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Found 369 results
  1. News Article
    Dozens of trusts have been hit with financial penalties after regulators questioned their claims to be compliant with maternity safety standards. The maternity incentive scheme, run by NHS Resolution, gives trusts “refunds” on their payments to its clinical negligence scheme if they meet 10 safety-related criteria, which trust boards must declare against each year. The 10 requirements include appropriate staffing, reviewing deaths using a national tool, and board oversight of maternity services. However, NHS Resolution can investigate if concerns are raised — for example in a Care Quality Commission inspection — and these conflict with the trust’s submission. The payments to trusts can then be withdrawn, or withheld if they have not already been paid. HSJ analysis of data shared by NHS Resolution found 24 trusts had to make one or more repayments in the first four years of the scheme, which started in 2018 and was relaunched after the pandemic. Read full story (paywalled) Source: HSJ, 17 June 2025
  2. Content Article
    The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) has published Recovery Beyond Survival, a review of the quality of rehabilitation care provided to patients following an admission to an intensive care unit. Based on 1,018 patients aged 18 and over who were admitted as an emergency to an ICU for four or more days between 1st October and 31st December 2022 (and who survived to hospital discharge), this report covers a range of specialities and ward areas, and identifies areas for improvement. Themes that emerge include the need for co-ordinated multidisciplinary care and good communication between professional groups, patients and their families. It also contains examples of excellent practice, such as early assessment for rehabilitation, the setting of short-term rehabilitation goals, the use of patient diaries, providing a leaflet on discharge with information about the availability of ongoing support, and the provision of follow-up appointments with the critical care team. This report goes on to make recommendations to support national and local quality improvement initiatives: Improve the co-ordination and delivery of rehabilitation following critical illness at both an organisational level and at a patient level. Develop and validate a national standardised rehabilitation screening tool to be used on admission to an intensive care unit. Undertake and document a comprehensive, holistic assessment of the rehabilitation needs of patients at risk of morbidity. Ensure that multidisciplinary teams are in place to deliver the required level of rehabilitation in intensive care units and across the recovery pathway. Standardise the handover of rehabilitation needs and goals for patients as they transition from the intensive care unit to the ward, and ward to community services. Provide patients and their family/carers with clear information.
  3. Event
    until
    Webinar overview: Understanding ISO 7101: Gain insights into the development and core principles of the standard. Benefits for the NHS: Learn the benefits of implementing the standard which can lead to improved patient outcomes, enhanced workforce wellbeing, and greater health equity. Implementation and certification: Discover practical steps for integrating the standard into existing NHS frameworks and quality improvement initiatives, as well as how to achieve certification. Q&A: Time to ask questions and hear from our expert(s)
  4. Content Article
    The Hand Hygiene Self-Assessment Framework is a systematic tool with which to obtain a situation analysis of hand hygiene promotion and practices within an individual healthcare facility. While providing an opportunity to reflect on existing resources and achievements, the Hand Hygiene Self-Assessment Framework also helps to focus on future plans and challenges. In particular, it acts as a diagnostic tool, identifying key issues requiring attention and improvement. The results can be used to facilitate development of an action plan for the facility’s hand hygiene promotion programme. Repeated use of the Hand Hygiene Self-Assessment Framework will also allow documentation of progress with time. Overall, this tool should be a catalyst for implementing and sustaining a comprehensive hand hygiene programme within a healthcare facility.
  5. Content Article
    Can you think of a campaign that has really got your attention, stuck with you and made you do something differently? Claire Kilpatrick has been involved in the World Health Organization’s (WHO) World Hand Hygiene Day campaign since its launch 17 years ago. In this blog, Claire gives her thoughts around campaigning, explains this year's World Hand Hygiene Day slogan, 'it might be gloves, it’s always hand hygiene', and shares some of WHO's campaign resources. All the outreach activities for a successful campaign take time and effort, and often considerable resources. But if it works, it can work for a long time! Do you know what campaign activities actually expect to achieve? How do you evaluate the reach and impact of any of your campaign efforts? Campaigning can ultimately help make up people’s minds with regards to what they think, how they will act and how they will continue to sell the message in the long term. Ideas exist about how you can undertake annual campaign evaluations. And even if your campaign impact expectations are not met, it doesn't mean your campaigning efforts aren’t worth it. You might still persuade people to change, in some way, at some point. You don't always dash out and buy those new running shoes immediately after you see the ad, but you might in a couple of month’s time because you remembered them… But, if people feel bombarded with information it makes it harder for them to become informed. This makes succinct campaign messaging and clarity even more important, in order to achieve the desired impact. For 17 years, since its launch, I have been involved in WHO's World Hand Hygiene Day campaign, commemorated every 5 May. Working with communications experts and colleagues in regions and countries around the world, I have learned so much about the importance of messaging and was inspired to come up with this year’s slogan: it might be gloves, it’s always hand hygiene. Why this theme? Because: Medical gloves used in healthcare—disposable gloves used during medical procedures—can get contaminated as easily as bare hands and do not protect 100%. When worn, gloves should be removed, for example, after touching a wound site/non-intact skin, and hand hygiene performed immediately. But not everyone knows or practices this. Regardless of whether gloves are worn, hand hygiene—at the right times and in the right way—is still one of the most important measures to protect patients and health workers. By 2026, hand hygiene compliance monitoring and feedback should be established as a key national indicator, at the very least in all reference hospitals. Currently 68% of countries report they are doing this. Do all countries know this is a mandate to be achieved? Excessive glove use contributes significantly to the volume of healthcare waste and does not necessarily reduce transmission of germs. An average university hospital generates 1,634 tons of healthcare waste each year and this number is increasing 2 –3% per year (especially since Covid-19); wealthier countries generate more waste. Appropriate glove use and hand hygiene can help minimise this waste. Some country efforts are evident in this regard, but more needs to be