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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; providing a space for people to come together and share their experiences, resources and good practice examples.  To support. WHO's World Immunisation Week, we have picked 14 resources full of practical advice about vaccination in a range of settings. 1 WHO: Vaccines explained "Vaccines Explained" is a series of illustrated articles from the World Health Organization that describe how vaccines work, how they’re developed and distributed and how their safety is carefully monitored. 2 EDUCATE KS3 lesson pack: HPV vaccination Co-produced by young people and researchers from the University of Bristol and London School of Hygiene and Tropical Medicine, ‘EDUCATE’ helps teach students about the human papillomavirus (HPV) vaccine and provide reassurance about receiving the vaccine, which is usually offered to teenagers at school as part of the national vaccination programme. 3 The Green Book: Immunisation against infectious diseases The Green Book is published by the UK Health Security Agency and contains the latest information on vaccination procedures for vaccine-preventable infectious diseases in the UK. It offers guidance on general safety considerations and clinical procedures relating to immunisation, as well as specific information on a wide range of diseases and vaccinations. 4 Vaccination awareness toolkit for children and young people The School And Public Health Nurses Association (SAPHNA) has coproduced this vaccination toolkit with children and young people. It aims to increase young people's awareness of what vaccines are, why they are important and what to expect from different types of vaccines. 5 Improving communication about the human papillomavirus (HPV) vaccination programme among families In England, young people aged 12 to 13 years are offered immunisation against HPV as part of the NHS vaccination programme. However, research by the National Institute for Health and Care Research (NIHR) Health Protection Research Unit in Behavioural Science and Evaluation at the University of Bristol has identified sustained inequalities in uptake by area and minority ethnic groups. They have produced a number of information videos to address information needs about HPV among young people. They were coproduced with young people from disadvantaged backgrounds and diverse ethnic groups. 6 A visual guide to vaccines for the UK routine vaccination programme This guide by the UK Health Security Agency is designed to help ensure healthcare workers administer the right vaccines at the right time. It provides photos of all vaccines used in the UK routine immunisation programme, as well as information on when each vaccine should be given and its different trade names and abbreviations. 7 Pain management in infant immunisation: A cross-sectional survey of UK primary care nurses Childhood immunisation is a critically important public health initiative. However, since most vaccines are administered by injection, it is associated with considerable pain and distress. Despite evidence demonstrating the efficacy of various pain management strategies, the frequency with which these are used during routine infant vaccinations in UK practice is unknown. This study aimed to explore primary care practice nurses’ use of evidence-based pain management strategies during infant immunisation, as well as barriers to evidence-based practice. 8 Shingles Vaccination Programme: GP toolkit for improving uptake About 1 in 5 people who have had chickenpox develop shingles, predominantly those who are over 70. However, uptake rates of the shingles vaccine are falling in London and across England. The purpose of this toolkit is to help GPs better protect their patients by suggesting ways to improve uptake of the shingles vaccine. These suggestions are based on best practice and evidence and have been shown to work with little or no cost to practices. 9 Interview with Charlet Crichton, founder of UKCVFamily UKCVFamily was set up in November 2021 to support patients in the UK who have had an adverse reaction to a Covid-19 vaccination. The group provides help and advocacy as well as raising awareness amongst healthcare professionals, the media and the Government. In this video for the hub, founder of UKCVFamily Charlet Crichton talks about why she established the group and describes the support it offers to patients. 10 Measles and rubella vaccine microneedle patch: new hope to reach the unreached children This Lancet article looks at how microneedle patches (MNPs) could potentially improve coverage of childhood vaccinations by providing a more thermostable, individual-dose, injection-free vaccine delivery device suitable for administration by local, non-medical personnel. MNPs could also reduce wasted vaccine doses, needle-stick injuries and breaks in the cold chain, as well as making waste management easier. 