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Sickle cell disease can affect people of all backgrounds but is more common in African and Caribbean communities. It has become one of the fastest growing genetic conditions in England, with 250 new cases every year. People living with sickle cell disease may experience painful crises, fatigue and an increased risk of serious health complications. Despite this, the condition is often not well understood.  At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. We have pulled together 8 useful resources about sickle cell disease that have been shared on the hub. They include recommendations on tackling inequalities, recognising and managing sickle cell disease in hospital, and managing pain.   1 Sickle Cell Society: Standards for the clinical care of adults with sickle cell disease in the UK These standards for the clinical care of adults with sickle cell disease were produced by the Sickle Cell Society in collaboration with a broad multi-disciplinary group of healthcare providers, patients and support groups. 2 The King's Fund: The implicit bias of sickle cell disease Although health outcomes have improved, evidence shows that people with sickle cell still feel marginalised. Their frustrations largely stem from a perceived lack of empathy in a healthcare system that does not fully recognise their struggles. When compounded with limited treatment pathways, these poor experiences leave many feeling neglected and unsupported. This blog from CJ Nwasike discusses sickle cell health inequalities. 3 Sickle cell comparative review to inform policy report: Providing evidence-based recommendations to tackle inequalities This study analysed data across a wide range of indicators and revealed striking inequalities, which were often reflected in the experiences of patients living with sickle cell across the country. The report adds further to the urgent need to address the underlying problems affecting the quality of care for patients with sickle cell. Importantly, this comparative research shows that improvements are also needed for other severe chronic conditions, such as cystic fibrosis and haemophilia, and that lessons can be learned from successes achieved in other specialties. This report includes a set of recommendations that aim to help tackle inequalities associated with sickle cell in the UK. 4 HSSIB: Invasive procedures for patients with sickle cell disease This investigation from the Health Services Safety Investigations Body sets out to review the care of patients with sickle cell disease who need to have an invasive procedure. Invasive procedures involve accessing the inside of a patient’s body, either through an incision (cut) or one of the body’s orifices. Specifically, the investigation focused on: how haematology teams – the specialists who treat people with blood disorders – are involved and informed when a patient with sickle cell disease is treated in another area of healthcare how patients with sickle cell disease are prepared for invasive procedures how and where clinical information relevant to the patient is shared. 5 HSSIB: Management of sickle cell crisis In this investigation, HSSIB used a real patient safety incident to explore how sickle cell crises are managed within hospital settings. In particular, the investigation considered: the knowledge nursing staff may have about the care of patients in sickle cell crisis how patient-controlled analgesia (PCA) – where a patient can use a device to give themself doses of pain relief medication – is considered holistically, such as monitoring the patient and staff workload. 6 Sickle Cell Society: 'The difference between life and death' Following on from the care failures highlighted in the 2021 report, 'No one's listening', this Sickle Cell Society report takes a deeper look at sickle cell nursing care. The findings show the need for vastly more resources, training and support in this critical area of care. The report highlights that not only is no-one listening, but that lives are still being put at risk. 7 Treating chronic pain in sickle cell disease — The need for a biopsychosocial model Clinicians are often unsuccessful at addressing chronic pain in sickle cell disease. In this perspective article in the New England Journal of Medicine, Childerhose et al. discuss how a biopsychosocial model can help capture people’s experience of chronic pain by affirming that biologic, neuropsychological, and socioenvironmental elements play a role in pain-related processes. 8 Sickle cell digital discovery report: Designing better acute painful sickle cell care The report explores the range of technology that is in place for accident and emergency clinicians, red-cell specialists, and ambulance care, to aid timely support to patients with sickle cell on their emergency hospital arrival. A number of focus groups and interviews were carried out with those that have lived experience of the disease, including patients who have suffered acute, painful sickle cell episodes during NHS A&E admissions. Research found a lack of individual care plans in place and, more broadly, no clear definition of what constitutes an actual care plan. A number of recommendations are set out in the report for the NHS and the wider healthcare system. Do you have a resource on sickle cell disease to share? We’d love to hear about it - leave a comment below or join the hub to share your own post.