done. And there are more facts available that you can use to explain these topics to your colleagues. The great news is, WHO provides a range of resources to help meet the World Hand Hygiene Day campaign goal—to bring people together and to maintain the profile of life saving infection prevention action. By providing these, WHO helps to cut down on the time, effort and materials that countries and healthcare facilities have to find to maintain their own campaign efforts. Essentially the campaign is nothing without local action, without you. So, for 5 May 2025, and for long term impact, here are some of things you could do: A campaign badge Use it in your email signature, in your socials, or you can even print it and make real badges/pins – show that you are always part of the campaign community. An advocacy slide Drop it in to your presentations. Posters Your own ready to use poster maker. Place these in your work areas. Aim to reach different target audiences. Personalise the posters and remember to change them over time to continue to get attention. Two-minute educational video Embed this new short video into your training sessions. In this eye-opening short story, follow two nurses—one who always practices hand hygiene at the right moments and another who relies on gloves. Spoiler: Gloves aren’t the hero here. Video background Use this as your backdrop for virtual meetings to maintain the campaign profile. Social media messages Use the WHO FAQs to create messages. Repost WHO’s social media messages around 5 May. Remember to use #handhygiene so we can have a socials takeover and have maximum reach. Idea for an engagement activity Start discussions in an informal way, for example, in wards or clinics when you visit, or advertise more formal sessions, maybe including treats! Use the WHO FAQs and then ensure that conversations are informed by actual staff experiences of glove use and hand hygiene. Consider how you will share copies of FAQs for ongoing reference. Improvement documents and tools To show impact over time, use the Hand Hygiene Self Assessment Framework alongside other infection prevention assessment tools. The results guide you to available improvement tools. One of the most popular resources on the WHO YouTube channel remains the 5 Moments for Hand Hygiene training video. Some of the most visited WHO web pages remain the how to handrub, how to handwash and 5 Moments for Hand Hygiene posters. Implementation is also key A guide to implementation for hand hygiene explains the necessary on-going commitment. WHO has a number of guides to implementation for different infection prevention topics, and I have just co-led on a new guide for implementing an infection prevention national action plan – to be launched by WHO in June. Global IPC community of practice Chat with people from around the globe to share and learn more on IPC. As the world of global health evolves, we will need to get even more creative, in both what we say and how we disseminate our messages. Partnerships might help this going forward. In a 2021 paper by Storr et al, they highlighted some considerations for the future around environmental cleaning and infection prevention, including combining advocacy efforts. They noted that “the current melee of global campaigns that countries are called on to be involved in may be resulting in competition and dilution of messages, rather than being complementary.” There is still a lot of buzz around hand hygiene, but I am grateful to be issuing this blog with Patient Safety Learning because the campaign is more than just hand hygiene and to continue to get attention we can do more together. But now that it’s 5 May, as my colleagues in the Global Handwashing Partnership say – all the best for clean hands! Further reading on the hub: Top picks: Nine resources about hand hygiene
  6. Event
    This conference focuses quality accreditation, monitoring and assurance. The conference will support you to develop systems and processes for local accreditation for quality. Accreditation can be used as a tool to encouraging ownership of continuous quality improvement, reduce variation and increase staff pride and team working. This conference will also update delegates on the New CQC Single Assessment Framework. For further information and to register visit: https://www.healthcareconferencesuk.co.uk/virtual-online-courses/quality-accreditation or email [email protected] Follow the conference on X @HCUK_Clare #QualityAccreditation hub members receive a 20% discount. Email [email protected] for discount code.
  7. Content Article
    Published by Healthcare Improvement Scotland in March, the new cervical screening standards include recommendations to ensure women receive accessible letters and information about screening and healthcare professionals are trained to support women to make informed choices. To support women to make informed decisions about cervical screening, information should be provided in a format and language that suits their needs. Support should be provided to enable informed decisions with opportunities for questions. Care should be compassionate, trauma informed, understanding and non-judgemental. Women should always be respected and supported in their choices and decisions. Further reading on the hub Top picks: Seven resources about improving access to cervical screening
  8. Content Article
    Hospital accreditation programmes are globally recognised as an important tool for enhancing quality and safety in healthcare; however, many programs in low- and middle-income countries (LMICs) are discontinued shortly after their establishment. This scoping review synthesized published evidence on factors influencing the establishment and sustainability of hospital accreditation programs in LMICs, to provide guidance to health stakeholders involved in these processes.  The included studies reported upon a broad range of patterns, innovations, influencers, enablers, and barriers concerning accreditation program establishment in LMICs. Key questions emerged, including the degree of government involvement, incorporation of international standards versus development of bespoke standards, the use of local versus external surveyors, the use of financial and other incentives to promote engagement, and mandatory versus voluntary approaches of program implementation. Resource constraints were recognised as the most important barriers to sustainable establishment, while the influence of global accreditation and donor agencies were viewed as presenting both positive and negative impacts. Health stakeholders are encouraged to reflect upon and apply the ACES-GLEAM framework, incorporating the guiding principles outlined in this paper, to help establish hospital accreditation programs in LMICs in a way that facilitates sustainability and effectiveness over time.
  9. Content Article
    Infections acquired in health care settings, including those antimicrobial resistant, cause tremendous suffering to patients, families and health workers and pose a high burden on health systems. Most of these infections are preventable with appropriate infection prevention and control (IPC) programmes and practices and basic water, sanitation and hygiene (WASH) services. Improving IPC and WASH saves lives and yields high economic gains. At the 77th World Health Assembly, all countries adopted the WHO global action plan and monitoring framework 2024-2030. This document provides the evidence on the expected return in investment in and guidance for implementing and monitoring the WHO global action plan on IPC at the country level.