11 Whooping cough resurgence as vaccination rates slump Official data on whooping cough show that reports of suspected cases are at a 15-year high in the first three months of 2024. This article in the Pharmaceutical Journal looks at why cases are increasing, including falling rates of children receiving the childhood 6-in-1 vaccine and maternal vaccination. It outlines the symptoms of whooping cough, describes how it can be treated and includes a map identifying infection 'hot spots' in England and Wales. 12 Enhancing vaccine confidence across ethnic minority communities The Collaboration for Change is a group of two UK universities, nine community organisations and two small and medium size enterprises, who have conducted research on how to improve vaccine uptake among ethnic minority groups. The report highlights the factors influencing vaccine uptake. 13 Vaccination in the UK: Access, uptake and equity Over the last decade, the uptake of vaccines in the UK has stalled and is in many cases falling. Declining rates of routine childhood vaccination in a country with a well-established universal healthcare system are extremely concerning and pose a significant public health risk, with outbreaks of preventable diseases such as measles and whooping cough already being seen. The Royal College of Paediatrics and Child Health (RCPCH)'s Commission on Immunisation policy report assesses how and why vaccine uptake has stalled or declined. It outlines the evidence and our recommendations to increase uptake of routine childhood vaccinations across three broad themes: access to services, improved data systems and strengthening public information, education and communication. 14 UK Covid-19 Inquiry: Module 4 -Vaccines and therapeutics The UK Covid-19 Inquiry has published its fourth report and recommendations following its investigation into ‘Vaccines and therapeutics of the United Kingdom’. It considers and makes recommendations on a range of issues relating to the development of Covid-19 vaccines and the implementation of the vaccine rollout programme in England, Wales, Scotland and Northern Ireland. Issues relating to the treatment of Covid-19 through both existing and new medications were examined in parallel. Do you have a resource or story to share about immunisation safety? We’d love to hear about it - leave a comment below or join the hub to share your own post.

When repeated harm occurs in healthcare, public debate often centres on identifying an individual responsible. Although accountability is essential, patient safety may be better served by asking another question first: Were there earlier signals that something was going wrong? This blog reflects the perspective of Aditi Desai, a surgeon with nearly three decades of clinical experience and an interest in patient safety systems, surgical quality monitoring and organisational learning. Recent high‑profile cases, such as the case of surgeon Yasser Jabbar at Great Ormond Street Hospital,[1] have prompted difficult reflection across the profession about how systems detect repeated patient harm. These situations understandably lead to questions about individual responsibility, but they also highlight the importance of recognising warning signals earlier. After nearly three decades in surgical practice, I have seen how outcomes can fluctuate. A surgeon may perform many procedures safely, then experience several complications in close succession. Some of this represents natural variation. But sometimes patterns emerge that should prompt earlier concern. Modern healthcare systems collect large amounts of clinical data, yet we rarely use it systematically to detect deteriorating performance early.[2] Risk‑adjusted monitoring of outcomes over time, combined with supportive mentoring and fair accountability, could help organisations intervene sooner, protecting both patients and clinicians. Improving patient safety requires moving beyond a simple choice between blaming individuals or fixing systems. Safer care depends on recognising both the human realities of clinical practice and the need for strong organisational oversight. Recognising the early warning signs of unsafe surgical practice Having practised surgery for more than 28 years, I have learned that clinical outcomes are rarely perfectly predictable. A surgeon may perform a hundred operations without complication. Then, within a short period, several adverse outcomes may occur—like unexpected bleeding, infection or an unintended injury during surgery. When this happens, patients suffer first and most. For clinicians, complications also carry a heavy emotional weight. Many doctors recognise the sleepless