Learning Disability Week is the third week of June every year. The event, organised by the charity Mencap, is an opportunity to raise awareness about different learning disabilities and challenge some of the barriers people who have learning disabilities face. According to Mencap, a learning disability is a person's reduced intellectual ability, meaning they can face difficulty with everyday activities. People with a learning disability can sometimes need extra support to learn new skills, understand complicated information or interact with other people. It can be particularly challenging for people with learning disabilities and their families when accessing healthcare services. To mark Learning Disability Week, we are sharing 18 resources, blogs and reports from the hub for patients, their families and healthcare professionals on breaking down these barriers. 1 Exploring the inequalities of women with learning disabilities deciding to attend and then accessing cervical and breast cancer screening, using the Social Ecological Model Women with learning disabilities are less likely to access cervical and breast cancer screening when compared to the general population. In this study, the Social Ecological Model was used to examine the inequalities faced by women with learning disabilities in accessing cervical and breast cancer screening in England. The authors suggest that multiple methods to reduce the inequalities faced by women with learning disabilities are needed, and that these can be achieved through reasonable adjustments. 2 Pharmacists can do more to bridge the safety gaps for people with learning disabilities People with learning disabilities are more likely to be taking multiple medicines, but labels are not designed with them in mind. This article in the Pharmaceutical Journal looks at a project run by a team at Leeds and York Partnership NHS Foundation Trust. The team ran exploratory workshops to listen to how people with learning disabilities engaged with information on medicines at home, at the doctors and at the pharmacy. The project highlighted that it is time to move away from standard labels and look towards more personalised medicine labels, actively promoting ways to support people with learning disabilities in taking their medicines. 3 Exploring deep sedation at home to support people with learning disabilities to access medical investigations with minimal distress In this blog, Mandy Anderton, a Clinical Nurse specialising in learning disability, explains how they are using shared decision making and reasonable adjustments to implement a new care pathway, where patients with a learning disability needing to undergo a medical investigation can receive deep sedation within their own home. Working with patients, carers, relatives, anaesthetists and others, the aim is to improve access to important medical investigations with minimal distress, where other avenues have been exhausted. 4 NHS England: Ask Listen Do – feedback, concerns and complaints Ask Listen Do resources are designed to support organisations to listen, learn from and improve the experiences of children and adults who are autistic or have a learning disability, their families and carers, and make it easier for people, families and paid carers to give feedback, raise concerns and complain. 5 NHS England: Guidance to support implementation of the Mental Capacity Act in acute trusts for adults with a learning disability This guidance supports trusts and community providers in enabling frontline staff to fulfil their legal requirements under the Mental Capacity Act (MCA) 2005, specifically when supporting people with a learning disability. Leadership within Trusts have been asked to ensure they understand the guidance, take the actions indicated and make these resources available to all frontline staff. 6 Tommy Jessop: Why I investigated hospital care for people like me People with a learning disability are more than twice as likely to die from avoidable causes than the rest of the population. Actor Tommy Jessop and BBC Panorama investigated some of the stories of families who say they were let down by their medical care. 7 How can GP practices help improve health outcomes for people with learning disabilities? In this Patient Safety Learning interview, Mandy Anderton explains some of the barriers people with a learning disability face in accessing safe care and how adjustments can be made within GP practices to improve outcomes. Mandy lists national improvements that she believes would reduce health inequalities in this area. 8 Making reasonable adjustments for patients with a learning disability is G.R.E.A.T. Developed by David Havard, this poster shows a number of ways in which reasonable adjustments can easily be made for patients with a learning disability. 9 HSSIB: Caring for adults with a learning disability in acute hospitals The aim of this investigation and report is to help improve the inpatient care of adults with a known learning disability in acute hospital settings. It focuses on people referred urgently for hospital admission from a community setting, such as a person’s home or residential home. 10 Video: The Oliver McGowan Mandatory Training on Learning Disability and Autism This animation aims to help staff and employers across health and social care understand Oliver's Training and why it is so vitally important. It was co-designed and co-produced with autistic people and people with a learning disability. Oliver McGowan died aged 18 in 2017 after being given antipsychotic medication to which he had a fatal reaction. He was given the medication despite his own and his family's assertions that he could not be given antipsychotics, and the fact that this was recorded in his medical records. The animation tells his story and highlights the increased risks facing people with learning disabilities and autism when accessing healthcare. 