  10. Content Article
    The Australian Commission on Safety and Quality in Health Care released a set of national standards which became a mandatory part of accreditation in 2013. Standard 9 focuses on the identification and treatment of deteriorating patients. The objective of the study was to identify changes in the characteristics and perceptions of rapid response systems (RRS) since the implementation of Standard 9. The authors concluded that implementing a national safety and quality standard for deteriorating patients can change processes to deliver safer care, while raising the profile of safety issues. Despite limited dedicated funding and staffing, respondents reported that Standard 9 had a positive impact on the care for deteriorating patients in their hospitals.
  11. Content Article
    The Royal College of Surgeons of Edinburgh’s Patient Safety Group is dedicated to upholding patient safety and ensuring that the highest standards of care remain central to the College’s mission. These core values are at the heart of everything the College does. Learn more in the attached e-flyer, including some resources available on page 2.
  12. Content Article
    The regulation of NHS managers must drive real change by addressing root causes, prioritising patient safety, and ensuring accountability without repeating past failures, writes Roger Kline in this HSJ article. Principles a code might adopt should include: Make safety the prime litmus test for all initiatives and “stop the line” (from board to ward and community setting) when it is not. Make speaking truth to power a precondition of effective leadership. Prioritise the duty of care all staff owe. Expect and support managers (and staff) to always behave respectfully to each other (and to patients) and to relentlessly seek to create a culture of psychological safety, civility and inclusion, not least by leaders and managers modelling the behaviours they should expect of all staff; Cease performative measures to tackle toxic cultures. Employer legal proceedings involving staff who have raised concerns should also be regarded as a “never event” and all costs disclosed. Employers must review at pace (with independent support) all cases of staff who have left or been dismissed after raising concerns with a view to helping them gain NHS employment; Appointment and appraisal decisions. Openness and transparency. Duty of candour. Specifically regarding as a breach of the Code “never events”.
  13. Content Article
    Digital clinical safety is becoming increasingly embedded into organisations, and along with it, compliance with the Data Coordination Board standards DCB0129 and DCB0160, which are mandated under the Health and Social Care Act 2012. However, there exists a number of challenges that are limiting the potential impact of the process. A Digital Health Networks CSO Council survey of clinical safety officers, conducted in 2024, highlighted key areas of concern, including a lack of understanding of the clinical safety process and importance of the CSO role, insufficient capacity for digital clinical risk management and lack of senior leadership buy-in. This white paper provides actionable insights to address these concerns, foster a culture of compliance with standards and improve digital clinical safety.
  14. Content Article
    The healthcare landscape is evolving rapidly, with increasing complexity in patient needs, technological advancements and regulatory requirements. As this complexity grows, ensuring patient safety remains a top priority. One of the most widely adopted strategies for enhancing safety is quality improvement (QI), but is QI the right tool for navigating and improving safety in an increasingly complex health system asks Patient Safety Learning’s Associate Director Claire Cox, in this blog for the hub. Understanding QI in healthcare Quality Improvement (QI) refers to systematic efforts to enhance healthcare processes and outcomes through data-driven interventions. QI frameworks, such as the Plan-Do-Study-Act (PDSA) cycle, Lean and Six Sigma, focus on continuous monitoring, identifying inefficiencies and implementing evidence-based solutions.[1] By targeting system vulnerabilities, inefficiencies and variations in care, QI initiatives aim to foster a culture of patient safety and deliver consistent safe and effective care. However, as healthcare systems become more complex, can QI alone address the multifaceted challenges of ensuring patient safety? The role of QI in enhancing safety within the NHS QI plays a crucial role in enhancing patient safety by adopting systematic, data-driven methodologies to improve healthcare delivery. Within the NHS, numerous organisations have established QI initiatives, teams and trained personnel to improve the safety and efficiency of care. The recently introduced NHS Impact framework aims to equip all NHS organisations, systems and providers with the skills and techniques required to embed continuous improvement into everyday practice.[2] Strengths of QI in enhancing safety Data-driven decision making QI frameworks rely on real-time data to identify trends, measure performance and implement solutions. This evidence-based approach helps in proactively addressing safety risks and reducing adverse events.[3] By leveraging robust data analysis, NHS organisations can identify systemic weaknesses and implement targeted interventions to enhance patient outcomes. Systematic and scalable interventions QI methods, such as Lean and Six Sigma, focus on standardising processes to minimise variability in care. This is particularly beneficial in high-risk environments, such as surgical units, emergency departments and intensive care units.[4] The NHS’s systematic approach ensures that successful QI initiatives can be scaled across multiple settings, fostering consistency and reliability in care provision. Continuous improvement culture A core strength of QI is its emphasis on continuous learning and adaptation. By actively engaging frontline healthcare professionals in problem-solving, QI fosters a safety-oriented culture that promotes innovation and accountability.[5] Within the NHS, the NHS Impact framework underscores the importance of building a shared purpose and vision, investing in people and culture, developing leadership behaviours, building improvement capability and capacity, and embedding improvement into management systems and processes.[2] Reducing costs while enhancing safety Preventing medical errors and reducing inefficiencies not only enhances patient safety but also lowers healthcare costs. Many hospitals have demonstrated significant financial savings by implementing QI-driven safety initiatives.[6] By reducing avoidable harm and improving workflow efficiencies, the NHS can achieve cost savings while maintaining high standards of care. Governance, patient safety and the quality dilemma Governance in healthcare, often referred to as clinical governance, is defined as “a system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish”.[7] This involves monitoring systems and processes to provide assurance of patient safety and quality of care across the organisation. A key challenge in QI implementation is navigating the quality and patient safety dichotomy. While quality improvement aims to enhance efficiency and effectiveness, it must not compromise safety. Balancing these aspects requires a structured approach, integrating QI methodologies with robust governance mechanisms to ensure that safety remains paramount. Limitations of QI in complex health systems 1. Resistance to change Implementing QI initiatives requires cultural and behavioural shifts, which can face resistance from healthcare professionals. Without strong leadership and engagement, efforts to improve safety may fall short.