Search the hub

Leadership Futures recently published a report 'Harnessing technology for human progress: Advancing into Industry 5.0', which is driven by a bold ambition: to transform organisations worldwide through technological advancements. In this blog, Caroline Beardall looks at the implications of this for healthcare and suggests five actions that organisation's should take to ensure we achieve the benefits from technology while keeping patient safety at the forefront of an evolving landscape. The recent Leadership Futures report 'Harnessing technology for human progress: Advancing into Industry 5.0' provides a valuable framework for integrating technology with human-centered leadership, which is highly applicable to advancing patient safety in health and care. Its vision of Industry 5.0 as a collaborative human-AI partnership offers a route to reduce errors, enhance clinician capacity and improve patient outcomes. However, realising these benefits requires caution—ethical and inclusive implementation strategies that address the complexities and risks unique to health and care settings. It throws up three fundamental challenges: How can healthcare leaders ensure AI tools are safe to use and that clinical staff can trust them? Who should be responsible if an AI system makes a mistake that affects a patient? How can healthcare organisations use technology to work better without losing the importance of human interaction and the skills needed for high levels of patient satisfaction and safety? In order to answer these questions, and deepen the discussion on harnessing technology responsibly to safeguard and improve patient care, there are some actions we can take to build on the report and begin to gain evidence and experience specific to healthcare. As the landscape of healthcare shifts and evolves, we should consider applying the following five actions (with examples of how to do this) so we can achieve the maximum benefits from technology for patient safety. 1. Foster collective, collaborative leadership across boundaries Leaders should actively promote cooperation and shared responsibility across organisational and professional boundaries, focusing on the overall patient journey rather than siloed departmental goals. This aligns with the report’s emphasis on human-machine collaboration and the need for integrative leadership cultures that support safe, seamless care delivery. By working collectively, leaders can ensure technology is implemented with broad input and oversight, reducing risks and enhancing patient safety. Implement interdisciplinary collaboration practices: Organise regular team meetings involving diverse healthcare professionals to discuss patient care holistically, ensuring all voices contribute to decision making. Create shared goals and aligned metrics: Develop common objectives focused on patient safety and quality that unify departments and reduce siloed working. Lead by example: Demonstrate collaborative behaviours and openness to input, encouraging a culture of trust and teamwork. 2. Embed ethical, human-centred use of technology Leaders must champion ethical principles in technology adoption, ensuring AI and digital tools augment rather than replace human judgment and empathy. This includes rigorous validation of new technologies, transparency in AI decision-making, and ongoing monitoring to prevent harm or bias. Prioritising patient experience and human values in technology deployment safeguards safety and trust. Prioritise transparency and clinician involvement: Engage frontline staff early in AI and technology design and deployment to ensure tools meet clinical needs and ethical standards. Establish continuous monitoring and feedback loops: Use data and user feedback to identify and mitigate risks or biases in technology that could impact patient safety. Promote ethical leadership training: Equip leaders with skills to balance innovation with patient experience and accountability. 3. Develop and support workforce readiness and engagement Preparing staff to work effectively alongside new technologies is vital. Leaders should invest in training that builds digital literacy, critical thinking and resilience, while also fostering a positive work climate where staff feel valued and supported. Engaged and confident clinicians are better able to use technology safely and maintain high standards of care. Invest in targeted training and digital upskilling: Provide contextual, in-app guidance and interactive training to help staff adopt new technologies confidently and efficiently. Foster a culture of psychological safety and empowerment: Encourage open discussion, honest feedback and staff involvement in decision making to build trust and resilience. Practice empathetic leadership: Focus on emotional and professional needs of staff to reduce burnout and improve engagement. 