11 Palliative Care for People with Learning Disabilities The Palliative Care for People with Learning Disabilities (PCPLD) is a charity created to ensure that patients with learning disabilities receive the coordinated support they need throughout their life. The PCPLD Network brings together service providers, people with a learning disability and carers working for the benefit of individuals with learning disabilities who have palliative care needs. 12 Nobody left behind: Improving the health of people with learning disabilities and reducing inequalities across primary care Mandy Anderton talks in depth about the cross-system programme they launched in Salford to improve the health of people with learning disabilities and reduce inequalities across primary care. Mandy shares their award-winning poster, summarising the programme’s activities and outcomes, and gives her top tips for delivering a successful patient safety improvement project. 13 Reasonable adjustments and designing services for patients and people with learning disabilities Caring for people with learning disabilities in an acute hospital setting can be challenging, especially if that patient has transitioned from children’s services to adult services. The experience in children’s acute care differs to adult acute care; this difference in processes of care can cause great anxiety for the patient and their family and carers. The reasonable adjustments that were perhaps made and sustained in children’s services may now not exist. The purpose of this blog is to demonstrate the importance for services to be designed around patients’ needs with patients, families and carers. If we get this right, the quality of care given will be improved, patient satisfaction increases and, in turn, a reduction in patient harm. 14 Cervical screening for people with learning disabilities: Learning resource for sample takers (NHS Wessex Cancer Alliance) Cervical cancer is preventable. By 2040 the NHS in England is aiming for a cervical cancer incidence rate of below 4 per 100,000 women (elimination status). To achieve this, we need to increase HPV vaccination rates and improve attendance for routine cervical screening particularly in younger people and underserved communities including patients with learning disabilities. This learning resource from the NHS Wessex Cancer Alliance explains the misconceptions and barriers to cervical screening, the consent and best interest decisions, and the role of the sample taker and the reasonable adjustments that can be made. 15 Safety spotlight: Mothers with a learning disability - Maternity and Newborn Safety Investigations (MNSI) Maternity care should be responsive to every woman’s needs. This Maternity and Newborn Safety Investigation (MNSI) safety spotlight focuses on mothers with a learning disability. 16 HSSIB investigation. Insulin: supporting safe self-administration for patients in the community with a disability Many people with diabetes manage and administer their own insulin, either by injection or using a combined monitor/pump device (a hybrid closed loop system). However, a disability or impairment may affect their ability to safely manage their own insulin if they are not supported. This can lead to short-term and long-term health problems, which can be life threatening. This Health Services Safety Investigation Body (HSSIB) investigation explored the the following areas in relation to the patient safety issue: supporting the development of people’s competency – that is, their skills, experience, knowledge and ability – to manage insulin recognising and responding when people’s circumstances change, such as deterioration in a disability assessment of people’s mental capacity to make decisions in relation to insulin. 17 Learning Together - A review of the quality of care provided to adults with a learning disability who were admitted to hospital acutely unwell The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) reviewed the care of adults with a diagnosed learning disability who attended/were admitted to hospital as an emergency between 1 July and 30 September 2024. The recommendations highlight areas that are suitable for regular local clinical audit and quality improvement initiatives by those providing care to this group of patients. 18 Voices for Safety podcast: Unequal cancer care for people with a learning disability in the UK This episode of Voices for Safety explores a critical patient safety issue: the inequalities people with a learning disability face when accessing cancer care. Host Dr Louise Gorman and Dr Oliver Kennedy explains how they are less likely to be referred for specialist tests, more likely to be diagnosed at a later stage, and around half as likely to receive treatment, resulting in much shorter survival times. They explore why these gaps exist – from communication challenges and diagnostic overshadowing to systemic barriers in screening and treatment – and discuss what needs to change across prevention, diagnosis, and care to create a more equitable system. Do you have a resource or story to share about learning disabilities? Could your insights or experiences help improve patient safety? Leave a comment below (join the hub for free first) or contact us at [email protected].

