executive, and then when nothing happened, I approached NHS England and the Secretary of State for Health and Social Care. Only after I had done this was I eventually contacted by the Trust to finalise and arrange payment of what I was owed. I should never have had to make such waves to be reimbursed for work I was doing at what ultimately amounted to less than the minimum wage. The Trust published its PSIRF plan and policy in December 2023, at a time when I was in theory still one of its Patient Safety Partners. Despite the many ideas, suggestions, documents and references to useful information I had shared, the Trust did not even let me know they were going to be published. The input I had offered was not used. Early in 2024, the Trust informed me that my services were no longer required, saying they had realised they weren’t yet ready to work with Patient Safety Partners. A classic and deeply ironic cop-out if ever there was one, as well as a shirking of their legislative obligations. I was incredibly disappointed at how I was treated. Those who know me know I do not walk away lightly from any challenge. The concern I am left with is that if the Trust I tried to help is this tick-box-entrenched and administratively shambolic and unresponsive in how it treats its Patient Safety Partners, where else is dysfunctionality occurring in that Trust and the wider NHS? I worry that the involvement of Patient Safety Partners in the creation of many PSIRF related plans and policies has been little more than a tick-box exercise. Having raised my concerns with NHS England, in May 2024 I received a reply. The letter negates any concerns raised using the kind of classic public sector assertion highlighted most recently by the Post Office Scandal. It opens with the statement, “Your experience and the issues you raised are not what we have heard from other Patient Safety Partners…” (nobody else has a problem with their computer system Mr Bates), a statement which I presume has oodles of evidence to support it. As for me, all I know for a fact is that while some Patient Safety Partners are satisfied, others feel undervalued and underutilised. But what would I know, I’ve only spoken to them… This is just one Patient Safety Partner's experience but we have also heard many positive experiences too where Patient Safety Partners are able to make an impact. Further reading: How do Patient Safety Partners feel about their role? Analysis of online survey results Patient Safety Partners: examples of impact Patient Safety Partners: influencing for safety Developing the Patient Safety Partner role: Imperial College Healthcare NHS Trust share their approach Patient Safety Spotlight Interview with Mark Smith, National Patient Safety Partner and South West Yorkshire Partnership Foundation Trust Patient Safety Partner Patient Safety Partners – lack of role clarity a barrier for impact We would love to hear your experiences of being a Patient Safety Partner, please add to the comments below (you will need to be a member of the hub and logged in). If you are a Patient Safety Partner, you can find out more about the Patient Safety Partner Network, and how to join here.

On 23 October 2024, the Patient Safety Commissioner for England published a set of Patient Safety Principles. In this blog, Patient Safety Learning sets out its reflections on these principles, highlighting key points included in its response as part of the public consultation process earlier this year. The Patient Safety Commissioner’s new Patient Safety Principles are intended to act as a guide for leaders at all levels on how to design and deliver safer care for patients and reduce avoidable harm, in a just and learning culture.[1] They are as follows: Create a culture of safety Leaders have a responsibility to lead by example to inspire a just and learning culture of patient safety and quality improvement. They should set out to keep people safe through the adoption of a safety management system and by embedding continuity of care, a culture of compassion and civility, effective listening, and restorative practice. Put patients at the heart of everything Leaders should put the patient at the heart of all the work that they do, with patient partnerships the default position at all levels of the organisation. They should consider the needs of patients and communities to deliver person-centred care. Leaders should ensure that the patient voice is central in the design of services, in obtaining fully informed consent and to the implementation of shared decision making. Treat people as equals People should be treated with respect, equity and dignity. Leaders should incorporate the views of all, and proactively seek and capture meaningful feedback from patients, workers, and communities, acknowledging that those from disadvantaged groups may need specific support and encouragement to contribute. They should act upon feedback, to embed equity of voice. Identify and act on inequalities Health inequalities, and their drivers, should be identified and acted upon at every stage of healthcare design and delivery to drive improvements in patient safety and experience. Identify and mitigate risks Targeted and coordinated action should be directed towards patient safety risks. Patients, workers and communities should be encouraged and empowered to proactively identify and speak up about risks, hazards and potential improvements. Leaders should promptly escalate new and existing risks to the most appropriate person or body. Be transparent and accountable Leaders should acknowledge that creating a culture of safety requires honest, respectful and open dialogue, where candour is the default position. This transparency should support a model of continuous improvement, which learns from both successes and events, and ensures that patients, workers and communities do not face avoidable harm due to a cover up culture. Use information and data to drive improved care and outcomes for patients and help others to do the same Leaders should enable patients to have access to their personal and other data to help them improve their own care. They should ensure that good quality data is collected and meets the needs of all patients, including those from underrepresented and inclusion health groups. Workers should be supported to use and share information and data to drive improved care and outcomes for patients, in accordance with the Caldicott Principles. Shared principles These principles were subject to a publication consultation, which we responded to on the 5 September 2024. You can find our full comments on each principle here. We welcome the principles that the Patient Safety Commissioner has set out today. There is significant overlap between these seven principles and the six foundations of safer care we identify in our report, A Blueprint for Action.