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Join this webinar on “Safe Birth and Neonatal Care – Strengthening Healthcare Systems for Every Newborn” on 13 June 2025, from 3:00 to 4:00 IST. This webinar aims to address system-level gaps in maternal and newborn care in India. The session will bring together healthcare professionals, policymakers, and patient advocates to discuss referral mechanisms, care standards, and strategies to improve outcomes for mothers and newborns. Focus Area: Safe care practices for newborns and children. Strengthening referral systems and delivery care. Reducing preventable maternal and neonatal deaths. System-level recommendations for safer healthcare. Join us to be part of this critical dialogue on advancing patient safety for every newborn and child. Register -
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Resilience Engineering principles are becoming increasingly popular in healthcare to improve patient safety. FRAM is the best-known Resilience Engineering method with several examples of its application in healthcare available. However, the guidance on how to apply FRAM leaves gaps, and this can be a potential barrier to its adoption and potentially lead to misuse and disappointing results. The article provides a self-reflective analysis of FRAM use cases to provide further methodological guidance for successful application of FRAM to improve patient safety.- Posted
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untilTraining to support the development of core understanding and application of systems-based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: purpose of patient safety incident response framework introduction to complex systems, system thinking and human factors restorative just and learning culture duty of candour involving staff in incident response involving patients, families and carers in incident response improvement science and developing system improvement plans general response techniques interviewing and asking questions conducting observations, understanding work as done systems frameworks response types patient safety investigation planning, analysis and report writing commissioning and oversight of an internal investigation a high-level overview of system-based response tools Who should attend: Lead investigators; Executives, commissioning, and service leads for investigations; Investigators supporting or overseeing 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. Register hub members receive a 20% discount. Email [email protected] for discount code.- Posted
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Patient safety articles by Professor Braithwaite
Patient Safety Learning posted an article in Research papers
Professor Jeffrey Braithwaite is Founding Director of the Australian Institute of Health Innovation, Director of the Centre for Healthcare Resilience and Implementation Science and Professor of Health Systems Research at Macquarie University. Professor Jeffrey Braithwaite is a leading health services and systems researcher with an international reputation for his work investigating and contributing to systems improvement. He has particular expertise in the culture and structure of acute settings, leadership, management and change in health sector organisations, quality and safety in healthcare, accreditation and surveying processes in the international context and the restructuring of health services. Professor Braithwaite is well known for bringing management and leadership concepts and evidence into the clinical arena and he has published extensively, with over 788 refereed contributions (including 15 edited books, 95 book chapters, 506 articles and 65 refereed conference papers; and 320 peer-reviewed abstracts and posters; and 231 other publications, e.g., international research reports). Links to some of Professor Brainthwaite's work can be found below. Patient safety articles by Professor Braithwaite Implementation Science and Translational Health Research Articles by Professor Braithwaite Resilient healthcare series Professor Jeffrey Braithwaite on patient safety and health systems improvement- Posted
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This Health Services Safety Investigations Body (HSSIB) report follows on from HSSIB's launch report, ‘Fatigue risk in healthcare and its impact on patient safety’, which introduced the concept of fatigue and outlined the risk posed to patient safety from staff fatigue. The International Civil Aviation Organization’s definition of fatigue was adopted by this investigation, where fatigue is defined as: “A physiological state of reduced mental or physical performance capability resulting from sleep loss, extended wakefulness, circadian phase [the natural daily internal body clock], and/or workload (mental and/or physical activity) that can impair a person’s alertness and ability to perform safety related operational duties.” The investigation engaged with a wide range of healthcare staff to learn what impact fatigue had on patient safety in acute NHS hospitals. The investigation explored the NHS systems and processes in place to capture and learn from the risk posed by fatigue on patient safety and staff safety. It also considered the main factors that contribute to healthcare staff being fatigued. The investigation shares findings from staff interviews, discussions and observational visits to several acute hospital trusts, combined with evidence from national bodies, forums and networks with insight on this topic. The report also refers to supporting surveys and literature. While the investigation focused on staff working in acute hospitals, the findings will be relevant to providers and staff in other health and care settings. Findings Staff fatigue contributes directly and indirectly to patient harm. However, there is little evidence available to help understand the size and scale of the risk, how it impacts on patient