4. Set clear, aligned objectives focused on quality and safety Leadership should establish clear, challenging and aligned goals at every level that prioritise patient safety and quality improvement over mere efficiency or target-driven metrics. This clarity helps reduce staff stress and confusion, enabling teams to focus on delivering compassionate, safe care supported by technology. Communicate clear expectations and priorities: Use consistent, transparent communication to align teams around patient safety goals and reduce ambiguity. Implement continuous feedback and learning systems: Regularly review performance data and patient feedback to refine objectives and improve care quality. Balance efficiency with human factors: Ensure operational goals do not compromise critical human skills or patient-centred care. 5. Champion diversity, inclusion and accountability in leadership Inclusive leadership practices that promote equality and diversity are essential to fostering innovation and ethical decision-making in healthcare technology adoption. Leaders must also clarify accountability frameworks for technology-related decisions and errors, ensuring responsibility is shared and transparent to maintain patient safety. Promote inclusive leadership practices: Value diverse perspectives and foster equity to enhance innovation and ethical decision-making Clarify accountability frameworks: Define roles and responsibilities clearly, especially concerning technology-related decisions and errors, to maintain trust and safety Model human-centred leadership traits: Practice self-awareness, compassion and mindfulness to create cultures of excellence, trust, and caring. By integrating these strategies, human-centric leaders can effectively translate the insights from the Leadership Futures report into practical actions that improve patient safety, staff satisfaction and overall health system resilience. This approach embraces complexity and change as opportunities, not obstacles, which then enables sustainable progress in better health and care delivery. Further reading Amelia N. 6 Effective Leadership Strategies for Healthcare in 2025. Edstellar, 31 December 2024. West M, et al. Leadership in Healthcare: a Summary of the Evidence Base. Kings Fund; Faculty of Medical Leadership and Management; Center for Creative Leadership, 2015. LeClerc L, Kennedy K, Campis S. Human-Centered Leadership in Health Care: An Idea That's Time Has Come. Nursing Administration Quarterly 2020; 44(2):p 117-26.

As we reflect on another year dedicated to enhancing patient safety, Claire Cox, Chair of the Patient Safety Management Network, shares some key highlights and achievements. The Patient Safety Management Network (PSMN) is an innovative network for patient safety managers and everyone working in patient safety. Your unwavering commitment and collaborative efforts have been instrumental in making the network a success. Here’s a look back at this year’s key moments. Membership and engagement Membership growth: This year, our network of 1800 grew by over 400 members from across various healthcare sectors, including acute trusts, ambulance services, community services, mental health services, primary care and social care. Meetings and participation: We hosted 47 meetings with an average weekly attendance of 103 participants. These gatherings fostered robust discussions, knowledge sharing and collaborative problem solving. Participants are patient safety managers, clinicians, patient safety partners, educators, risk and governance managers, reflecting that the Network is open to anyone working in patient safety in the UK. Expert speakers: We welcomed 47 distinguished speakers from different areas of the healthcare system, who shared valuable insights and innovations in patient safety, inspiring discussion and ideas for patient safety improvement. Networking: Colleagues connected with each other outside of the Network meetings, collaborating and sharing perspectives and good practice. We inspired another Network: In November, Sarah Charles gave a presentation on the Multi Agency Review Group (MARG). MARG is a system-wide group that supports the review of joint incident investigations. It is a mechanism for the surrounding region to meet up, share and contact each other with ease. Key topics and discussions Throughout the year, we explored a wide range of crucial topics, including: Patient Safety Incident Review tools: We deepened our understanding of PSIRF tools such as ACCIMAP, FRAM (Functional Resonance Analysis Method), SEIPS (Systems Engineering Initiative for Patient Safety), observational studies and After Action Reviews. We learned about the tools and importantly how to apply them Engaging with families: Engaging discussions were held around thematic reviews, focusing on family and patient engagement models, learning about the harmed patient pathway from AvMA and improving safety culture. Improving safety culture: We heard from various Trusts about their PSIRF journey, learning reviews, Schwartz Rounds and strategies for supporting staff affected by patient safety