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Last month, Public Policy Projects hosted their annual Patient Safety Forum in partnership with Patient Safety Learning. Held at the Royal College of Surgeons of England in London, it was attended by senior healthcare leaders, patient safety experts, representatives from the HealthTech industry, frontline healthcare professionals and patients. In this article, Patient Safety Learning reflects on the recurrent theme of safe systems and safe cultures.  Safe systems and cultures formed an integral theme throughout the Forum. Across the discussions, one message stood out clearly—safety cannot be something we focus on only when inspections are approaching or when things go wrong. It has to be built into everyday practice. One speaker framed this idea simply—every day should be a CQC (Care Quality Commission) day. Not because staff fear inspection, but because the systems around them consistently support safe care. When systems work well, healthcare professionals can deliver the care they want to give without constantly battling the structures and culture around them. Yet the conversations during the day also highlighted how far many parts of the system still have to go… Fatigue—“I’ll sleep when I’m dead” A significant discussion focused on staff fatigue and the culture that has developed around it in healthcare. Rather than being treated as an exceptional risk, fatigue is something that is just expected. In some cases it has become a misplaced badge of honour—evidence of dedication to the job. The example phrase of “I’ll sleep when I’m dead” resonated with many. A response no doubt born from a sense of utter powerlessness and lack of evidence that things will change. But normalising exhaustion creates unsafe systems for both staff and patients. Senior Nurse, Maggie Pacheco, shared an example from her own experience. After working six consecutive night shifts she was asked to take on a seventh. It did not feel safe, and during that shift a near miss occurred. Her story reflected a wider reality—systems that rely on exhausted staff are systems that increase risk. Sue Strudwick, Patient Safety Partner, highlighted that fatigue also shapes how care is delivered. When staff are constantly depleted, the system pushes them into reactive responses rather than preventative thinking. Creativity, reflection and improvement require energy and time, both of which fatigue removes. If healthcare is serious about safe systems, then fatigue cannot remain normalised. Staff support must be prioritised and built into the design of rotas, policies and expectations. Structural change is required, not symbolic gestures. Staff safety as a foundation of safe systems The forum also highlighted the importance of ensuring that staff themselves feel safe at work. Healthcare workers continue to face violence, harassment, racism and sexual abuse in some workplaces. These experiences damage morale, wellbeing and the ability to focus on patient care. A safe healthcare system cannot exist if the people delivering care do not feel physically and psychologically safe themselves. Protecting staff is therefore not separate from patient safety—it is part of it. When silence signals risk Another strong theme was the importance of psychological safety, particularly when it comes to speaking up and raising safety concerns. Silence in an organisation is sometimes interpreted as stability. In reality, it can indicate the opposite. Panellists described the presence of “shut up signals” within teams and organisations—signals that speaking up is unwelcome or risky. These signals may appear through dismissive responses, defensive leadership or negative consequences after raising concerns. Once staff recognise them, they quickly learn that raising issues carries a personal cost. The impact on patient safety is significant. When staff do not feel able to speak openly about risks or mistakes, organisations lose their early warning systems. Problems remain hidden until they escalate into serious harm. Language and responses after incidents play an important role here. Punitive reactions can discourage openness and suppress learning. Safe cultures, by contrast, make it easier for staff to raise concerns and share information when something goes wrong. Many of the guests in our Speaking up for patient safety interview series highlight the same issues surrounding psychologically unsafe cultures, and the devastating impact this can have on patients and staff. From blame to systems thinking Closely linked to speaking up is the way organisations respond when incidents occur. Healthcare is a complex system where harm rarely results from a single individual’s actions. During the forum, Ted Baker, Chair of the