[8] 2. Fragmented healthcare systems Modern healthcare systems involve multiple stakeholders, including hospitals, primary care providers, insurers and policymakers. QI initiatives often struggle with alignment across these diverse entities, limiting their effectiveness in ensuring comprehensive patient safety.[9] 3. The need for holistic safety strategies Although QI is a powerful tool, it may not be sufficient on its own. Addressing safety in complex systems requires integration with other approaches, such as human factors engineering, regulatory frameworks and digital health innovations.[10][11] 4. Data overload and implementation challenges Although data is essential for QI, excessive reliance on metrics can lead to ’analysis paralysis’. Additionally, implementing QI interventions at scale can be resource-intensive, requiring time, training and financial investment.[12] In my experience, teams often seek more data, sometimes requesting information that we don’t have access to or that isn’t always reliable. There are times when data merely describes a potential problem rather than addressing it directly—but because gathering data is easier than implementing solutions, it can become the default focus, slowing progress. The use of emerging safety science tools for reviewing ‘work as done’ has yielded valuable insights into the discrepancies between ‘work as imagined’ and ‘work as actually performed’. These insights highlight the complexities and adaptive nature of real-world work practices, often revealing gaps between prescribed procedures and practical execution. However, while these insights provide a nuanced understanding of workplace dynamics, they do not always translate into tangible, quantifiable data that directly supports QI methodologies. QI relies heavily on measurable data to assess performance, identify inefficiencies and implement evidence-based interventions.[13] Traditional QI approaches, such as PDSA cycles, Lean and Six Sigma, are data-driven, emphasising statistical analysis and process metrics.[14] In contrast, the insights derived from safety science tools often emphasise qualitative aspects, such as human factors, resilience engineering and system complexity.[15] While these insights enrich our understanding of organisational performance, they may not always align with the structured, empirical requirements of QI methodologies. Bridging this gap requires integrating qualitative insights with quantitative data collection methods. Techniques, such as ethnographic observations, safety culture assessments and frontline worker narratives, can complement QI initiatives by providing context to numerical performance indicators.[16] The way forward: Integrating QI with broader safety strategies To maximise its impact, QI should be integrated with other safety-enhancing approaches: Human factors engineering: Designing systems that account for human limitations can reduce errors and enhance safety.[17] Regulatory and policy support: Strong governance structures and safety regulations can reinforce QI efforts.[18] Digital health solutions: Leveraging artificial intelligence, electronic health records and predictive analytics can complement QI initiatives for improved safety outcomes.[19] Interdisciplinary collaboration: Engaging multiple stakeholders—patients, families, carers, clinicians, administrators and policymakers from differing healthcare sectors across the system—can ensure a holistic approach to safety improvement.[20] Conclusion QI is a vital component in enhancing patient safety within the NHS, providing a data-driven, systematic approach to continuous improvement and cost reduction. The NHS Impact framework ensures that governance and patient safety remain central to healthcare delivery.[21] However, in an increasingly complex system, QI should not be viewed as a standalone solution. Instead, it must be integrated with broader strategies, including human-centred design, technology, policy support and cross-sector collaboration.[22] A safety management systems approach, as highlighted in Healthcare Safety Investigation Branch (HSSIB) reports, is essential to embedding a proactive, system-wide perspective on patient safety.[23] Additionally, aligning QI efforts with patient safety standards and Patient Safety Learning standards ensures a structured, evidence-based approach to mitigating risks and driving sustainable improvements.[24] Furthermore, regulatory frameworks, such as the National Patient Safety Strategy and the NHS Patient Safety Incident Response Framework (PSIRF). provide additional guidance for fostering a learning culture and improving incident response. In conclusion, while emerging safety science tools offer profound insights into the realities of work as done versus work as imagined, these insights must be systematically incorporated into data-driven QI frameworks. By integrating qualitative and quantitative approaches, organisations can achieve a more comprehensive and effective strategy for continuous improvement and enhanced safety performance. The key challenge for healthcare leaders is not whether QI is essential, but how to optimally combine it with these frameworks and strategies to build a resilient, high-quality healthcare system that continuously evolves to meet patient safety needs. References Institute for Healthcare Improvement. The Model for Improvement, 2020. NHS England. About NHS Impact, 2024. [Accessed 21 February 2025]. Berwick DM. The science of improvement. JAMA, 2008; 299(10): 1182-4. Graban M. Lean hospitals: Improving quality, patient safety, and employee engagement. Taylor & Francis Group, 2016. Batalden PB., Davidoff F. What is "quality improvement" and how can it transform healthcare? Quality & Safety in Health Care, 2007; 16(1): 2-3. Makary MA, Daniel M. Medical error—the third leading cause of death in the US. BMJ, 2016; 353, i2139. NHS England. Governance, patient safety, and quality, 2024. Greenhalgh T., et al. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Quarterly, 2004; 82(4), 581-629. Shortell SM., et al.  Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress. Milbank Quarterly, 1998; 76(4), 593-624. Carayon P, et al. (Human factors systems approach to healthcare quality and patient safety. Applied Ergonomics, 2014; 45(1), 14-25. Carayon P, Schoofs Hundt A., Karsh, B-T, et al. Work system design for patient safety: The SEIPS model. Quality and Safety in Health Care, 2014; 15(Suppl 1), i50–8. Pronovost P.J, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 2006; 355(26): 2725-32. Institute for Healthcare Improvement. Quality improvement essentials toolkit, 2021. Deming WE. Out of the crisis. MIT Press, 1986. Hollnagel E, Woods DD, Leveson N. Resilience engineering: Concepts and precepts. CRC Press, 2006. Vincent C. Patient safety. John Wiley & Sons, 2010. Reason J. Human error. Cambridge University Press, 1990. Leape LL, et al. Transforming healthcare: a safety imperative. BMJ Quality & Safety 2009; 18(6), 424-8. Wachter RM. The digital doctor: Hope, hype, and harm at the dawn of medicine’s computer age. McGraw-Hill Education, 2015. Grol R., et al. Improving patient care: The implementation of change in health care. John Wiley & Sons, 2020. NHS England. The NHS Impact Framework: Embedding Continuous Improvement. 2023. Dixon-Woods M, Martin G. Does quality improvement improve quality? Future Hospital Journal, 2016; 3(3): 191–4. Healthcare Safety Investigation Branch. Safety management systems: an introduction for healthcare. 2023. Patient Safety Learning. The Patient Safety Standards. 2020.