At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That’s why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples. We have collated 15 resources relating to men's health, including information about male cancers, men's mental health, how to engage men earlier and insights around the impact of traditional ideas of masculinity on patient safety. *Trigger warning: some of the content below focuses on suicide. 1 Men's Health Strategy for England This document sets out the government’s 10-year strategy for men’s health in England. It details the government’s vision for men’s health over the next 10 years and actions they are taking now to improve the health and wellbeing of all men and boys in England. 2 Men’s Health: How to improve health outcomes, knowledge, and behaviours This report sets out the findings of new research conducted by Healthwatch England to inform the Government’s first-ever men’s health strategy for England. They commissioned a nationally representative poll of 3,575 men aged 18+ in June 2025 and also drew on local Healthwatch engagement, with men from diverse backgrounds, spanning a wide range of ages, ethnicities, occupations, and areas. 3 Men’s health: The lives of men in our communities Men in England are facing “a silent health crisis”, dying nearly four years earlier than women, while suffering disproportionately higher rates of cancers, heart disease and type 2 diabetes, according to a report by the Local Government Association. They are urging the Government to implement a men's health strategy similar to the women's health strategy of 2022. It wants men’s health to be recognised as “a national concern”. 4 Overcoming the barriers to engaging with prostate cancer Orchid is the UK’s leading charity for those affected by male cancer. In this interview, we speak to Ali Orhan, Chief Executive and Director of their Overcoming the Barriers to Engaging with Prostate Cancer project. Ali tells us how they are working alongside a network of volunteer community champions to improve awareness, support better outcomes and reduce health inequalities. 5 Prostate Cancer UK: risk checker Prostate cancer is the most common cancer in men, but most men with early prostate cancer don’t have symptoms. Use this risk checker to find out what you should do. 6 Samaritans Handbook: Engaging men earlier: a guide to service design This handbook from the Samaritans provides a set of principles upon which wellbeing initiatives for men should be based, drawn from what men have said is important to them. By following these principles, wellbeing initiatives are more likely to be effective for, and appeal to, men going through tough times before reaching crisis point. 7 Infopool prostate cancer patient resource This patient resource created by Prostate Cancer Research aims to equip patients and the public with information about prostate cancer. It contains information on testing and diagnosis, treatment choices, living with side effects, and clinical trials. 8 Men's Health - How can we take action? Here are our top 5 things to know and do Top tips for men on keeping healthy and advice on prostate and testicular cancer. 9 Prostate Cancer UK: Best practice pathway Developed to support healthcare professionals at the front line of prostate cancer diagnosis and care, Prostate Cancer UK's Best Practice Pathway uses easy to follow flowcharts to guide healthcare professionals deliver best practice diagnosis, treatment and support. 10 HSSIB report: Management of acute onset testicular pain This investigation reviewed the diagnostic and treatment pathway for testicular torsion. There was a predominant focus on delays and the human factors associated with the pathway. The investigation identified system-wide recommendations designed to prevent delays to the identification and treatment of testicular torsion happening in the future. 11 Prostate cancer: getting information and support This leaflet helps signpost people to support and information about prostate cancer, both nationally and regionally. 12 Why harmful gender stereotypes surrounding men’s approaches towards their feelings need challenging This blog explores men's mental health – how men are reluctant to seek support when they are struggling, why the suicide rate is so high, what initiatives exist to encourage men to seek help and what more could be done. 13 King's Fund blog: Inequalities in men’s health: why are they not being addressed? Almost half of England’s population is male, yet inequalities in men’s health seldom get specific attention. The women’s health strategy for England shone a light on the health care needs of girls and women through their life course, highlighting areas specific to their health – such as maternity and the menopause – and inequalities in health outcomes. But the wide, and widening, health inequalities experienced by men also require focus. 