Health Services Safety Investigations Body (HSSIB), highlighted the importance of shifting the question from “who is to blame?” to “how did the system allow this to happen?” Frontline staff frequently create workarounds to protect patients when systems or policies do not function well in practice. These adaptations often keep services running safely despite structural weaknesses. If organisations focus only on individual blame, they risk overlooking the system conditions that allowed harm to occur in the first place. A systems approach enables learning and improvement rather than fear and defensiveness. Leadership and culture change Underlying many of these issues is the need for a different style of leadership. Creating safe systems requires leaders who listen, collaborate and engage with those delivering and receiving care. Solutions are more likely to be sustainable when they are developed with frontline staff and patients rather than imposed from above. Working with patients, the public and Patient Safety Partners were repeatedly highlighted as an important part of cultural change. A healthcare system that values patient experience alongside operational metrics is more likely to identify risks early and respond effectively. What organisations measure also shapes their culture. When success is defined solely through activity and productivity, the human experience of care can easily be overlooked. Balanced measures that include safety and experience are essential for creating systems that truly support quality care. Culture is the system The conversations at the Patient Safety Forum made clear that safety cannot be separated from culture. Policies and processes matter, but the everyday behaviours, expectations and norms within organisations matter just as much. Safe systems are created when staff are supported rather than exhausted, when concerns can be raised without fear, and when organisations seek to understand system failures rather than simply assign blame. Changing culture is never quick or easy. But if healthcare systems want to improve patient safety, they must be willing to challenge the norms that have become embedded in everyday practice and redesign systems that allow safe care to happen consistently. Share your insights Have you seen patient safety affected either positively or negatively by culture and systems? Share your thoughts on this article and the issues raised by commenting below (sign up first for free). Or you can email our editorial team at [email protected].

There are many different types of bias, some more commonly known than others. This resource has been created to help explain different types of bias and to provide some practical examples of how some of these can impact patient safety. The content has been developed following a Patient Safety Education Network session led by Samia Sakuma, lead Quality Governance Lead for Paediatrics at West Hertfordshire Teaching Hospitals NHS Trust. Types of bias and practical examples Anchoring bias – Sticking with your initial impression. Example: "I was right the last time". Aggregate bias –- Assuming evidence from population groups applies equally to an individual patient. Example one: A frailty pathway recommends conservative management for older adults with pneumonia. An individual patient who is usually very active and independent is not considered for escalation early, despite clinical deterioration. Example two: Pain assessment guidance based on average recovery patterns following surgery leads staff to underestimate significant postoperative pain experienced by one patient whose response differs from expected norms. Ascertainment bias – Judgements influenced by prior expectations or contextual information. Example one: A patient known to attend frequently with abdominal pain is initially assessed as having another functional episode, delaying recognition of acute appendicitis. Example two: Documentation describing a patient as “anxious” influences subsequent assessments, resulting in physical symptoms initially being attributed to anxiety rather than investigated further. Availability bias – Where people overestimate the importance or likelihood of events based on how easily examples come to mind. Example: A patient comes in with flu-like symptoms, it must be flu as its flu season. The patient had strep A infection that was unresolved but this was not treated as the flu diagnosis took precedence. Base rate neglect – Ignoring how common or uncommon conditions are when making decisions. Example one: A a rare neurological diagnosis is prioritised in a patient with headache, while more common causes such as medication side effects or dehydration are considered later. Example two: Chest pain in a young adult is assumed to be