incidents. Achievements Our inaugural PSMN Symposium In September, together with the Patient Safety Education Network (PSEN), we held our first Patient Safety Symposium. Our annual symposium was a hub of creativity, innovation and collaboration. Members shared experiences, strategies and solutions to emerging patient safety challenges. This year’s focus was on the practical application of SEIPS and ACCIMAP. We are grateful to BD for hosting the event at their Safety and Innovation Hub in Winnersh, Berkshire, which allowed us to offer the symposium free to PSMN and PSEN members. Our first book: 'Patient Safety - Emerging Applications of Safety Science' This year also marked the release of our first book, 'Patient Safety: Emerging Applications of Safety Science'. The book delves into the evolving landscape of patient safety, exploring the latest research, methodologies and applications of safety science in healthcare. Featuring contributions from leading experts within our Network, it offers practical insights into the implementation of safety principles and tools in real-world healthcare settings. The book serves as a resource for professionals seeking to improve patient safety through the application of scientific frameworks and evidence-based strategies. We’re delighted at how positively the book has been received and are already exploring ideas for a second edition. Looking forward to 2025 We are excited about the year ahead, and we look forward to building on our successes and continuing to collaborate on initiatives that make healthcare safer for all. We are already booked up to April with speakers and welcome ideas for topics and new speakers. With the appointment of new staff to our Patient Safety Team, we’re going to be developing new networks (watch this space!) with the PSMN being the hub of all our networks. A big thank you! I would like to extend a heartfelt gratitude to all members for your dedication and contributions to the Network. Your hard work and engagement are what make the PSMN so impactful. I’d also like to say a thank AQUA, who assist taking notes at Network meetings, and BD who provided some tech setup funding for the private forum on the hub. I’d especially like to thank Patient Safety Learning for hosting the Network on the hub and providing us with invaluable support to grow and develop the PSMN over the past three years. Together, we are making significant strides in patient safety. Wishing you a safe and happy New Year! How to join the Patient Safety Management Network You can join by signing up to the hub today. When putting in your details, please tick Patient Safety Management Network in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected].

Training to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations Being open and apologising when things go wrong Challenges/complexities associated with cases where there is more than one investigation Effective communication, including dealing with conflict and difficult conversations Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation Sharing findings Signposting and support: including loss, trauma and stress Who should attend: Lead investigators conducting patient safety incident investigations Executive and service lead for duty of candour Executive and service lead for patient safety Executive and service lead for the supporting response to patient safety incidents Investigators supporting patient safety incident investigations Facilitator: Jo Perruzza is a former mental health nurse and has been a clinician, a clinical leader and a senior manager in mental health provider organisations. With a passion for patient safety and an expert in psychological safety she brings experience of leading internal and external investigations. hub members receive a 20% discount. Email [email protected] for discount code.

Training to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations Being open and apologising when things go wrong Challenges/complexities associated with cases where there is more than one investigation Effective communication, including dealing with conflict and difficult conversations Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation Sharing findings Signposting and support: including loss, trauma and stress Who should attend: Lead investigators conducting patient safety incident investigations Executive and service lead for duty of candour Executive and service lead for patient safety Executive and service lead for the supporting response to patient safety incidents Investigators supporting patient safety incident investigations Facilitator: Jo Perruzza is a former mental health nurse and has been a clinician, a clinical leader and a senior manager in mental health provider organisations. With a passion for patient safety and an expert in psychological safety she brings experience of leading internal and external investigations. hub members receive a 20% discount. Email [email protected] for discount code.