14 The incredibly obvious thing you should do about painful testicles Watch this short film about what to do if you experience pain in your testicle/s, by Cardiff Fertility Studies and the British Fertility Society, made in partnership with Orchid. 15 An Unfilled Prescription: Tapping Pharmacy's Potential to Boost Men's Health This report from the Men's Health Forum examines the role of community pharmacy in improving men’s health in the UK, the theme of Men’s Health Week 2026. The report sets out a five-point plan that pharmacies should adopt to become a male-friendly pharmacy, which encourages more men to engage. Share your insights and experiences Have you, or a loved one, experienced any of the issues raised in this blog? Would you like to share your insights to help improve outcomes in men's health? Perhaps you work in men's health and can share some of the barriers to safe care and what you believe needs to change to improve outcomes. You can share your thoughts in the comments below (sign up first for free) or email our team at [email protected].

At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. Diabetes is a condition that causes the amount of glucose in a person's blood to be too high. When you have type 1 diabetes, your body can’t make any insulin at all, whereas with type 2, you either can’t make enough insulin, or it can’t work properly. There are also other types of diabetes including gestational diabetes, which some women develop during pregnancy, maturity onset diabetes of the young (MODY) and latent autoimmune diabetes in adults (LADA). It is important that people with diabetes are supported to maintain good blood glucose control through diet, insulin and other diabetes medications, to prevent both acute and long-term complications. We’ve selected our top picks of useful resources about diabetes. Self-management is perhaps the most important aspect of treating diabetes effectively, so we've included some resources aimed at helping patients manage their diabetes too. 1 HSSIB reports The Health Services Safety Investigation Body (HSSIB) has published a series of reports considering the self-administration of insulin by people with diabetes mellitus. Each report focuses on specific groups of people who, due to their circumstances, may be at increased risk of harm because of the way they self-administer insulin. Insulin: supporting safe self-administration for patients in the community with a mental health problem Insulin: supporting safe self-administration for patients in the community with a disability Insulin: supporting patients to safe administration in inpatient settings 2 Decoding diabetes research – an innovative approach that makes scientific knowledge accessible to everyone In this blog, Jazz Sethi, Founder and Director of the Diabesties Foundation and part of the global team that developed D-Coded, discusses the need for the resource and outlines how it will help people living with diabetes to better understand and manage their condition. 3 Leading for patient safety: a conversation with Partha Kar Partha Kar, National Specialty Advisor for NHS England, has led work that has had an enormous impact for patients and for patient safety. In this video podcast, Steph O'Donohue from Patient Safety Learning talks to Partha about his leadership style and how it has helped him drive forward significant change in an often challenging context. 4 Decision support tool: making a decision about managing type 1 diabetes This leaflet from NHS England aims to help people with type 1 diabetes decide between the different technologies available to manage diabetes. It contains summaries of devices available and infographics outlining eligibility criteria for continuous glucose monitors (CGM), insulin pumps and hybrid-closed loop systems. 5 10 Year Vision: For diabetes prevention, care and treatment This report from Diabetes UK sets out a clear plan for the UK government about how it can improve health outcomes and tackle inequality for people living with diabetes by 2035. 6 D1abasics: Equipping staff to care safely for inpatients with diabetes The inpatient diabetes team at University Hospital Southampton NHS Foundation Trust recently launched D1abasics, an initiative that aims to improve inpatient care for people with diabetes. In this blog, Diabetes Consultant Mayank Patel and Inpatient Diabetes Specialist Nurse Paula Johnston outline the approach and explain how it will equip staff across all specialties with the basic knowledge to care safely for people with diabetes in hospital. 7 Improving diabetes care in inpatient mental health settings Despite the prevalence of diabetes amongst individuals with Serious Mental Illness (SMI), diabetes care is not currently audited within mental health inpatient settings as it audited in physical health settings. This project piloted an audit to assess the diabetes care within London NHS Mental Health Trusts. 