musculoskeletal without structured assessment, despite cardiac conditions still occurring at a measurable background rate. Commission bias – Preference for action rather than watchful waiting, even when intervention may not help. Example one: antibiotics are prescribed for likely viral infection because active treatment feels safer than observation, exposing the patient to avoidable side effects. Example two: Additional imaging is requested despite low clinical indication, contributing to unnecessary radiation exposure and incidental findings. Confirmation bias/belief bias – the tendency to search for, interpret, favour and recall information in a way that confirms or supports one's prior beliefs or values or decisions. Example: Labelling a child at handover as a ‘drama queen’, thus anything that child does is interpreted through this lens. The child’s abnormal saturations were felt due to her being anxious and hyperventilating, however there was a genuine medical nonanxiety related need for oxygen, the child then had a respiratory arrest. Diagnostic momentum – A diagnostic label becomes accepted and passed along without reassessment. Example one: A patient admitted with a presumed urinary tract infection continues to be treated for this diagnosis despite lack of supporting results, delaying identification of sepsis from another source. Example two: An ambulance handover describing “stroke” leads teams to continue that pathway even after features inconsistent with stroke emerge. Framing effect – Where people’s decisions are influenced more by how information is presented than by the information itself. Example: What order do you present things. The first things you discuss are what stick in peoples minds. The language you use also frames something in a particular way. Calling a follow up protocol “Active surveillance” as opposed to “watchful waiting” can really make a big difference in whether people agree to this or not. Gamblers fallacy – The mistaken belief that past random events can influence the probability of future independent events. Example: sepsis is relatively rare. If you have treated two patients in a row with sepsis, when you see a third patient you don’t believe the sequence can continue so you will go out of your way to find a diagnosis that isn’t sepsis, whereas each patient should be assessed afresh. Over valuing bias/endowment effect – Causes individuals to overvalue what they own, often irrationally. Example: Spending time reading in depth articles on a medical condition such as mesenteric adenitis and reviewing guidance on managing this. Therefore diagnosing patient as having mesenteric adenitis because of the time expended on gathering and reviewing information on this thereby potentially missing another diagnosis. Psych-out error - Physical illness incorrectly attributed to mental health or behavioural causes. Example one: Agitation in a patient with known mental health needs is attributed to psychiatric relapse before delirium secondary to infection is recognised. Example two: Shortness of breath in a patient with anxiety history is initially managed as panic symptoms, delaying diagnosis of pulmonary embolism. Sutton’s slip – Focusing on the most obvious or common explanation without adequate verification. Example one: a patient with recurrent falls is assumed to have mechanical instability, while medication-related hypotension is identified later. Example two: Hyperglycaemia in a person with diabetes is attributed to poor control, delaying recognition of steroid-induced glucose elevation. Visceral bias – Emotional reactions influencing clinical judgement. Example one: Challenging interactions during previous admissions unintentionally influence the urgency of reassessment when the patient re-attends unwell. Example two: A highly likeable patient’s reassurance that they feel “fine” reduces concern despite abnormal observations requiring escalation. Yin–yang out – Belief that a patient has already had extensive assessment, so further evaluation is unlikely to help. Example one: A patient with multiple previous admissions for chest pain receives limited reassessment because earlier investigations were normal, despite new symptoms. Example two: Repeated attendance with headaches leads to reduced diagnostic curiosity when new neurological signs develop. Zebra retreat – Avoiding consideration of rare diagnoses after being discouraged or corrected previously. Example one: After earlier feedback about over-investigating rare conditions, clinicians hesitate to pursue an uncommon metabolic disorder despite suggestive features. Example two: A rare drug reaction is not revisited because previous similar concerns were felt to be unlikely, delaying recognition when it genuinely occurs.