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 knowledge resources, 6900 member from 95 countries and over 1 million unique users. In this blog, the hub's Editor, Samantha Warne, reflects on the top 10 most popular pieces of content on the hub in 2024. It showcases the breadth of original content shared on the hub from patients, frontline staff and leaders in patient safety. 1 Covid-19 : A risk assessment too far? A blog by David Osborn In a series of blogs for the hub, David Osborn, a health and safety practitioner has explored the way Government departments have handled healthcare worker safety during the Covid-19 pandemic. In this blog from September, David reflects on the misuse and abuse of ’risk assessment’, the very cornerstone of workplace health and safety. David explains how this left hundreds of thousands of healthcare workers at risk of catching Covid-19 as they provided close-quarter care to infectious patients. As the narrative unfolds, David introduces new information evidenced by emails and other correspondence obtained through Freedom of Information (FOI) requests. 2 A simple guide to the Patient Safety Incident Response Framework (PSIRF) NHS organisations in England are changing the way they investigate patient safety incidents with the introduction of the Patient Safety Incident Response Framework (PSIRF). NHS England has produced detailed resources for patient safety leaders and policy makers about the purpose of PSIRF and what organisations are expected to do to deliver this part of the NHS Patient Safety Strategy. Our discussions with frontline clinicians, patient safety managers, educators and Patient Safety Partners have highlighted the need for a simple guide that helps communicate PSIRF to a wide range of stakeholders, including those who do not work in healthcare. This guide provides information about what PSIRF is and why it’s been introduced. 3 Patient Safety Incident Response Plan (PSIRP) finder As part of PSIRF, every NHS trust is required to create and publish a Patient Safety Incident Response Plan (PSIRP). Patient Safety Learning is compiling PSIRPs from all NHS trusts in England in our PSIRP finder. Making these documents accessible in one central place will make them easy to find, allow trusts to compare ways of working and highlight variation in how trusts are approaching PSIRF implementation. We will continue to add links to plans as they become available. 4 Application of SEIPS and AcciMap to a patient safety incident At the first Patient Safety Education Network meeting of the year, Chris Elston, a patient safety education lead, shared with the group a patient safety incident that happened at this trust. In this blog he describes how he used Safety Engineering Initiative for Patient Safety (SEIPS) and Accident Mapping (AcciMap) to learn from it. 5 Electronic patient record systems: Putting patient safety at the heart of implementation Electronic patient record (EPR) systems have the potential to improve patient treatment, increase efficiency and reduce the costs of healthcare. However, it has become increasingly evident that introducing EPR systems comes with serious patient safety risks. In the report 'Electronic patient record systems: Putting patient safety at the heart of implementation', Patient Safety Learning looks at this in depth. Drawing on a recent roundtable event, it considers how patient safety can, and must, be put firmly at the heart of the design, development and rollout of EPR systems. This blog gives a summary of the report and the 10 principles it sets out for safe EPR system implementations. 6 My experience of an outpatient hysteroscopy procedure Studies indicate that some women do not find hysteroscopy procedures painful. However, it is now widely recognised that many women experience severely painful and traumatic hysteroscopies. At Patient Safety Learning, we have worked with patients, campaigners, clinicians and researchers to understand the barriers to safe care and call for improvements. We believe that no woman should have to endure extreme pain or trauma when accessing essential healthcare. We invited women to share their hysteroscopy experiences with us, and this blog is one of many stories shared on the hub. We’d like to thank all the patients for to sharing their experiences to help raise awareness of the patient safety issues surrounding outpatient hysteroscopy care. 7 Patient Safety: Emerging Applications of Safety Science There are few resources and books for professionals within the patient safety sector that use case studies to model the practical application of theories of patient safety incident investigation. Exploring these theories, this book, published earlier this year, brings together contributors from a variety of academic and healthcare professions, alongside those with lived experience, to help you understand some of the emerging theories of safety science and their practical application. 8 A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift Corridor nursing has featured heavily in the media this year as it is increasingly being used in the NHS as demand for emergency care grows and A&E departments struggle with patient numbers. In this anonymous account, a nurse shares their experience of corridor nursing, highlighting that corridor settings lack essential infrastructure and pose many safety risks for patients. They also outline the practical difficulties providing corridor care causes for staff, as well as the potential for moral injury. Using the System Engineering Initiative for Patient Safety (SEIPS) framework, they describe the work system, the processes and how that influences the outcomes. 9 The hospital told me to GO HOME, but my daughter was critically sick. A bereaved mother’s 11 patient safety lessons It was a beautiful sunny summer’s day. Twenty-five year old Gaia Young had been out for a gentle bike ride to do some shopping, came home and had an ice cream in the garden in north London that afternoon. Just hours later she was dead. Gaia, the only daughter of Dorit Young, died of an unexplained brain condition after an emergency admission to a London teaching hospital on a Saturday night in July 2021. This is Dorit's story, as a bereaved mother, about lessons she has learnt following the unexpected death of her previously well daughter Gaia. Dorit has written 11 patient safety lessons in the hope this helps other families be more assertive if they have a critically sick relative in hospital. 10 World Patient Safety Day 2024 The theme of this year's World Patient Safety Day was 'Improving diagnosis for patient safety'. In this blog for World Patient Safety Day, Patient Safety Learning sets out the scale of avoidable harm in health and care and highlights the need for a transformation in our approach to patient safety. We reflect on the theme of this year’s event and our World Patient Safety Day blogs shared on the hub, drawing out some key areas, including rapid and timely diagnosis; improving investigations into diagnostic error and the importance of listening to patients. Share your experiences on the hub 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.