safety, and those staff groups who may be most at risk of fatigue. There was variation in how the concept of fatigue was understood and the impact it could have on patient safety and staff safety across the healthcare system. This inconsistent understanding prevented fatigue risks being addressed. The risks posed by staff fatigue are not always clear to trusts. The systems and processes needed to provide the information to assess staff fatigue risk are not always well developed or well used. However, some trusts were starting to explore these risks. A positive safety culture was a key enabler to support healthcare organisations to recognise and manage fatigue risk. Staff fatigue is not routinely captured as part of patient safety event reporting or routinely considered as part of patient safety event learning, or other governance processes. Fatigue was perceived by organisations and staff as an individual staff risk, with limited organisational accountability. This sometimes led to a blame culture and punitive actions when staff were fatigued, and limited actions to drive improvement. Fatigue arises from a number of personal and organisational factors, which can overlap. Organisational factors that contributed to staff fatigue included workload, long shifts, insufficient rest facilities and inadequate rest breaks during and between shifts. Personal factors that contributed to an increased risk of fatigue included caring responsibilities, menopause, pregnancy, religious practices and socioeconomic factors. Fatigue was found to have a negative impact on staff safety. A key risk related to this was staff driving home after a long shift and being involved in fatal car accidents or near misses. There are barriers to acknowledging the risk posed by staff fatigue. These include historical beliefs and norms around working long and additional hours, pride and ‘heroism’ of NHS staff. The demands on healthcare services, and workforce and financial constraints, limited the ability of some organisations to address fatigue risks. There is limited regulatory and national oversight of the risks posed to patient safety by staff fatigue in healthcare. There was limited consideration of the risk of staff fatigue in national initiatives addressing workforce challenges and care delays. The systems-based approach and supporting materials provided to trusts implementing the NHS England Patient Safety Incident Response Framework (PSIRF) helped to prompt consideration of staff fatigue in safety event learning, but this was not routine in all organisations. Safety recommendations HSSIB recommends that NHS England/Department of Health and Social Care identifies and reviews any current processes that may capture staff fatigue related data. The output of the review should identify how information about factors impacting on staff fatigue can be collated and further enhanced to aid the understanding of fatigue risk in healthcare. This data will help inform the development of any future strategy and action to address staff fatigue risk and its impact on patient safety. HSSIB recommends that the NHS Staff Council, via the Health, Safety and Wellbeing subgroup, convenes fatigue science experts and other key stakeholders to develop and test a consensus statement defining fatigue for all healthcare staff. The group should work with existing networks to promote the definition and a shared understanding of the causes and impacts of fatigue. This will help to support a consistent understanding of fatigue among healthcare providers and improve the understanding of factors that may impact on staff fatigue and patient safety. Safety observations Research funding and commissioning bodies can improve patient safety by prioritising future research to measure and assess the impact of staff fatigue on staff and patient safety. This should include patient experience and the health economics of staff fatigue due to reduced performance and productivity. Healthcare organisations and professional bodies can improve patient safety by including aspects of fatigue when conducting staff surveys in order to help build an understanding of the level of fatigue and any impact on staff performance and patient safety. This will help organisations assess and understand the risks associated with staff fatigue, and to monitor and manage the risk of staff fatigue. Healthcare regulators and professional bodies can improve patient safety by: considering how they can contribute to driving improvement in the understanding and awareness of staff fatigue; considering how they can support and share best practice on mitigations for the risk of staff fatigue; considering organisational and individual factors that may have contributed to staff fatigue when making decisions about regulatory assessment and action. Government and national organisations can improve patient safety by accounting for the impact of staff fatigue on patient safety when developing national priorities for NHS services. Healthcare organisations can improve patient safety by considering the principles and activities for a systems approach to fatigue risk management and the roadmap to implement this as described in the Chartered Institute of Ergonomics and Human Factors white paper ‘Fatigue risk management for health and social care’. Related reading on the hub: Managing fatigue as part of a safety culture – a blog from Nancy Redfern, Emma Plunkett and Roopa McCrossan Why we need to manage fatigue in the NHS – a blog from Nancy Redfern and Emma Plunkett CIEHF: Fatigue risk management for health and social care- Posted
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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 hub members receive a 20% discount. Email [email protected] for discount code.- Posted
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- System safety
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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 hub members receive a 20% discount. Email [email protected] for discount code.- Posted