nights and intense self‑reflection that follow when a patient is harmed. In recent years, public discussions around cases of repeated patient harm have raised difficult questions about how healthcare systems detect unsafe practice. The case of Yasser Jabbar at Great Ormond Street Hospital, widely reported in the UK, has prompted reflection not only about accountability but also about whether earlier signals of unsafe care might have been detectable. The instinctive response is often to ask: “Who is the rogue clinician?” But from a patient safety perspective, an equally important question may be: “Where was the signal that care was becoming unsafe?” Distinguishing variation from unsafe care All clinical practice carries risk. Even highly skilled surgeons experience complications. Medicine is complex, and outcomes vary according to patient condition, procedural difficulty and chance. The real challenge is distinguishing between: Expected complication rates and natural variation, and Patterns that may indicate deteriorating performance or unsafe practice. This distinction is rarely straightforward. It requires careful interpretation of clinical outcomes and trends over time. The human side of surgical practice Medicine often expects clinicians to perform at a consistently high level throughout long careers. Yet surgeons, like everyone else, experience illness, fatigue, personal stress and periods of reduced resilience. Most clinicians continue working through these pressures because the culture of medicine places great value on strength, reliability and professionalism. Recognising this human reality does not diminish professional responsibility. Instead, it highlights the importance of systems that can identify when a clinician may be struggling and offer support or review before patient harm accumulates. The missing safety infrastructure Healthcare organisations collect vast amounts of data about procedures and outcomes. Yet in many systems, we still lack robust mechanisms that can: Risk‑adjust outcomes for patient complexity. Monitor outcome trends over time. Identify negative outliers early. Trigger timely peer review or mentoring. Such systems are not primarily about punishment. Their purpose is to protect patients while supporting clinicians to maintain safe practice. Moving beyond 'individual versus system' Patient safety discussions often frame harm as either the fault of an individual clinician or the result of system failure. In reality, safety depends on both. Strong systems should be able to detect emerging risks early, while still ensuring fair accountability when unsafe practice becomes clear. This approach aligns with the principles of a just culture, where organisations seek to understand and respond to risks rather than relying solely on retrospective blame.[3] A role for data, mentorship and oversight In other high‑performance fields, such as aviation and elite sport, continuous monitoring and coaching are routine. Medicine has traditionally been slower to adopt this approach. Yet supportive oversight and mentoring could help clinicians identify and address problems earlier in their careers or during periods of difficulty. Clinicians may benefit from ongoing coaching and feedback, not only during training but throughout their professional lives.[4] Surgeon and writer Atul Gawande, the WHO checklist pioneer, highlighted this idea in his TED Talk “Want to get great at something? Get a coach”, where he describes how even experienced surgeons can improve performance and safety through structured coaching and peer observation.[5] Looking forward Cases where repeated harm occurs inevitably raise questions about accountability. Where clear incompetence or unsafe practice exists, fair accountability is essential. But patient safety improves most when healthcare systems are able to recognise warning signs early, before serious harm accumulates. By combining risk‑adjusted data, supportive oversight and a culture of learning, healthcare organisations can better protect patients while supporting clinicians to maintain safe practice. Ultimately, safer care depends not only on responding to failure, but on building systems capable of recognising risk sooner. References Triggle N. Great Ormond Street doctor who botched surgery harmed nearly 100 children. BBC News, 29 January 2026. Royal College of Surgeons of England. Surgical outcomes data and transparency. Outcomes FAQ. NHS England. Being fair tool: supporting staff following a patient safety incident. 9 May 2025. Pradarelli JC, Yule S, Panda N, et al. Optimising the implementation of surgical coaching through feedback from practicing surgeons. JAMA Surgery, 2021; 56;(1): 42-49. doi:10.1001/jamasurg.2020.4581. Gawande A. Want to get great at something? Get a coach. TED Talk, April 2017.