Facere Melius are the only NHS Framework Provider approved training supplier that worked closely with NHS England in developing tools and guidance to support PSIRF. Training to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations Being open and apologising when things go wrong Challenges/complexities associated with cases where there is more than one investigation Effective communication, including dealing with conflict and difficult conversations Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation Sharing findings Signposting and support: including loss, trauma and stress Who should attend: Lead investigators conducting patient safety incident investigations Executive and service lead for duty of candour Executive and service lead for patient safety Executive and service lead for the supporting response to patient safety incidents Investigators supporting patient safety incident investigations Register

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 Friday 27 September 2024, Patient Safety Learning held its first Patient Safety Symposium, organised with the Patient Safety Management Network and Patient Safety Education Network. This blog provides an overview of the event, which focused on the application of Patient Safety Incident Response Framework (PSIRF) tools and methods.  Background First introduced in Autumn 2023, PSRIF is the new NHS approach to investigating patient safety incidents. At the core of this is the promotion of systems-based approaches for learning from incidents rather than methods that assume simple, linear identification of a single cause. If implemented effectively, these approaches can help us gain a clearer understanding of the causal factors of harm and lead to safety improvements. However, they also represent a complex innovation in the NHS’s approach to incident investigation, requiring appropriate training and support for those implementing them. How to use systems-based approaches to investigations promoted by PSIRF are regular topics of discussion at two of the biggest peer-support networks hosted by the hub: Patient Safety Management Network (PSMN) – this is an innovative network for patient safety managers and everyone working in patient safety. In just over three years this has grown to now over 1700 members. Patient Safety Education Network (PSEN) – a peer network for those in patient safety education and training roles with over 450 members. These networks provide a shared space to discuss new policies that impact their work, and to share knowledge and resources with their peers. A recurring theme that often emerges from these discussions is an appetite for more practical opportunities to learn about these new systems-based approaches to investigation. Planning the symposium Building on conversations in the Networks, we began planning earlier this year for a new event focused on implementing PSIRF tools and methods. Patient Safety Learning, working with Claire Cox (Chair of the PSMN), Chris Elston (Chair of the PSEN) began planning a symposium that would: Allow members of the Networks from different parts of the country, in different health settings, both inside and outside the NHS, to explore these issues in person. Help to increase understanding and discover the practical application of two of these approaches: Systems Engineering Initiative for Patient Safety (SEIPS) and AcciMaps. Help assess the value of case study based interactive training and the potential for future symposiums. Helping to bring this event to life, the medical technology company BD kindly agreed to host this at their Safety and Innovation Hub in Winnersh, Berkshire. This enabled us to hold the event for free, with members of the PSMN and PSEN invited to attend. Kicking off the day The event was opened with a short set of introductions by: Helen Hughes – Chief Executive of Patient Safety Learning Tracey Herlihey – Deputy Director of Patient Safety (Digital) at NHS England Claire Cox – Chair of the Patient Safety Management Network Tracey Herlihey, previously Head of Patient Safety Incident Response Policy at NHS England when PSIRF was introduced, reflected on how the framework had evolved over the past couple of years. She noted positive signs that PSIRF’s introduction had enabled people in different roles to start to talk more openly about patient safety incidents. This is particularly important as different roles can bring different perspectives on how to use PSIRF tools, allowing us to learn from each other. She also emphasised the real power and value of events such as this symposium, where people can be brought together to discuss how best to make PSIRF work for patient safety improvement. Before going into the day, all attendees were asked to follow a simple set of rules, based on how the PSMN and PSEN operate: Speak in plain English, no acronyms. Introduce yourself by your name and your place of work – no job titles, a flattened hierarchy where all voices are valued. Provide a safe space to ask questions/peer support. Feel free to network, make connections and