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- System safety
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untilTraining to support the development of core understanding and application of systems-based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: purpose of patient safety incident response framework introduction to complex systems, system thinking and human factors restorative just and learning culture duty of candour involving staff in incident response involving patients, families and carers in incident response improvement science and developing system improvement plans general response techniques interviewing and asking questions conducting observations, understanding work as done systems frameworks response types patient safety investigation planning, analysis and report writing commissioning and oversight of an internal investigation a high-level overview of system-based response tools Who should attend: Lead investigators; Executives, commissioning, and service leads for investigations; Investigators supporting or overseeing 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. Register hub members receive a 20% discount. Email [email protected] for discount code.- Posted
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To raise decision quality, non-medical options must be considered. Anna Dixon, MP and health policy expert, and Connie Jennings, director of stronger communities for the Walsall Housing Group, share insights with the hosts of The Choice podcast .- Posted
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In this podcast interview series, NHS whistleblower Peter Duffy and Patient Safety Learning’s Chief Executive Helen Hughes explore how the healthcare system responds when its staff raise concerns about patient safety. In each episode, Helen and Peter interview someone who has spoken up about patient safety issues in healthcare organisations, or who works to help staff raise concerns where they see unsafe care. In this episode, Beatrice Fraenkel, ergonomist and Non Executive Director at Stockport NHS Foundation Trust discusses the importance of understanding the issues that lead to poor culture and harm in healthcare organisations. She describes the Board's radical approach to establishing a Just Culture during her time as Chair of Mersey Care NHS Foundation Trust and the huge investment needed to build trust between healthcare staff and their employers. She also talks with Peter and Helen about the importance of understanding the needs, views and emotions of people in the wider community that each trust serves. They discuss the universal impact of fear and anxiety on human behaviour and the need to ensure lessons are really understood before attempting to put solutions in place to tackle issues, on any scale. Subscribe to our YouTube podcast to keep up to date with the latest episodes. View a transcript of this interview Read a blog from Peter and Helen about the interview series- Posted
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This blog describes the approach taken by researchers at the Exeter HSDR Evidence Synthesis Centre when they performed a systematic review on safety management systems in healthcare. They research practice in five English-speaking high-income countries: The Netherlands, Australia, Canada, Ireland and New Zealand. Having started their literature review, the team realised that whilst the components of a safety management system—leadership commitment and safety policy, safety risk management, safety assurance and safety promotion and culture—were present in the patient safety approaches of all of the countries we were looking at, only one of them had actually implemented safety management systems in their healthcare system. This resulted in a change of approach which looked at the differences in how key components of a safety management system were implemented. Read the research study: The implementation of Safety Management Systems in healthcare: a systematic review and international comparison (March 2025)- Posted
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We talk about patient-centred care but we don’t have patient-centred systems. Understanding “why this matters” is essential to making progress in creating patient-centred in healthcare systems. #NavigatingHealth is a social impact project effecting health system change. Find out more in this video.- Posted
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- Person-centred care
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untilThis course from Medled will: Develop an understanding of PSIRF and systems based learning. Explore how Safety II can be integrated into an Incident Investigation. Facilitate understanding in how to effectively apply a response planning process. Demonstrate a diverse range of tools to investigate incidents, such as SIEPS. Discuss a range of tools for capturing every day work. Demonstrate a range of tools for synthesising information gathered, such as timeline mapping and work system scans. Provide an opportunity to discuss how to respond proportionately to patient safety incidents. Explain how to write an effective investigation report. Explore how to apply principles of safety science to understand causation. Look at conducting interviews; including recognising signs of shock and post-traumatic stress. Register- Posted
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In 2016, the Care Quality Commission looked into how acute, community and mental health trusts investigate and learn from deaths. This resulted in new national guidance. Here they report on their assessments of how NHS trusts are putting it into practice.- Posted
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- Patient death