8 Diabetes tech: Do national aspirations and local practice align? In this blog, a person with type 1 diabetes describes their recent experience upgrading their insulin pump, a medical device used to continuously deliver insulin instead of taking multiple daily injections. They describe how communication issues and gaps in staff knowledge led to a significant delay in accessing the pump, which caused them significant stress. They also ask whether recent announcements about increased access to diabetes technology over the next few years will match up to the reality experienced by people with diabetes accessing care at local healthcare organisations. 9 NHS England - Language Matters: language and diabetes The language that healthcare professionals use to talk about diabetes can have a profound impact on how people living with diabetes, and those who care for them, experience their condition and feel about living with it. This guidance by NHS England sets out practical examples of language that will encourage positive interactions with people living with diabetes. When people with diabetes feel encouraged and empowered to manage their condition, it has been shown to make a difference to their health outcomes. The examples in ‘Language Matters’ are based on research and supported by a simple set of principles. 10 Key things to remember if you use injectable medication to treat your diabetes This checklist by TREND Diabetes outlines the steps patients should take to ensure they inject their insulin or other diabetes medication correctly. It explains the importance of taking steps such as moving injection sites and changing needles, and outlines how failing to do this can affect blood glucose control. 11 Improving safety for diabetic inpatients: 4 key steps In this video, Partha Kar, National Specialty Advisor for Diabetes, shares four steps to improve safety for inpatients with diabetes, based on information from the National Diabetes Inpatient Audit. He also highlights key resources to help staff improve their knowledge of diabetes and understand how to offer the safest care to people with diabetes when they are staying in hospital. 12 Diabetes technology is life-changing, but we need to be prepared when it fails In this blog, Andrew Stroud talks about his family's experiences supporting their daughter, Bia, to manage her type 1 diabetes. He describes the huge value of technology in improving diabetes management and reducing the mental burden of the condition on people with diabetes and their parents and carers. However, like all technology, medical devices for diabetes can fail, and Andrew highlights the need to be prepared for this situation to ensure the person with diabetes is safe while they cannot use the devices they rely on every day. 13 How safe are closed loop artificial pancreas systems? Closed-loop artificial pancreas systems are self-regulating systems for administering insulin to patients with type 1 diabetes. They allow for tighter blood glucose control and reduce the decision-making burden for people with diabetes. In this blog, Lotty Tizzard, Patient Safety Learning's Content and Engagement Manager, takes a look at the benefits and potential patient safety risks associated with closed-loop artificial pancreas systems (APS). People with diabetes have developed the algorithm that runs these systems and made it freely available to anyone wanting to build their own DIY artificial pancreas. This has spurred the medical tech industry to develop commercial systems, which will make the technology more widely available. But there are challenges in ensuring accessibility to all people with type 1 diabetes who would benefit from the technology, and there are questions about regulation and liability. 14 A systematic approach to insulin safety (video series by Communications PharmSocNI) This video series looks at systematic approaches to insulin safety, including: Human Factors - A Journey of Discovery; SEIPS – The Swiss Army Knife Approach; and Summary & Applying the Learning. 15 System-wide strategies for better diabetes care chapter 1: Evidence approved medicines and chapter 2: Ensuring equitable access to glucose sensing technology for type 2 insulin users Two reports from Public Policy Projects (PPP). Chapter 1 calls for changes in the use of approved medicines to improve diabetes care in the UK and chapter 2 highlights the opportunities and challenges brought by CGM technology to type 2 insulin users and other patient groups. 