steal ideas. These introductions were followed by a short icebreaking activity, before attendees headed into their first workshop of the day. Workshop 1: AcciMaps The first workshop began with a session on the history and principles of AcciMaps from Professor Mark Sujan. Mark is a Chartered Ergonomist and Human Factors specialist and has worked in patient safety and other safety critical industries for over 25 years. He is also Senior Science Investigation Educator at the Health Services Safety Investigations Body. Accimaps, or Accident Mapping, is a tool initially developed by Jens Rasmussen. Applied in patient safety, it involves creating a graphical presentation of factors within a system that contribute to the occurrence of a patient safety incident. These factors are arranged into a series of levels representing different parts of the system that the event took place in: Government policy and budgeting. Regulatory bodies and associations. Local area government planning and budgeting. Company planning. Physical processes and actor activities. Equipment and surroundings. Mark’s key reflection that resonated with many symposium participants was of the value of a different mindset in incident investigation, not just about the application of the tools such as Accimaps. Following Mark’s insightful and informative presentation, attendees were split into groups at tables and provided with a scenario of a patient safety incident that needed to be investigated. Though fictional, this was drawn from aspects of previous real-life cases. Each table was asked to consider the issues and produced their own AcciMap. Reflecting on this exercise, some key thoughts from attendees included: This approach could help to gain a viewpoint of the ‘bigger picture’ in which an incident occurs; it’s most definitely a reflection of the system in which an incident occurs and not just looking at the ‘people factors.’ There were some significant differences in the causal factors identified by different groups, reflecting the mix of expertise and roles in the room. This reinforced the value of a team-based approach to applying Accimaps and the value of educational events, working through simulations to inform learning and application. The value of using debriefing techniques in healthcare alongside this, and building this into the wider organisational culture—not just when incidents occur. Also taking an appreciative inquiry approach, looking for what went well within the scenario. Other systems-based approaches that could work alongside this, such as After Action Reviews and Swarm Huddles. Lunch break and escape room During the lunch break, attendees had the opportunity to participate in two patient safety ‘escape rooms’ in the BD Safety and Innovation Centre simulation suite, set up as a hazard identification exercise. Participants assessed the hazards in a community based setting and another in a hospital environment. This was a fun approach to a serious set of issues that generated much discussion. There was also an opportunity for patients to purchase a copy of a new book, Patient Safety: Emerging Applications of Safety Science, from Class Professional Publishing. This book brings together contributors from a variety of academic and healthcare professions, alongside those with lived experience, to help understand some of the emerging theories of safety science and their practical application. It is written by people who work in patient safety, including members of the PSMN and PSEN who were in attendance at the symposium. Workshop 2: SEIPS The afternoon workshop kicked off with an introduction to SEIPS by Nikki Fountain, Network member and Business Manager to the Chief Medical Officer at Great Ormond Street Hospital for Children NHS Foundation Trust. The symposium attendees were asked to carry out a SEIPS analysis after being shown a short video that illustrated a simulation of a routine and normal work scenario—taking blood in an ill-suited work environment. SEIPS is a framework for understanding outcomes within complex socio-technical systems. It is a conceptual tool that depicts the interactions between three key components: work system, process and outcomes. Patient safety incidents result from multiple interactions between work system factors. SEIPS prompts you to look for interactions rather than simple linear cause and effect relationships. Following Nikki’s introduction, attendees were split into groups at tables again and asked to carry out a SEIPS analysis of the scenario they had watched. Chris, Claire and Helen enjoyed creating the video although no acting awards are likely to be awarded! Reflecting on this exercise, some key thoughts from attendees included: While there were elements of good teamwork in the scenario, there was a notable trend of staff not recognising other colleagues becoming gradually overwhelmed. While nothing went ‘wrong’ in this scenario, the patient received the treatment required, observation showed that both the patient and staff member had a negative experience and there were