  15. Content Article
    Digital technology offers the opportunity to revolutionise patient care, supporting the NHS to become more efficient, productive, cost-effective, and importantly, safer. This report published Public Policy Projects, in collaboration with Patient Safety Learning, highlights that the NHS will fail to unlock these opportunities without the prioritisation of patient safety. It sets out that although there are examples of successful technology implementation across the NHS, patients continue to be put at risk as efforts to digitalise services are not adequately considering patient safety. Key findings from this report include: A lack of user-centric design and interoperability between digital technologies is limiting scalable digital transformation and putting patients at risk. Digital clinical safety is being developed across the NHS, but a lack of resource and siloed working limits the ability for consistent monitoring of digital systems. A lack of understanding of digital technology and data is often tolerated among NHS leadership and the workforce is not adequately trained and/or supported to utilise digital technology. Opportunities to learn from the NHS patient safety reporting system are limited by a lack of data transparency and capacity for analysis. Digital poverty presents inherent patient safety risks where non-digital routes of access are not maintained, meaning digital transformation risks inadvertently widening inequalities. Commenting on the publication of this report, Patient Safety Learning's Chief Executive Helen Hughes said: “Digital health technologies will be key to delivering the forthcoming Ten Year Health Plan. However, if we are to fully realise the benefits of these changes, patient safety needs to be at the heart of these developments. When designing and implementing new technologies in health and care, we need to take a user-centred approach, with patient safety at its core. As this report highlights, there are some promising examples of where this is already happening. Though as the recommendations set out, greater action is needed with system-wide collaboration, to ensure that the opportunities of new technologies are realised and the risks to patient safety are addressed. Patient safety needs to be at the centre of everything we do.”
  16. Content Article
    Doctors in the US report fear of liability risk and the need to practice “defensive medicine.” In 2024, the American Law Institute revised the legal standard for assessing medical negligence. Understanding the implications of this change is crucial for balancing patient safety, doctor autonomy and the legal system’s role in health care. This JAMA article examines the new standard of care, seeing it as a shift away from strict reliance on medical custom as it invites courts to incorporate evidence-based medicine into malpractice law. Although states may adopt the recommendations from the American Law Institute at different times and to varying degrees, the restatement offers healthcare professionals and the organisations in which they practice an opportunity to reconsider how medical negligence will be assessed, and to focus more directly on promoting patient safety and improving care delivery. Nonetheless, doctors should recognise that, at least for now, many courts will continue to rely significantly on prevailing practice in assessing medical liability.
  17. Content Article
    Safety is the foundation of trust in healthcare and a critical benchmark for achieving CQC Outstanding. These comprehensive guides from by Perbinder Grewal equip healthcare leaders and teams with the knowledge, strategies, and tools to embed exceptional safety standards across every level of their organisation.  How to Elevate Your Organisation to CQC Outstanding in Caring How to Elevate Your Organisation to CQC Outstanding Safety Standards How to Achieve CQC Outstanding Status in the Safe Domain How to Achieve CQC Outstanding Status in the Effective Domain How to Achieve CQC Outstanding in the Responsive Domain How to Achieve Outstanding CQC in the Well-Led Domain
  18. Event
    This National Virtual Summit focuses on supporting staff to deliver good complaint handling and implementing and monitoring adherence to the PHSO National NHS Complaint Standards which are now being used and embedded across the NHS. Through national updates, practical case studies and in depth expert sessions the conference aims to improve the effectiveness of complaints handling within your service, and ensure that complaints are welcomed and lead to change and improvements in patient care. The conference will also reflect involving people and their families in complaints and integrating the process with the Patient Safety Incident Response Framework (PSIRF) to ensure patient safety actions and learning. For more information and to register, visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/nhs-complaints-summit or email [email protected] Follow on Twitter @HCUK_Clare #NHSComplaints hub members receive a 20% discount. Email [email protected] for discount code.