16 National Diabetes Foot Care Audit 2018 to 2023 Ulceration of the foot in people living with diabetes presents significant challenges, including emotional, physical and financial costs, and is associated with increased risk of both amputation and death. It affects between 1 and 2% of all people with diabetes each year and its management accounts for approximately 1% of the total NHS budget. The aim of the National Diabetes Foot Care Audit is to measure factors associated with increased risk of ulcer onset and adverse ulcer outcomes, and to share information relating to best clinical practice. 17 Diabulimia: what is it and why have so few people heard of it? Type 1 diabetes with disordered eating (T1DE), or diabulimia as some experts call it, is a serious eating disorder that people with type 1 diabetes can develop where the person reduces or stops taking their insulin as a way of managing their weight. The condition can be life-threatening. Although studies are limited, it’s estimated that eating disorders affect more than a third of patients with type 1 diabetes. This episode of the Healthcare Improvement podcast looks at diabulimia and a new toolkit published by SIGN, part of Healthcare Improvement Scotland, which sets out recommendations to raise awareness and provide guidance on how best to support people living with the diabulimia. 18 NHS England: Children and young people diabetes toolkit This toolkit is designed to support integrated care systems (ICSs) to design, plan, and deliver high-quality treatment and care for children and young adults aged 0-25 years with all types of diabetes. 19 Insulin therapy in primary care The management of insulin therapy requires knowledge of the type of diabetes it is being used for and appropriate dosing, as well as correct injection technique, to prevent complications and medication errors. Diabetes nursing specialist Debbie Hicks shares key points on the management of insulin therapy for nurses in primary care. 20 Handbook: Diabetes footcare in dark skin tones Covering essential topics such as physiology, history-taking, assessment techniques, and investigative methods, this handbook has been designed to provide essential information as well as quick tips to healthcare professionals to improve foot care for people with dark skin living with diabetes. Featuring clinical assessments and visual/audio guides, this handbook is the product of a unique collaboration across healthcare professional specialities, and with input from people living with diabetes. 21 Addressing racial inequalities in paediatric diabetes Dita Aswani and Fulya Mehta are both consultant paediatricians and NHS England national advisors for Children and Young adults’ (CYA) diabetes. In this blog, they outline racial inequalities that persist in paediatric diabetes and present five key areas for change. In summary they talk about what healthcare professionals can do to reduce inequalities through their own practice. Do you have a resource or story about diabetes to share? We’d love to hear about it - leave a comment below or join the hub to share your own post.

At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples.  Dementia is an umbrella term for a number of diseases that affect the brain, with Alzheimer’s disease its most common cause. We have picked a range of resources and reflections about keeping people with dementia safe in health and care settings, and when considering medication choices. 1 Alzheimer's Society: Checklist for possible dementia symptoms This checklist has been developed by the Alzheimer’s Society to allow patients to check symptoms that could be a possible sign of dementia. Endorsed by the Royal College of General Practitioners (RCGP), it is a simple tool to help patients and their families clearly communicate their symptoms and concerns to a GP or other healthcare professional. 2 Seeing the unseen: Rethinking dementia diagnosis Across 2024 and 2025, Alzheimer’s Research UK surveyed more than 500 people affected by dementia and over 160 healthcare professionals to understand the realities of diagnosis. This report shares findings from this process and considers what works, what gets in the way, and what needs to change. 3 Health and social care support for people with dementia The Care Quality Commission (CQC) looked at people's experiences of living with dementia when using health and adult social care services, including the experiences of families and carers. It sets out the main themes that influence whether an experience is good or poor, and what health and care services are doing to improve these experiences. CQC will use the findings in this report to help shape their work to define what good care looks like for people with dementia and inform the next phase of CQC’s Dementia Strategy. 