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In healthcare, errors could have serious consequences for patients and staff. High-risk industries, such as aviation, have improved safety by taking a systems approach, known as safety management systems. Safety management systems are generally considered to have four key components: leadership commitment and safety policy; safety risk management; safety assurance; and safety culture. Safety management systems need to be context-specific to be effective. Evidence on the use of safety management systems in health care is therefore needed to inform policy decisions. A systematic review was undertaken to investigate the application of safety management systems to patient safety in terms of effectiveness, implementation and experience. The authors included evidence from Australia, Canada, Ireland, the Netherlands and New Zealand because their healthcare systems are similar to the United Kingdom’s. They included policy documents, research papers and accounts of patient and staff experiences. The study found that the Netherlands was the only country with a patient safety programme explicitly based on a safety management system approach. The programme was associated with improvement in some aspects of patient safety in hospitals but there was significant variation in its implementation and outcomes. The main components of a safety management system were also identified to some extent in the patient safety approaches of the other four countries, along with evidence of influence from high-risk industries and ‘safety science’ more widely. Across all five countries, there was a change in the patient safety discourse away from the narrow focus on reporting and learning from incidents. Without denying the importance of this element, the new approaches to patient safety adopted broader definitions of safety (e.g. including psychological and cultural safety) and harm (e.g. including harm resulting from social inequalities and structural oppression), and emphasised the importance of taking a systems perspective and involving everybody, especially patients and families, in the processes of assessing and creating safety, and learning from successful practice as well as failures. Although these new ideas were present in the policies of all countries, their translation into practice was not always clear, and robust evidence of their effectiveness was not available. Although there is a considerable overlap between the Dutch PSP and the NHS patient safety strategy in terms of specific components, one important difference is the role of leadership within individual healthcare organisations. While the role of leadership is also acknowledged in the NHS patient safety strategy, the responsibilities of the top management and the lines of accountability in relation to patient safety within a healthcare organisation are not always clearly defined. The responsibilities of local patient safety specialists are most clear but they may not have the authority or capacity to ensure patient safety throughout the organisation.- Posted
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A Learning Health System is not a technical project. It is the evolution of an existing health system into one capable of learning from every patient. This paper outlines a recently published framework intended to aid the understanding, design, development and evaluation of Learning Health Systems.- Posted
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The Learning Healthcare System: Workshop summary (2007)
Sam posted an article in Research, data and insight
The Learning Healthcare System is a summary of the Institute of Medicine (US) two-day workshop held in July 2006, convened to consider the broad range of issues important to reengineering clinical research and healthcare delivery so that evidence is available when it is needed, and applied in health care that is both more effective and more efficient than we have today. Embedded in these pages can be found discussions of the myriad issues that must be engaged if we are to transform the way evidence is generated and used to improve health and health care—issues such as the potential for new research methods to enhance the speed and reliability with which evidence is developed, the standards of evidence to be used in making clinical recommendations and decisions, overcoming the technical and regulatory barriers to broader use of clinical data for research insights, and effective communication to providers and the public about the dynamic nature of evidence and how it can be used.- Posted
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Last month Public Policy Projects, in partnership with Patient Safety Learning, held their Patient Safety Forum 2025, as part of a new patient safety policy programme between the two organisations. Taking place at the Royal College of Physicians in London, in attendance were senior healthcare leaders, patient safety experts, representatives from the HealthTech industry, frontline healthcare professionals, patients, policy makers and the media. In this article, Patient Safety Learning’s Chief Executive, Helen Hughes, and Director, Clare Wade, look back at the day and share their reflections on the event. Digital health technologies are likely to be central to the successful delivery of the UK’s forthcoming 10-Year Health Plan. However, if we are to fully realise the benefits of new devices and innovations, patient safety needs to be at the heart of their development, implementation and use. In working towards this, it is vital that we bring together people from across the health and social care system who have the right knowledge, skills and experiences to contribute to this. We have therefore been delighted to partner with Public Policy Projects (PPP) over the past six months on a patient safety programme that culminated in our Patient Safety Forum on Thursday 27 February 2025. Leading up to this event, between October and December 2024, we hosted with PPP three roundtable sessions discussing patient safety through the lens of technology, digital innovation and data-driven transformation. The outcomes of these events are summarised in a new report, Patient safety in the digital NHS: user-centric approaches to technology and transformation.