potential risks in handling and supply of samples that could lead to problems. There were areas where there may be obvious quick fixes to put in place, but the challenge would be to make these sustainable under normal work pressures. There was a conversation about how patients could be involved in SEIPS style analysis, and how this would work in practice. Some reflections of SEIPS being used individually at trusts, when this is perhaps more effective as a group tool. End of day reflections Concluding the day, attendees reconvened in the main meeting space and shared reflections on the event, which included the following points: Great to have such a diverse range of participants at this event. One table featured student nurses, a representative from NHS England, a GP and a senior director from an independent trust. This was a genuine and much valued flattened hierarchy that enabled confident engagement and shared learning. You don’t need to wait for a safety incident to use these tools for safety improvement. Everyone can make a valuable contribution to patient safety discussions, both those in clinical and non-clinical roles. Different types of expertise are greater than the sum of the parts when pooled together. Appetite to see more system leaders/decision makers in the room for these type of events to underline the commitment to transforming how we approach incident investigation in trusts. Following the event we asked attendees to complete a short feedback form offering their reflections on the day. When asked what was their key takeaway learning, answers included: “The timeliness of utilisation of various tools, and the need to be aware of perceptions affecting the outputs from using the tools and the need for a multi-disciplinary approach.” “Mindset over method. Diversifying thinking. Accimapping for improvement rather than for incidents.” “Networking empowers. Great to hear that other organisations are struggling with similar issues, that proves that we are on a journey to change the safety culture.” “We're all in the same boat, it was great to hear how other organisations are embedding some of the learning tools.” “Thinking about the different tools being part of your learning response toolkit and that it's not either/or...you may want to use more than one tool and the same incident - different ways of looking at what happens and there is no one way or right way.” We also asked attendees if there were any PSIRF tools or approaches they would be more likely to implement at their organisation after attending this event. Responses included both Accimaps and SEIPs, the subject of both workshops, but also SWARM huddles which were discussed at several points across the day. Other general reflections from attendees included: “Really useful to have a space and down time for reflection, thinking and learning with and from peers. Great that the schedule was generous with time and only had 2 sessions and lengthy breaks to enable this.” “It was truly wonderful, so well thought out so engaging. Attending on my own and having table already mapped out was brilliant. The interaction. The lunchtime escape rooms and the ice breaker. Such a great networking opportunity. The best meeting in this field ever.” “Love the honesty in the room and sharing.” “It was an excellent networking opportunity, and I have since been in contact with a new peer. We have shared our current PSII reports and provided a critical friend approach to each other.” “A wonderful opportunity to network and learn from each other, really well considered agenda, and fabulous presenting. Felt like a family as we know each other virtually. The informal 'ness' of the setting allowed us to really network and get to discuss key issues we face. I really enjoyed listening and learning from the experts.” How to join a hub network You can join by signing up to the hub today. When putting in your details, please tick the relevant Network in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected]. The founders of each group have set the following criteria for who can join: Patient Safety Management Network – UK hub members in a health or care service provider organisation who have an active patient safety role. National NatSSIP Network – UK hub members involved in or leading NatSSIP/LocSSIP work in their organisation. Patient Safety Partner Network – UK hub members in a health or care service provider organisation who volunteer officially as a Patient Safety Partner. Patient Safety Education Network – UK hub members involved in patient safety education/ training in their organisations. The community excludes commercial training providers. Patient Safety Paediatric Leaders Network – UK hub members who are strategic-level decision makers in a specialist children’s hospital or unit with a leadership responsibility for patient safety and/or quality. You should have a role that reports to a member of the Executive and have been nominated by your CMO or CNO, and are committed to reducing avoidable harm and improving the quality and safety of paediatric care.