Phil Ross is the Chair of the Design in Mental Health Network, Co-Founder of Safehinge Primera, and a Trustee at the Centre for Mental Health (UK). In this blog, Phil describes a collaborative Quality Improvement project that aimed to ensure a door alarm system acted as a trusted safety aid, not a constant distraction. When it comes to service user safety in mental health settings, every second counts. That’s why Aspen Wood, Mersey Care NHS Foundation Trust’s new 40-bed low secure unit for people with learning disabilities, installed 67 full-door ligature alarm systems. The system that invisibly transforms the entire door into a weighing scale, detecting any sustained load and triggering an alert for staff to proactively intervene and save a life. However, frontline NHS teams using full-door ligature alarms and other full-edge systems shared a challenge: frequent false alarms. These alarms are disruptive, distracting, and desensitising. For staff already stretched, these alerts became a barrier to the calm, therapeutic environments we’re all working to create. Not one to shy away, we listened. Then we acted and together, co-launched a Quality Improvement (QI) initiative to solve the issue. The cost of constant alarms in mental health wards Imagine being a nurse on a mental health ward where an alarm sounds 10-20 times every day. Each alarm demands immediate attention – a possible ligature attempt – yet almost every time it turns out to be a false alert. Front-line caregivers were understandably anxious that alarm fatigue – the desensitisation to alarms due to overexposure – could undermine patient safety. The false alarms were also distracting staff from providing care. Alarm fatigue is not a trivial inconvenience; it’s a well-documented clinical risk. In healthcare settings, when clinicians face an overload of alarms, they can become desensitised, leading to slower responses or ignored alerts.[1] In the context of mental health, the stakes are especially high – an ignored alarm could mean a patient death by suicide. Recent findings in the UK have highlighted this danger: an NIHR review noted that “‘alarm fatigue’ associated with surveillance technology use can even have fatal consequences”.[2] Tragically, this was echoed by a real-world incident in Essex, where an 18-year-old patient was found unresponsive after staff failed to respond for over 52 minutes to a bathroom sensor alert. The inquest revealed that staff had grown so accustomed to frequent alerts on their digital monitoring system that “alert fatigue” had set in.[3] Aspen Wood’s alarm challenge: 600+ alerts and a team determined to help At Aspen Wood, the alarm overload soon after installation quickly became recognised as an urgent patient safety and operational issue. The Trust’s leadership moved swiftly, bringing us in to discuss the issue and creating a cross-functional working group to explore ways to resolve it. Around the table were clinicians from the wards, Estates managers, the Trust’s risk and patient safety leads, our team of experts from Safehinge Primera, who developed the full-door anti-ligature alarm, and Pinpoint, who provide the staff attack alarm system that relays door alerts to staff devices. This collective approached the problem to try and understand the issue in greater detail and explore ways to solve it. Everyone agreed on a critical point: expecting zero alarms wasn’t realistic, but we should aim to get as low as possible (there will always be some incidents or tests). The team set an initial target: roughly one ligature alarm per day across Aspen Wood – ambitious yet attainable with the right improvements. Collaborative problem-solving Several concrete solutions emerged from the discussions and subsequent development work: ● Adjusted sensitivity threshold: When the QI team discussed weight sensitivity, the Trust’s Risk team highlighted that the door alarm was much more sensitive than other safety devices within the room - the load release curtain tracks released around 20 kg. Our full door alarm was set to a 7 kg weight threshold, unnecessarily sensitive. Here, the adjustable weight threshold became a big advantage for the Trust, changing to 15 kg for this user group (with the benefit of keeping lighter weight sensitivity when used for people with eating disorders). This change sharply cut false positives without compromising safety (indeed, the team carried out a series of lab tests based on a range of different previous ligature attempts). ● Firmware enhancements and battery life: Our team also rolled out a new approach to greatly improve battery life. The new firmware also introduced smarter data logging – essentially enabling the system to be more intelligent about what triggered it, so that staff could get feedback if improper use of the door was causing alarms (like wedging the door open or hanging objects). These behind-the-scenes tweaks enhanced the system’s robustness and reduced nuisance triggers by providing helpful feedback for staff. ● Localised and silent alerting: Initially, a door ligature alarm at Aspen Wood would broadcast an alert across the entire hospital network via the staff attack alarm system. This meant a single bathroom incident could set off alerts on multiple wards, needlessly alarming staff beyond the affected area. The system was reconfigured