[1] The key findings of this report were reflected throughout the discussions at our Patient Safety Forum: 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. Introduction to the Forum To begin the event, Helen Hughes, Chief Executive of Patient Safety Learning, welcomed participants, sponsors and panellists to the Patient Safety Forum. The goals of the event and our partnership with PPP were to: Ensure that technology introduced to service delivery is patient centred and safe. Embed a culture of patient safety within UK healthcare. Support patient safety being a core purpose of Integrated Care Systems (ICSs) and to ensure the patient voice is core to the design of safety at system level. The initial keynote speech at the Patient Safety Forum was then provided by Jeremy Hunt MP, Chair of the All-Party Parliamentary Group on Patient Safety. He reflected on his first experiences of patient safety in his previous role as Secretary of State for Health and the scale of avoidable harm in the healthcare system. Jeremy spoke about a report published in December by Imperial Institute of Global Health Innovation and the charity Patent Safety Watch, which had highlighted the gap in healthcare between the UK and best performing OECD countries.[2] The report showed that if the UK matched the top 10% of OECD countries, this would equate to 13,495 fewer deaths per year. The report also underlined the cost of unsafe care in England, estimated at £14.7 billion per year. He also talked about the areas that he believes should be key patient safety priorities, identifying the following four areas: Creating a centralised system to collate and prioritise patient safety recommendations. To improving and revitalise the Care Quality Commission. To tackle cultural issues in the NHS, with reform of the clinical negligence system an important element of this. Not normalising avoidable deaths. Patient safety and Integrated Care Systems Following the morning keynote address, the first panel session of the Forum focused on the need to position patient safety as a core purpose across ICSs. This featured the following participants: Helen Hughes – Chief Executive, Patient Safety Learning Sir Liam Donaldson – Chair of North East and North Cumbria Integrated Care Board (ICB), Special Envoy for Patient Safety, World Health Organization Kate Provan – Associate Director Clinical Effectiveness and Improvement, NHS Greater Manchester Matthew Mansbridge – Senior Safety Investigator, Health Services Safety Investigations Body (HSSIB) Tim James – Clinical Director and Nursing Executive, Oracle Health UK Sir Liam Donaldson opened the first panel by explaining that when approaching patient safety as an ICB, it must be viewed through the lens of avoidable harm. Some of the issues discussed with the panellists were: The need to reduce variation across healthcare in how patient safety incidents and avoidable harm are both responded to and acted on. The difficulties of reducing avoidable harm while working against the backdrop of persistent blame cultures in parts of the NHS, which undermine efforts to learn and improve. The difficulties that organisations can face in attempting to respond to mismatched reporting requirements across various bodies in a complex operating environment. Errors occurring in weak systems, where services are performing at suboptimal level and with poor practitioner performance. We need to tackle the normalisation of deviation from good practice At Patient Safety Learning, we believe that greater action is required to create clarity about the role of ICBs and ICSs in patient safety. We set this out previously in in our 2023 report, The elephant in the room: Patient safety and Integrated Care Systems.[3] A HSSIB investigation report published this year echoed these points, highlighting the lack of overarching principles for ICBs and ICSs to take a consistent approach to safety management. [4] [5] With greater clarity around the roles, ICBs and ICSs have the potential to drive systemic improvements in patient safety. However, to do so effectively, they require enhanced tools, commitment and capacity that support patient safety. Culture and regulation The second panel session at the Forum focused on how patient safety improvement could be driven forward and supported through culture and regulation. This featured the following participants: Sue Holden – Executive Chair, Advancing Quality Alliance Dr Alan Clamp – CEO, Professional Standards Authority for Health and Social Care Norman MacLeod – Patient Safety Partner Moyra Amess – Director - Assurance and Accreditation, CHKS A key element of this panel discussion was how to create a psychologically safe culture in healthcare. This extended not just to creating a culture of incident reporting, but also ensuring staff and patients see clear examples of those reports being acted on for improvement. Psychological safety is when someone feels they are safe to speak up with ideas, questions, concerns or mistakes without fear of being punished or humiliated. We have a number of different resources available on this topic on the hub, our platform to share learning for patient safety. To overcome blame cultures in the NHS, the panellists all emphasised the importance of kind leadership: “Leaders have an active choice to be kind in healthcare, and it makes such a difference, it is hard in a pressurised system, but it is a choice we can all make.” Panel members also discussed some of the challenges for regulators and regulation, highlighting the following points: Regulators must prioritise safety over regulations. The need for the regulatory environment to continually evolve to meet new patient safety opportunities and challenges, such as the