  19. Content Article
    This blog from Pentland Medical and Dawn Stott Associates highlights the findings from their report ‘Surgical airway securement: A report analysing responses to a survey, focus groups and freedom of information requests’.[2] The aim of the work is to look at patient harm from surgical airway securement in critical care environments and, ultimately, to underscore the importance of continuous learning, a culture of transparency and collaboration across disciplines to sustain improvements in patient safety. Background Securing an airway device is a critical component of patient safety, particularly in situations where airway management is essential to life support, such as during surgery, emergency care or critical illness. The airway device, typically an endotracheal tube or laryngeal mask airway, ensures that a patient’s airway remains open for adequate oxygenation and ventilation. The WHO Guidelines for Safe Surgery states that “Securing the airway of a patient undergoing general anaesthesia is the single most critical event during induction.”[1] As all healthcare professionals working in the anaesthetic environment will know, properly securing the device is paramount as any displacement or dislodgement can lead to life-threatening complications like hypoxia, aspiration or airway obstruction. Ensuring that the airway stays in place for the time needed is an equally important part of this process. Currently, this is often done with the use of off-label materials, such as tape and ties, which can cause facial damage ranging from minor redness to severe tissue damage. This tape can also pose an infection risk, but, perhaps more pertinently, any off-label methods are not fit for purpose. Although they are embedded in healthcare practice and are used world over, tape and ties were never designed to perform airway securement. Consultation on airway device securement Following an inaugural round table discussion meeting led by Dawn Stott Associates, a ‘cross sector’ Short Life Working Group (SLWG) was formed to consult on the way an airway device is currently secured when a patient is undergoing a surgical intervention. The group’s goals were to identify systemic barriers to the standardisation of airway management and to develop guidance to support a more robust and consistent way of securing the airway device. The group’s mission was to: review current policy, guidance and legislation to help interpret and apply them to daily anaesthetic practice to support healthcare facilities and personnel with materials and resources on airway device securement and management to help ensure compliance with policy to establish an environment where standardisation of approach is accepted to make guidance available to support healthcare professionals ensure that the patient is safe. The group also reviewed the broader issues around patient safety and the cultural challenges around change management in securing an airway device with tapes. Current guidance What has been astonishing for the SLWG is that no guidance exists from any recognised bodies in the UK on securing an airway device. The Difficult Airway Society (DAS) is generally regarded as the leading authority on anything airway related, not just in the UK but also internationally. However, while the DAS guidance states that healthcare professionals should secure the airway device, it does not go beyond this to advise on best techniques or materials that should be used. This absence of national guidance has resulted in an inconsistent approach to securing an airway device within UK hospitals, and with it the risk of facial harm, infections and more serious incidents that are entirely preventable. Until now there has not been any solution designed and risk-assessed to secure an airway device in the theatre environment, leaving a vacuum where healthcare professionals worldwide are forced to improvise by developing their own techniques and by using off-label generic materials such as tape and ties. There are also a huge number of varying circumstances encountered involving the use of different airway products and surgical positions that further complicates matters when it comes to a standardised approach to airway device securement. It is the opinion of the SLWG that the report we have produced provides compelling evidence for an urgent review of the existing practices for airway securement and for guidelines to be established, which include the requirement for dedicated medical devices to perform airway device securement. The study We used three approaches to gather information: A survey for healthcare practitioners was developed to explore whether there is a standardised approach to securing an airway device in their hospital. The intention was to use the findings to support ongoing work around safer patient care and better clinical outcomes. Focus groups were held to provide insight into how things are currently being done. Freedom of Information (FOI) requests were sent to NHS Foundation Trusts. The information requested was for the period between the 1 January 2020 to 31 December 2023. The FOI requests were designed to define how patient safety is delineated around securing an airway device and how standardisation can be improved to ensure the reduction of current incidents of failure and infection to patients. What we found The responses from the FOI requests show that a substantial number of trusts have experienced inadequate patient outcomes because of poor airway management (see the tables below). It also highlighted that many trusts do not report these patient safety incidents. This is sometimes due to the normalisation of the process and that the incidents are so ‘small’ it is not felt necessary to report them. Feedback from one Trust suggested that many professionals involved in the management of airway did not want to change their practices. Several Trusts stated that they did not routinely record this type of information and would therefore only be able to fulfil the FOI request if they were paid to do so under Section 12 of the FOI Act, underlining the lack of normal visibility of this data. Total responses to the FOI questions Five hospitals were unable to provide the information in the format requested but responded as follows: Key findings from the survey 23% of the people surveyed were aware of incidents of poor patient care resulting from their airway securement techniques. How people currently secured an airway: - 57% used tapes and ties - 20.16 % used elastoplast or similar - 4.3% used a fit for purpose device (not specified) - 8.7% used a mixture of methods depending on procedure - 9.4% didn’t respond. 56.5% of the respondents were aware of the infection risks associated with using tapes. However, they continued to use this as a method of securing the airway device even though it is an unlicenced and unhygienic way of managing the securement. 95.7% of the respondents were aware that the airway may migrate during the intervention and could cause serious harm to the patient but continued to use the same methods of securement. During the focus groups we asked about communication. The responses below showed that there wasn’t always an open and honest culture within the operating department. Infection Prevention and Control guidance The National Infection Prevention and Control Manual, Chapter one, Standard Infection Control Precautions (SICPs) states that care equipment can be easily contaminated with blood and other bodily fluids and infectious agents.[3] They classify care equipment as either: Single use – equipment which is used once on a single patient then discarded. Must never be reused even on the same patient. Single patient use – equipment which can be reused on the same patient. Reusable invasive equipment – used once then decontaminated e.g. surgical instruments. Reusable non-invasive equipment (often referred to as communal equipment) – reused on more than one patient following decontamination e.g. commode, patient transfer trolley. Multi-patient rolls of tape are, by definition, classified as ‘non-invasive re-usable equipment’, which by reason of the SICPs above, must be decontaminated to adhere to the National Infection Control Standards. As findings from our surveys/focus groups made clear, this is not happening because rolls of tape by their structure cannot be decontaminated. Education Ongoing education is one of the most crucial elements of managing the securement of the patient airway. Many organisations have integrated crisis management training, including human factors education into their anaesthesia and airway management programmes.[4] Simulated learning offers a dynamic and risk-free environment where learners can apply theoretical knowledge to practical scenarios, enhancing understanding and retention. By mimicking real-world situations, it allows individuals to develop critical skills, problem-solving abilities and confidence without the consequences of real-life errors. Encouraging innovation and change There is a continuing desire to make airway management safer. Innovations and new equipment continue to be developed to support safer anaesthetic practices; however, if healthcare professionals were to put forward the suggestions of tapes and ties to the regulatory bodies that manage new innovations, they would not pass the scrutiny and rigor and endure the processes in place to get the product to market. This speaks volumes about the archaic way of securing an airway device – but how do we encourage change within an environment that is entrenched in history and a ‘this is the way we have always done it’ mentality? New regulatory systems and sometimes political unawareness can cause pressures on the industry due to their often single-minded need to cut headline costs. Only recently, the Association for British Healthcare Industries announced that £50k worth of registration projects have been withdrawn due to the costs associated with compliance. This will have a catastrophic impact on much needed healthcare innovation and products that are designed to support patient safety.