Claire Cox, Patient Safety Lead at Kings College Hospital NHS Foundation Trust, shares a recent technique she used to explain the difference between 'work as imagined' and 'work as done'. Claire's example (a pathway for a patient coming to A&E, who also has a mental health issue) highlights the safety risks of competing guidance and the importance of co-production moving forward. The phrase work as imagined vs work as done is often used within patient safety but it's not always an easy concept to explain. I recently tried a new tactic to bring the realities of this concept to life, and show why it is so important to address these issues - in this case relating to a mental health pathway in A&E. My aim was to explain how some of the policies we try to use don't actually work well together in practice when we have a patient come to A&E with a both a mental and physical health problem. I started off by printing every piece of policy, guidance, standard operating procedure, related documentation on the trust intranet, HSIB reports, NICE guidance and anything I could find from the wider NHS. I pinned it across the walls in the meeting room. There were more than 150 items relating to how we should care for the patient in these circumstances. We put the pathway that we 'imagined' at the top, like a process map along the wall. We then placed all of the policies and documents below the pathway at the relevant points. Then I got the staff to tell me what actually happens. It became clear very quickly that the policies contradict each other. In trying to follow two policies, you couldn't actually adhere to either one properly. It was impossible for staff. Once we did that exercise, participants in the room could see how the people writing policies did not perhaps understand how 'work is done'. So it was decided that any new policy that encompassed this mental health pathway for A&E would be co-written by patients, families and the staff doing the work. Importantly, this would include all staff involved - admin, clinical and management. Once that had been written it would go through stages of testing to make sure it was working well and to incorporate necessary flex in the system when unexplained or unintended things happen. We would look at and test the vulnerabilities within that system or process. The exercise took time and effort but it was an effective way to show people the challenges and barriers to safe care in a specific context. My advice to others trying to do the same would be to get it all out, expose it, make it as visible as possible. Sometimes you have to be the one to put the writing on the wall. Related reading Postcards from work: Exploring archetypes of human work through micro-narratives Work as is done, work as imagined Electronic observations – how safe is it? Proxies for work-as-done: a blog series by Steven Shorrock, Humanistic Systems Share your thoughts What did you think of Claire's example? Could you see this working in a different area of healthcare?Do you have any tips or techniques to share that could help others explain the challenges they face on the ground to large groups of people? Share your thoughts by commenting below (sign up here first for free), or get in touch with our content team at [email protected]

Marsha Jadoonanan, nurse and Head of Patient Safety and Learning at HCA Healthcare UK (HCA UK), spoke to us about a recent opportunity to learn from patient safety incidents involving wrong site anaesthetic blocks. She describes the new learning approach she and her colleagues used, which focused on engaging staff working in a variety of roles to create a safe space to focus on identifying ‘work as done’.

This conference focuses on improving practice and patient safety to reduce Extravasation Injury, ensuring front line clinicians are aware of the risk of extravasation and how to recognise, treat and escalate extravasation injuries when they do occur. This conference will enable you to: Network with colleagues who are working to reduce Extravasation Injury Learn from outstanding practice in recognizing, treating and escalating extravasation injury Reflect on national developments and learning Ensure vesicants are administered in the safest way Develop your skills in training frontline staff to recognize evolving injuries Understand how you can implement preventative measures Identify key strategies for improvement Educate patients to raise alarm and improve consent procedures Develop protocols to support practice Understand the role and competencies of the NHS trust lead for extravasation Ensure effective treatment, and early intervention in severe wounds Learn from case studies in cancer, maternity, radiology and paediatrics Ensure you are up to date with the latest legal cases Self assess and reflect on your own practice Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register hub members receive a 20% discount. Email [email protected] for discount code.

This webinar by the Institute for Safe Medication Practices in the US is aimed at: Pharmacists, physicians, nurses Medication safety officers Quality professionals Risk managers Leaders in pharmacy and nursing Pharmacy and anaesthesia technicians Although most medications in healthcare today have a wide margin of safety, there remains some which can cause serious harm or death if they are misused. To reduce the risk of error with these “high-alert” medications, special precautions and high leverage strategies should be implemented to avoid serious patient safety events. Numerous organizations have taken steps to identify these medications, but many are still less than confident that they have taken all the necessary precautions against serious patient harm. Join the ISMP faculty as we focus particular attention on the potential safe use risks with heparin, concentrated electrolytes, and magnesium using the results from ISMP’s National Medication Safety Self Assessment® for High-Alert Medications. Faculty will review specific safety characteristics of each these important drug classes, describe self-assessment findings related to the use of these medications, and discuss the necessary practice strategies for harm prevention when using these high-alert medications. Register for the webinar 3.00pm Eastern Time (US and Canada), 8.00pm GMT

Infection is a leading cause of childhood deaths, but many of these deaths are avoidable with timely treatment. The national Before Arrival at Hospital Project (BeArH), funded by the National Institute for Health Research (NIHR), explored what happens to children under five years of age with serious infections before they are admitted to hospital. The aim of this research was to explore what helps children get help quickly and what might slow this process down, so that lessons could be learned for the care of this group of children in the future. This forum will be led by Professor Sarah Neill, Dr Damian Roland and Natasha Bayes. To join the research forum and hear the findings of this important research project from the study team, email [email protected] for the Microsoft Teams link.