growing use of artificial intelligence (AI) in healthcare. Being clear on how to understand ‘what good looks like’, what organisations are doing to work towards this and how this is measured. Not subsuming safety within quality. Being alert to system failure in healthcare like the frogs in a saucepan analogy—the water heating slowly to the point of catastrophic harm because we have tolerated normalised deviance. Insight through triangulation of data—patient and, staff perspectives and experience and data. Harnessing information and sharing for patient safety The next panel session at the Forum was on the opportunities and challenges presented by the development of new systems for sharing and utilising patient data to improve outcomes. This featured the following participants: Professor Sam Shah – Professor of Digital Health, College of Medicine and Dentistry, Ulster University Jonathan Webb – Head of Safety & Learning, NHS Wales Professor Maureen Baker CBE – Former Chair, Professional Record Standards Body Mark Linggood – Director of Product Management, RLDatix A key area of discussion in this session was on the use of AI and the need to understand the advantages and limitations of this in improving the sharing and use of healthcare data. This included the use of AI in diagnostics, sentiment analysis and how it can support deeper organisational learning. Panel members also highlighted the following points: The need to improve interoperability—the ability of different systems, devices, applications or platforms to work together and exchange information effectively. This still presents significant barriers to sharing data in real-time. Difficulties that patients and families face in navigating the NHS and having control over their own care. This has recently been the subject of a new blog series we have published on the hub. The importance of clinical engagement in the design and procurement of digital systems. That the digital safety standards are essential and need to embraced, supported and championed by system regulators such as CQC, which unfortunately isn’t the case. Improving how we can share and use patient data, and the implications of this for patient safety, is an area we have previously looked at in detail around electronic patient record (EPR) systems. While EPR systems have the potential to improve patient treatment, increase efficiency and reduce the costs of healthcare, their implementation also comes with serious patient safety risks. In July last year, we published a new report on this topic, Electronic patient record systems: Putting patient safety at the heart of implementation.[6] This outlined the key patient safety risks associated with choosing and introducing new EPR systems and identifies 10 principles to consider for safer implementation. Health inequalities and patient safety The focus of the final panel session of the Forum was on the connection between health inequalities and patient safety. This featured the following participants: Jono Broad – President Elect - Patient Safety, Royal Society of Medicine Sandra Igwe – Chief Executive, The Motherhood Group Professor Habib Naqvi MBE – Chief Executive, NHS Race and Health Observatory Jacob Lant – Chief Executive, National Voices Health inequalities often result in poorer outcomes for some patient groups, including impacting on their safety during care and treatment. Discussing these issues, panel members made the following points: Research has found that, in too many cases, black mothers are treated in an inhumane way by maternity healthcare professionals, including examples of the barriers in providing pain relief and a lack of empathy. The need to do more to ensure appropriate minority representation in healthcare organisation staffing and leadership. Addressing racial biases in medical devices, such as the accuracy of pulse oximetry, and recommendations of the Government’s review of unfair biases in their design and development more broadly. Vulnerable groups have longer wait times—as services do not cater for their needs, a ‘one size fits all’ strategy doesn’t work in healthcare. Health inequalities can lead to a breakdown in trust by communities, which leads to further patient safety issues if patients are reluctant or fearful of accessing services. Closing remarks At the end of the Patient Safety Forum, Dr Penny Dash, Chair of NHS North West London and the incoming Chair of NHS England, gave a keynote address.[7] Penny set out how she had approached her independent review into the patient safety landscape, commissioned by the Government to be published ahead of the 10-Year Health Plan.[8] [9] She noted the overcrowded and fragmented patient safety landscape, highlighting that her team had identified over 127 organisations in England involved in patient safety to some degree. Penny emphasised that quality should encompass productivity and efficiency as well as safety and effectiveness. She said: “We know that well-managed services lead to more efficient use of resources–that in itself is a big quality opportunity. We can actually do things for less that frees up money for more care.” Looking forward, she said she hoped the NHS would be given a “balanced scorecard” to measure quality, alongside the priorities in its annual planning guidance. She said there were many metrics available, but they could be “presented and brought into board papers” better than they were.