so that door ligature alarms now alert only the local ward. This change empowers the ward staff to quickly verify and respond, and, if it is a serious incident, staff can still escalate using their Personal Infrared Transmitter (PIT) alarm. The result is fewer interruptions hospital-wide and a more scalable response protocol. The Mersey Care team had always opted for silent alarms to prevent disrupting service users with learning disabilities, an approach we’re seeing adopted nationally across all care pathways. ● Staff training refreshers: We worked with the Trust to co-create simplified support materials to ensure staff felt confident managing the alarm system. A quick-reference poster was designed (with input from Aspen Wood’s clinical team) to support new or bank staff on how to swiftly reset a door alarm after an incident. Training sessions were scheduled, including hands-on practice using our mobile training unit. This conscientious approach acknowledged that technology is only as effective as the people using it. ● Stronger interface and support: Both Safehinge Primera and Pinpoint also recognised that closer integration and joint support when complex technical issues arise would help Mersey Care’s Estates team resolve issues quickly and easily. We also worked together to create a joint troubleshooting guide for the Aspen Wood team, so any issues could be quickly pinpointed (no pun intended) and resolved. By improving the interface between the two systems and clarifying responsibility, the Trust gained confidence that “issues” would no longer fall into a void between different suppliers, but instead, a collaborative team of experts. Results: from 600 alarms to just 6 – a transformative difference The results were even better than we’d hoped for…not 30 alarms per month, but just 6 alarms. When the stakeholders reconvened at the end of April 2025, our door alarm dashboard evidenced that alarm rates had plummeted. This has restored the alarm system to its intended role: a trusted safety aid, not a constant distraction. Reliability through the system's continual monitoring (avoiding the costly daily check requirements from push-bar, door edge type alarm systems) and adjustable weight sensitivity meant the alarms were keeping staff focused on time to care, whilst ensuring service user safety too. “The current pressure on frontline teams is huge, so when the built environment adds noise instead of support, it’s a problem that Estates are asked to resolve quickly. What made this initiative work was the openness on all sides. Together, we made the Safehinge Primera full-door ligature system smarter and safer for everyone, and something that we hope will help other NHS Trusts across the country.” Chris Murphy, Assistant Director of Estates and Facilities, Mersey Care NHS Foundation Trust A model for best practice: hopeful lessons beyond Aspen Wood The journey at Aspen Wood carries hopeful lessons for mental health facilities everywhere. Alarm fatigue in an inpatient mental health setting is not an insurmountable fate; it’s a challenge that can be overcome through empathetic, curious, and determined collaboration. Mersey Care didn’t shy away from flagging the problem, and in partnership with suppliers, they created the space to carry out an analysis and co-create solutions. The outcome made our alarm smarter, more user-friendly, and tailored to the ward’s needs. In doing so, they upheld a core principle of patient safety: technology must augment, not hinder, the human care process. This story also underlines a broader point in NHS mental health services: collaboration and continuous improvement are key. Just as we strive to co-produce care with service users, here we see collaboration between clinicians, engineers, and estates teams. The result – a dramatic reduction in alarms and a safer, calmer ward – speaks to the power of being conscientious (putting service user and staff needs first) and determined (not giving up on a good idea, even when it hits bumps in the road). By staying curious (asking “Why is this happening? How can we fix it?”) and maintaining a positive mindset that a solution would be found, the Aspen Wood team exemplified the best of NHS innovation culture. Looking ahead, Mersey Care’s Aspen Wood can serve as a model of best practice that we’re actively rolling out with other mental health Trusts. References 1. HSSIB. Investigation report: The impact of staff fatigue on patient safety. 2025. (Accessed online 11.02.26). 2. Griffiths JL, Saunders KRK, Foye U et al. The use and impact of surveillance-based technology initiatives in inpatient and acute mental health settings: a systematic review (preprint). 2024. (Accessed online 11.02.26). 3. BBC News. Essex mental health patient died despite staff alarm – inquest. (Accessed online 11.02.26) Further reading Reiter-Millard B. Tackling Alarm Fatigue. Safehinge Primera. 2025. (Accessed online 11.02.26) Opinions expressed in blogs and other content are those of the author. Patient Safety Learning welcomes sharing content and opinions that promotes safer patient care and for the reduction of avoidable harm. The views expressed on the hub however do not necessarily represent Patient Safety Learning's views or values. References to a specific product or service does not imply a recommendation or endorsement.