[5] How collaboration can make things happen This project has highlighted the importance of a team approach when trying to develop a standardised approach to different parts of the critical care environment. Another issue the project group discussed was how standardisation of certain practices made things much easier. However, it was thought that all approaches for standardisation should be backed up by rationale and be evidence based. Those involved in the discussions felt that training of new members of the team would be much easier if certain ways of working were standardised. Conclusion Effective airway device securement is a critical component of patient safety in clinical settings. Proper securement techniques reduce the risk of unplanned extubation, displacement, infection risks, facial tissue harm and compromising the airway, which can lead to life-threatening complications. Healthcare providers must be well-trained in securing airway devices and remain vigilant in monitoring their stability throughout patient care. Standardised protocols, high-quality materials and evidence-based practices are essential for ensuring the reliability of airway device securement. Regular assessments, interdisciplinary collaboration and the use of checklists further enhance safety by promoting consistency and reducing errors. In their WHA 72.6 Resolution (2019), WHO Health Ministers mandated for the global patient safety action plan 2021-2030 to be implemented.[6] Within the resolution at 5.3 they suggest they will make available guidance on how to create cultures that operate transparently and encourage speaking up.[7] Unfortunately, through the research we have undertaken and discussions we have had with individuals throughout this project, we have witnessed a damaging culture that exists within the healthcare environment. We believe that this is leading to a nation of healthcare professions who feel let down, devalued and unable to speak up and speak out to support better patient results. We did meet and talk to some professionals who worked in an environment of support and nurture, but sadly the majority of individuals felt unheard in a massive environment of ‘noise’. It has become evident that trusts generally only change their practices following an incident which is costing them more than it would have done to use a product that is designed for purpose. Failure to see the impact of such obstinacy on the patient and their wellbeing is a very blinkered approach to improvement and innovation. By prioritising proper securement practices, healthcare teams can improve patient outcomes, prevent adverse events and reinforce a culture of safety in airway management. Ongoing research and innovation in device design and securement techniques will continue to advance this critical aspect of patient care. Despite its contributions, this study is not without limitations and future research is needed with larger and more diverse samples, refining methodology and exploring additional variables. However, the outputs do highlight the issue that the project is championing for change. We are pleased to report that our work has garnered international interest, prompting efforts to replicate the exercise in both the USA and Europe. This global recognition underscores the significance of our findings and highlights the potential for broader applications in enhancing safety standards worldwide. These strategies, combined with continuous education and integration of innovative technologies, demonstrate the potential for significant improvement in patient safety related to airway device management. References World Health Organization. Guidelines for Safe Surgery 2009. Safe Surgery Saves Lives, 2009. Pentland Medical and Dawn Stott Associates. Surgical airway securement: A report analysing responses to a survey, focus groups and freedom of information requests, November 2024. NIPCM. National Infection Prevention and Control Manual, Chapter one; Standard Infection Control Precautions (SICPs). Tankard K, Sharifpour M, Chang MG, Bittner EA. Design and Implementation of Airway Response Teams to Improve Patient Safety. J Clin Med 2022; 11(21): 6336. https://doi.org/10.3390/jcm11216336. Fick M. Insight: Medical device makers drop products as EU law sows chaos. Reuters, 19 December 2022. World Health Organization. WHO Global Patient Safety Action Plan 2021 – 2030. Towards eliminating available harm in healthcare, 3 August 2021. World Health Organization. Consensus statement: Role of policy-makers and health care leaders in implementation of the Global Patient Safety Action Plan 2021–2030, 13 July 2022. You can read the full report of this study here or by scanning the QR code below:
  20. Content Article
    The Professional Standards Authority (PSA) are reviewing their Standards of Good Regulation and Standards for Accredited Registers to ensure they effectively protect the public and uphold professional standards. It’s important to PSA to hear directly from a wide range of people who are involved with, and who are affected by, PSA's work, so they are seeking views from regulators, Accredited Registers (and prospective Accredited Registers), patient organisations and individuals, registrants/professionals, healthcare employers, professional bodies/unions and members of the public.  The consultation responses received will all be considered and used to develop their approach going forward. This could be by introducing new Standards on areas such as culture, governance or duty of candour, or the removal or simplification of current standards. The deadline for responding is 5pm on 8 May 2025. PSA has already had initial discussions with stakeholders to sense-check our proposals. Following their feedback, they have now drawn up and launched this public consultation. Their proposals for change include: bringing the two types of standards into alignment where it is possible making the standards clearer, more accessible and transparent, whether/how they should take an interest in organisational governance, culture and leadership given how often it emerges as a challenge in the health and social care sector, and the impact it can have on performance, whether measures could be introduced to remove gaps in criminal convictions checks for some health and social care practitioners, and whether new criteria for registers applying for accreditation will support public confidence. This public consultation is your opportunity to influence what we look at and how we do it when assessing regulator and voluntary register performance.
  21. News Article
    A legal challenge brought by leading doctors against the medical regulator amid rising concerns over the use of physician associates is due to reach court. The British Medical Association (BMA) is bringing a case at the High Court in London against the General Medical Council (GMC), accusing the regulator of abandoning its responsibilities to patients' safety by blurring the lines between doctors and non-doctors. The BMA claims the GMC has been using the term "medical professionals" to describe all those it regulates – doctors as well as physician and anaesthesia associates (PAs and AAs). The association says the term should only be used to refer to qualified doctors. The BMA maintains that PAs and AAs are neither doctors nor medically qualified, with the distinction crucial to patient safety. It says there is evidence of widespread confusion in the public as to the roles of associates. The GMC has stated that each profession type is prominently labelled on its public-facing registers, and in search functions, meaning that when patients search its registers it will be clear whether someone is a doctor, a PA, or an AA. Read full story Source: Medscape, 12 February 2025 Further reading on the hub: Physician associates: What are the patient safety issues? An interview with Asif Qasim Partha Kar: We need a pause to assess safety concerns surrounding Physician Associates
  22. Content Article
    In 2022, the Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme was established to support cultural change and a new bold, reimagined model of care for the future across all NHS-funded mental health, learning disability and autism inpatient settings. The culture of care standards for mental health inpatient care set out in this guidance support all providers to realise the culture of care within inpatient settings everyone wants to experience – people who need this care and their families, and the staff who provide this care. They apply across the life course to all NHS-funded mental health inpatient service types, including those for people with a learning disability and autistic people, as well as specialised mental health inpatient services such as mother and baby units, secure services, and children and young people’s mental health inpatient services.