[10] Reflections from Patient Safety Learning This was the first face-to-face event as part of our new patient safety policy programme with PPP. We had a magnificent line up of speakers with expert chairing of panels and a great turn out on the day. The Forum was significantly oversubscribed and we had a long waiting list that we had to close. We are sorry that not everyone was able to attend, next year we plan to make the event even bigger and better. We have received enthusiastic feedback from panellists, sponsors and participants, many saying that this was the best event on that topic that they’d ever attended. There was huge energy in the auditorium with conversations during the breaks that were equally inspiring, with people keen to push ahead on improving patient safety in their own organisations. There was also a supportive theme that ran throughout the discussions, with a number of panellists and participants stressing the need for greater kindness and empathy in the health service. Helen’s thoughts One personal story shared at the Forum that really resonated with me was shared by Sue Holden, Executive Chair, Advancing Quality Alliance. She recalled a time early in her career as a midwife when she had met with parents to share information as to why their newly born baby had suffered severe avoidable harm during the birth. At the end of the meeting, which she said had been at times challenging and emotionally hard for all, the father of the baby showed Sue two envelopes that he’d previously prepared. On opening the one passed to her, Sue found a financial donation to the hospital’s fundraising appeal. When she asked what was in the other one, the father explained that he was a solicitor and it was a prepared letter outlining the clinical negligence action he would have taken if faced with a lack of information and defensiveness. Sue described how this has always stayed with her, and I felt that this is a strong metaphor for the choices we all make for patient safety. It made me think, how often do we, as clinicians, patient safety experts or organisational leaders, look the other way? Do we just follow process? Or do we embrace honesty, integrity and justice, putting patients and families at the heart of the work we need to do to take action for improvement. Many of the Forum participants shared their challenges in doing the right thing, raising questions about organisational culture and behaviours that don’t prioritise patient and staff safety. As Penny Dash said, we must role model the behaviour we want to see in others. We must listen and act with kindness. And as Sir Liam said, “'find harm', go looking for it, use data and analysis to understand it and address it.” Clare’s thoughts At a time when the NHS is grappling with the toughest challenges in its history, it was heartening to have so many enthusiastic, positive delegates join us last Thursday. Connections were made and reignited, and conversations about issues and how to combat them were shared. Although everyone is in no doubt of the hill we all have to climb, there was a collective voice keen to find solutions and make change happen. I met new people, listened to different perspectives and drew energy from being in such a positive space. Our keynote speakers offered their insights, and panel members brought opinions from their own experiences encouraging us to challenge beliefs. It's important that we all take these opportunities to refresh, engage and reenergise. Thank you to everyone who joined us, we hope to see you again soon. References Public Policy Projects. Patient safety in the digital NHS: user-centric approaches to technology and transformation, 28 February 2025. Imperial Institute of Global Health Innovation & Patent Safety Watch. National State of Patient Safety 2024: Prioritising improvement efforts in a system under stress, 12 December 2024. Patient Safety Learning. The elephant in the room: Patient safety and integrated care systems, 11 July 2023. HSSIB. Safety management systems: accountability across organisational boundaries, 13 February 2025. Patient Safety Learning. Patient safety across organisational boundaries: Patient Safety Learning’s response to HSSIB investigation, 13 February 2025. Patient Safety Learning. Electronic patient record systems: Putting patient safety at the heart of implementation, 31 July 2024. Department of Health and Social Care. Dr Penelope Dash confirmed as new chair of NHS England, 3 March 2025. Department of Health and Social Care. Review of patient safety across the health and care landscape: terms of reference, 15 October 2024. Patient Safety Learning welcomes a new review of patient safety across the health and care landscape, 15 October 2024. Health Service Journal. New NHSE Chair seeks ‘clear accountability and responsibility’, 4 March 2025.- Posted
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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.- Posted
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The growing pressure of workload and staff shortages – and the decline in patient satisfaction in primary care in the UK – is a topic that’s generating a lot of discussion in healthcare. Host Kristina Wanyonyi-Kay and guests Patrick Burch, Georgia Black, and Sean Manzi discuss: How might increasing access to NHS care and changing how pathways are navigated impact a patient’s experiences of the healthcare system? The power of multidisciplinary teams in tackling complex problems by defining the right pathway How does a busy GP make a judgment call when they’re balancing the pressures of time, capacity, and urgent patient needs? What is the system level approach, and what trade-offs have to be made?- Posted
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In this video, Terry Fairbanks, director of National Center for Human Factors in Healthcare, discusses why it matters to integrate human factors engineering and system safety engineering into healthcare.- Posted