[2] For example: “Put patients at the heart of everything” aligns with our foundation on “Patient engagement”. 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. “Use information and data to drive improved care and outcomes for patients and help others to do the same” aligns with our foundation on “Data and insight for patient safety”. We would also consider that these principles, when taken together, align with our view set out in A Blueprint for Action about the need for a transformation in our approach to patient safety placing this as a core purpose of health and care. The Patient Safety Commissioner’s proposed principles also share much in common with the World Health Organization’s (WHO) Global Patient Safety Action Plan.[3] This sets out a vision of a “world in which no patient is harmed in healthcare, and everyone receives safe and respectful care, every time, everywhere” and a goal of achieving the maximum possible reduction in avoidable harm as a result of unsafe care. There is again significant overlap between the points included in its seven strategic objectives and these principles. The principle “Put patients at the heart of everything” also reflects a wider international initiative in patient safety, the WHO Patient safety rights charter that was published earlier this year.[4] The Charter aims to outline patients’ rights in the context of safety and promotes the upholding of these rights, as established by international human rights standards, for everyone, everywhere, at all times. Areas not covered by the principles In our consultation response we also highlighted several areas not included in these principles. We would suggest these should also be considered when creating guidance for senior leaders on how to deliver safer care for patients and reduce avoidable harm. Shared learning This is one of the six core foundations of safer care we identify in A Blueprint for Action. Healthcare is systematically poor at learning from harm. If patients are to be safer, we need people and organisations to share learning when they respond to incidents of avoidable harm, and when they develop good practice for making care safer. It is vital that patients, clinicians, managers, and health and social care system leaders share learning about safety practice and performance to make care safer. This was the key driving force behind the creation of the hub, our platform to share learning for patient safety. Patient safety standards One of the primary reasons for the persistence of avoidable harm is that healthcare does not have or apply standards of good practice for patient safety in the way that it does for other issues. Standards that do exist are insufficient and inconsistent. At Patient Safety Learning, we believe that health and social care organisations need to have standards for patient safety. These can inform 'what good looks like' and enable organisations to self-assess against them.[5] Designing for safety and safety in use Treating patient safety as a core purpose of health and care requires us not just to respond to and mitigate the risk of harm, but also to design healthcare to be safe for patients and the staff who work within it. This would include greater use of human factors expertise and systems thinking to inform the safe design, safety management and approaches to investigating unsafe care. This is also covered in depth as part of the Global Patient Safety Action Plan’s second strategic objective, ‘High-reliability systems’. Challenge of implementation Publishing these principles, the Patient Safety Commissioner said that: “The Patient Safety Principles act as a guide for leaders at all levels on how to design and deliver safer care for patients and reduce avoidable harm, in a just and learning culture. They are relevant to healthcare providers as well as commissioners, regulators, manufacturers, and the broader supply chain. The principles provide a clear framework for planning, decision-making, and working collaboratively with patients as partners.”[1] While we welcome this aspiration, how these are used in practice will determine their success. We need everyone—politicians, policymakers, patients, families and communities, clinicians, managers, system and professional regulators, researchers and academics, and health and social care system leaders—involved in this effort. All too often when it comes to patient safety, there exists an implementation gap between what we know improves patient safety and what is said about this compared to what is done in practice.[6] An example of this can be seen concerning the first of these principles, “Create a culture of safety”. This emphasises the role of leaders having a responsibility to lead by example to inspire a just and learning culture of patient safety. A similar aspiration is also identified in the NHS Patient Safety Strategy, which includes patient safety culture as one of the two foundations required in working towards its safety vision “to continuously improve patient safety”.[7] However, despite this commitment in the NHS, blame cultures and a fear of speaking up continue to persist. As highlighted in our recent report analysing the NHS staff survey results, there often exists a significant gap in this respect between what organisations say about their approach to safety culture and how staff feel.[8] If these principles are to be realised, they will need not just to be accompanied by a endorsement from the Department of Health and Social Care and the NHS, but also clear action. References Patient Safety Commissioner for England, Patient Safety Principles, 23 October 2024. Patient Safety Learning. The Patient Safe Future: A Blueprint for Action, 2018. WHO. Global Patient Safety Action Plan 2021-2030, 3 August 2021. WHO. Patient safety rights charter, 18 April 2024. Patient Safety Learning. Standards, Last accessed 4 September 2024. Patient Safety Learning. Mind the implementation gap: The persistence of avoidable harm in the NHS, 7 April 2022. NHS England. The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019. Patient Safety Learning. We are not getting safer: Patient safety and the NHS staff survey results, 26 March 2024.