  23. Content Article
    Patient safety and high-quality care is the foundation of healthcare delivery, aimed at minimising risks, errors and harm to patients. It is important for students in their pre-registration education to understand that the principles of patient safety, and delivering safe and high-quality care, is not merely an academic requirement but a professional and ethical duty. By embedding patient safety into the core of pre-registration learning, educational establishments can ensure that the healthcare professionals of the future are equipped with the knowledge, skills and attitudes necessary to deliver high-quality, safe and effective care. The guiding principles of effective patient safety encompasses a wide range of practices, including the prevention of medical errors, learning from those errors, effective communication among healthcare teams and fostering a culture that has the patient’s wellbeing at its heart. Medical errors, which often range from diagnostic inaccuracies to medication mistakes, with equal deviations of harm, are a leading cause of preventable harm worldwide. Teaching students early in their careers to recognise and mitigate these risks is essential for building a resilient healthcare system with deep-rooted patient safety practices at its heart. Learning ‘on the shop floor’ should never be underestimated for its importance in pre-registration learning. Classroom and simulation-based learning both provide a safe environment for students to practice procedures and decision-making without risking patient safety. Life-like mannequins and virtual reality tools imitate the real-world scenarios, enabling pre-registration students to gain confidence and competence in handling complex situations. The importance of collaborative learning experiences between all healthcare professional students fosters teamwork and communication. Patient safety often hinges on effective partnerships, as errors can occur when information is not adequately shared among team members. By ensuring patient safety is an integral part of any pre-registration programme enables the students to develop a mutual respect and understanding of other healthcare professionals’ roles and the impact they have in the delivery of safe and effective patient care. Pre-registration education highlights the development of critical thinking skills. Encouraging students to explore case studies, reflect on errors and propose solutions nurtures a proactive approach to patient safety. The educational programme must provide opportunities to explore the ethical principles and legal responsibilities underpinning patient care, ensuring students understand the gravity of their actions and that accountability and transparency are integral to a culture of safety. Educators and patient safety specialists play a pivotal role in cultivating an environment where patient safety is a shared priority. Open and supportive discussions about errors, near misses and system failures help normalise the learning process and reduce stigma. Encouraging students to report, reflect and learn from near-misses and mistakes fosters a mindset focused on continuous improvement rather than blame. Despite its obvious importance, integrating patient safety into pre-registration learning can be challenging. Factors such as limited resources, time constraints and varying levels of expertise may hinder comprehensive training. However, advancements in technology and the growing recognition of patient safety’s importance provide opportunities for innovative approaches. Online modules, augmented reality, and mentorship and working placements within the local governance/quality teams can supplement traditional teaching methods. It is important that influential bodies such as the Nursing and Midwifery Council (NMC), General Medical Council (GMC), Health and Care Professions Council (HPCP) and other accreditation bodies ensure that patient safety within pre-registration education is an integral part and meets rigorous standards. In mandating specific competencies and assessments related to patient safety, these entities hold institutions accountable for producing competent healthcare providers. The integration of patient safety into pre-registration education is vital for preparing future healthcare professionals to navigate the complexities of modern healthcare. By prioritising safety at the earliest stages of education, institutions not only protect patients but also empower students to become confident, ethical and effective practitioners. In an era where the stakes are higher than ever, investing in patient safety education is an investment in the future of healthcare itself.
  24. Content Article
    Regulation and regulators play a critical role in assuring the quality and safety of care, and undertake a range of influential activities. This includes setting appropriate standards of care; assessing and monitoring care actually being delivered within healthcare systems, often through intensive data collection and inspection; intervening when standards of care are suboptimal, with options ranging from supportive guidance to legal sanction; and, perhaps most fundamentally, determining whether organisations and practitioners can provide care in the first place, through licensing and registration. Healthcare organisations and practitioners are heavily scrutinised by an array of these external regulatory actors and activities. There are around 126 different oversight bodies in the NHS that have some role in assessing, monitoring and regulating patient safety. Despite this – and indeed, likely in part due to this supervisory complexity – disastrous care failures still happen with distressing regularity, with healthcare regulators often identified as having missed or misunderstood the emerging signs of impending failure. This situation poses an urgent set of questions. How can regulators, and the regulatory work that they do, be organised in ways that: enable close and attentive monitoring of the complex activities of delivering care; support constructive, honest but appropriately challenging interactions with healthcare organisations and practitioners; and facilitate ongoing improvement and learning – both within healthcare organisations and regulators themselves? 
  25. Content Article
    The Quality and Patient Safety Competency Navigator is a self-assessment tool. It will help you identify and develop the key competencies needed to provide safe and quality care. It will also sign-post you to relevant educational resources and learning opportunities. Who can use the QPS Competency Navigator? This resource is for everyone and can be useful for: students to develop skills for safe patient care staff to self-assess competence and identify learning needs line managers to guide professional development conversations healthcare educators to inform the design of learning programmes. patients to learn how they can play a role in supporting quality and patient Safety. How to use the QPS Competency Navigator? The QPS Competency Navigator describes six topics related to quality and patient safety. You can explore these depending on your role. You can use the tool to identify specific knowledge and skills that you need to develop and discover ways to learn more about a topic.
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