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Internationally there is recognition that a holistic quality management system (QMS) approach will enable healthcare organisations to meet the needs of their populations and continuously improve the care and experience provided. In NHS Wales, the Duty of Quality was introduced in 2023 through the Health and Social Care (Quality and Engagement) (Wales) Act 20201 and requires Welsh NHS bodies to establish an effective QMS where appropriate focus is placed upon Quality Control, Quality Planning, Quality Improvement and Quality Assurance The 90-day cycle methodology was used to explore how high performing organisations manage for quality – identifying universal findings across all the organisations, a summary of what a QMS can achieve and the importance of the role of the Board. The findings informed the development of a QMS Framework for healthcare which has supported the development of the Duty of Quality and includes: A definition of quality: Continuously, reliably and sustainably meeting the needs of the population that we serve (aligned to the Duty of Quality). A definition of QMS for NHS Wales: An operating framework to continuously, reliably and sustainably meet the needs of the population we serve. Descriptions of the four aspects within a QMS: Quality Planning, Quality Improvement, Quality Control and Quality Assurance and examples of tools and resources that can be used to support their implementation. Descriptions of the organisation enablers for a QMS: leadership, workforce and culture; learning, improvement and research; whole system approach; and, information (aligned to the Duty of Quality Standards). A methodology to implement and embed a QMS: an adaptation of Quality as an Organisational Strategy (QOS) informed by the experience of piloting the approach at directorate and organisation level.- Posted
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The challenges of navigating the healthcare system
Patient_Safety_Learning posted an article in Care pathways
Navigating the healthcare system in the UK can be complex and frustrating for patients, families and carers. We hear time and time again on the hub about the lack of joined up care and communication within and across organisations. Failing to share the right information at the right time can create significant patient safety risks. Poor communications, both with patients and between healthcare professionals, can result in misunderstandings and mistakes resulting in poor outcomes and potentially patient harm. In a new series of blogs on the hub, patients and their relatives describe the challenges and barriers they have faced when trying to navigate the healthcare system. Although every experience of navigating the healthcare system is different, the blogs in this series highlight some clear themes: Confusing communications and correspondence. Information not accessible across departments. Disjointed electronic systems, often not talking to each other. Concerns around the impact of delays to treatment and diagnostic tests. Near misses managed by patients and family members. Concerns for more vulnerable patients and those without advocates. The negative impact on mental health and stress levels. Not knowing who to contact to chase referrals, appointments or results. Read Sue’s story Sue’s husband Neil has a very rare chronic condition and is under the care of many different specialties. In this blog, Sue shares her and Neil’s experiences of trying to coordinate the healthcare system and highlights the challenges and frustrations they continuously face. Read David’s story In this blog, David shares his story about his elderly sister who has dementia, and a mix up with an urgent referral which led to a near miss. Read Margaret’s story Margaret’s father has dementia and a complex set of health issues. In this blog, Margaret shares her experience of trying to coordinate their elderly father's upcoming surgery. Read a university student’s story Moving to university is a big transition for many. In this anonymous blog, a student describes how persistent health issues led to a frustrating journey through the healthcare system. These stories illustrate how disjointed systems can affect patient and carer experiences and have a negative impact on health outcomes. Commenting on the issues highlighted in the series, Chief Executive of Patient Safety Learning, Helen Hughes says: “Poorly coordinated care is not only confusing and frustrating for patients but also creates safety risks that can result in serious avoidable harm. We hear many examples, such those covered in this blog series, of patients and their families facing a complex and fragmented healthcare environment. When they raise concerns about care and treatment, in too many cases they encounter an unresponsive system where they are left to ‘join the dots for patient safety’. The needs of patients should be central to improving health and care services, actively listening and acting on their experiences and insights when things go wrong for safety improvement.” Share your story What has been your experience of navigating the healthcare system? What is and isn’t working? How does it feel as a patient or carer when you hit barriers? Has your health been affected? Share your story in our community forum or contact our editorial team at [email protected]. Related reading Lost in the system? NHS referrals "I love the NHS, BUT..." Preventing needless harms caused by poor communication in the NHS (DEMOS, November 2023) Robust collaborative practice must become the bedrock of modern healthcare Robbie: A homeless patient’s struggles with the system Digital-only prescription requests: An elderly woman sent round the houses Lost in the system: the need for better admin Digital-only prescription requests: An elderly woman sent round the houses- Posted
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This study aimed to develop a systematic method to identify and classify different types of communication failures leading to patient safety events. The authors developed a taxonomy code sheet for identifying communication errors and provide a framework tool to classify the communication error types.- Posted
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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 hub members receive a 20% discount. Email [email protected] for discount code.- Posted
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