Do you find implementing Joy in Work a challenge? Are you unsure where to start? Or, have you implemented Joy in Work for your team already and want to share your experiences? If so, the Joy in Work Curiosity Collective is for you! Join Julia Wood and John Rouse for monthly virtual 45 minute discussions aimed at navigating the challenges of implementing and sustaining Joy in Work. Each session will tackle complex issues and questions surrounding Joy in Work. These discussions could make all the difference between implementing and sustaining a successful Joy in Work project and one which leaves you wondering where things went wrong. In this session attendees will guide the selection of topics, which means that the content is tailored to your challenges and draws upon your experiences. The Joy in Work Curiosity Collective sessions are part of the Improving Joy in Work Special Interest Group. Find out more

Do you find implementing Joy in Work a challenge? Are you unsure where to start? Or, have you implemented Joy in Work for your team already and want to share your experiences? If so, the Joy in Work Curiosity Collective is for you! Join Julia Wood and John Rouse for monthly virtual 45 minute discussions aimed at navigating the challenges of implementing and sustaining Joy in Work. Each session will tackle complex issues and questions surrounding Joy in Work. These discussions could make all the difference between implementing and sustaining a successful Joy in Work project and one which leaves you wondering where things went wrong. In this session attendees will guide the selection of topics, which means that the content is tailored to your challenges and draws upon your experiences. The Joy in Work Curiosity Collective sessions are part of the Improving Joy in Work Special Interest Group. Find out more

Do you find implementing Joy in Work a challenge? Are you unsure where to start? Or, have you implemented Joy in Work for your team already and want to share your experiences? If so, the Joy in Work Curiosity Collective is for you! Join Julia Wood and John Rouse for monthly virtual 45 minute discussions aimed at navigating the challenges of implementing and sustaining Joy in Work. Each session will tackle complex issues and questions surrounding Joy in Work. These discussions could make all the difference between implementing and sustaining a successful Joy in Work project and one which leaves you wondering where things went wrong. In this session attendees will guide the selection of topics, which means that the content is tailored to your challenges and draws upon your experiences. The Joy in Work Curiosity Collective sessions are part of the Improving Joy in Work Special Interest Group. Find out more

Do you find implementing Joy in Work a challenge? Are you unsure where to start? Or, have you implemented Joy in Work for your team already and want to share your experiences? If so, the Joy in Work Curiosity Collective is for you! Join Julia Wood and John Rouse for monthly virtual 45 minute discussions aimed at navigating the challenges of implementing and sustaining Joy in Work. Each session will tackle complex issues and questions surrounding Joy in Work. These discussions could make all the difference between implementing and sustaining a successful Joy in Work project and one which leaves you wondering where things went wrong. In this session attendees will guide the selection of topics, which means that the content is tailored to your challenges and draws upon your experiences. The Joy in Work Curiosity Collective sessions are part of the Improving Joy in Work Special Interest Group. Find out more

The predominant approach to improving safety in healthcare has involved studying adverse outcomes to identify system vulnerabilities and correct them. While this approach is useful, it has limitations. As a result of continuously investigating and analysing errors, patient safety professionals can experience stress and may view their systems and teams as unusually unsafe. This webinar will articulate the value of Success Cause Analysis (SCA) in promoting learning and organisational culture change. They will describe SCA considerations for each component of traditional event analysis, how they established SCA within their organizations, and how you can deploy SCA in your facility. Additionally, participants will learn how to mitigate “third victim syndrome” for safety professionals analysing only errors and how to involve patients and families in patient safety and quality process reviews. Speakers: Dr Komal Bajaj, chief quality officer, NYC Health + Hospitals/Jacobi and North Central Bronx Dr Lara Musser, deputy chief quality officer and practicing emergency medicine physician, NYC Health + Hospitals/Jacobi and North Central Bronx Kathy Lospinuso, RN, BSN, director of risk management at NYC Health + Hospitals/Jacobi Gayle Kolt, MPH, RN, director of risk management and regulatory affairs at NYC Health + Hospitals/Jacobi and North Central Bronx, NCB Campus Vinita Parkash, senior research scientist at the Yale School of Public Health and clinical associate professor of Pathology at Yale School of Medicine, Register for the webinar

Themed Together to Regenerate Health and Care, the programme will showcase inspirational improvement work from all sectors and explore how we can create a system of health and care that truly meets the needs of our communities. You can now explore six new topic streams - Safety, People, Population, Change, Leadership and Science, and find sessions that address the challenges that you and your organisation face. Register