4 Keeping patients with dementia safe: an interview with Alison Keizer and Fran Hamilton When people with dementia enter a new healthcare setting, the environment may be confusing and difficult to navigate. They may be unable to use their usual coping strategies and have difficulty communicating their needs and concerns to staff. This can present a wide range of risks to their safety while accessing care. In this interview, Alison Keizer, trust-wide Dementia Lead, and Fran Hamilton, Occupational Therapist and Deputy Dementia Lead at Sussex Community NHS Foundation Trust, describe the patient safety issues affecting patients with dementia and suggest how they can be supported to reduce these risks. 5 World Alzheimer Report 2025: Reimagining life with dementia – the power of rehabilitation This report from Alzheimer's Disease International explores the important topic of dementia rehabilitation, combining expert essays and real-world case studies from multiple countries globally to examine how the concept is defined and implemented, as well as practical considerations of how to best adapt rehabilitation practices for people living with dementia in different contexts. 6 National Audit of Dementia: Spotlight Audit in Memory Assessment Services 2023/24 This report examines waiting times, access to assessments, treatment, and post-diagnostic support for people with dementia in memory assessment services. The results indicate that there is still a great deal of variation between services in key results such as average waiting time for patients, the proportion of patients diagnosed with dementia, and the provision of post diagnostic support and therapy. 7 The role of integrated care systems in improving dementia diagnosis The Alzheimer’s Society commissioned The King’s Fund to explore the development of Integrated Care Systems (ICSs) through the lens of dementia diagnosis—to consider what opportunities ICSs present to approach dementia differently and to improve diagnosis rates by doing so. The research team explored enablers and barriers to improving dementia diagnosis through interviews with stakeholders and people affected by dementia in three case study ICSs. 8 Alzheimer's Society: 'This is me' leaflet This simple leaflet was developed by the Alzheimer's Society for anyone living with dementia, or experiencing delirium or other communication difficulties. It provides a central place where those closest to the person can fill in key information about them, such as their preferred name, cultural background, routines and likes and dislikes. The leaflet can then be shown to health and social care professionals in new and unknown settings to help them better understand the person and deliver care that is tailored to their individual needs. 9 Dementia UK: Making the home safe and comfortable for a person with dementia Dementia can have a significant impact on a person’s daily life, including how well they function within their home. Memory issues or problems recognising and interpreting the objects around them can cause the person frustration or create safety issues. Dementia UK have produced a leaflet with tips and guidance on how to make the home more safe for someone with dementia. 10 Alzheimer's Society: Tips for carers - questions to ask the doctor about antipsychotics Antipsychotic drugs may be prescribed for people with dementia who develop symptoms such as aggression and psychosis. This webpage from the Alzheimer's Society provides information on the prescription of antipsychotic medications for people living with dementia. It describes their potential side effects and includes a list of helpful questions that carers should ask healthcare professionals before the person they care for is prescribed antipsychotic medication. 11 Assessment, diagnosis, care and support for people with dementia and their carers: A national clinical guideline These national clinical guidelines from Health Improvement Scotland, the first to be published in nearly 20 years, provide recommendations on the assessment, treatment and support of adults living with dementia. It calls for greater awareness of pre-death grief for people with dementia, their carers and their loved ones, as they fear the loss of the person they know. To accompany the guidelines, a podcast has been produced by Health Improvement Scotland speaking to professionals, including Dr Adam Daly, Chair of Healthcare Improvement Scotland’s Guideline Development Group and a Consultant in old age psychiatry, and Jacqueline Thompson, a nurse consultant and the lead on pre-grief death for the guideline. 12 Alzheimer’s Society: Improving access to a timely and accurate diagnosis of dementia in England, Wales and Northern Ireland A formal diagnosis of dementia can help people living with the condition and their families gain a better understanding of what to expect and help to inform important decisions about treatment, support and care. This report from the Alzheimer's Society highlights the barriers to accessing a timely and accurate dementia diagnosis and advocate for practical changes and tangible solutions to overcome them. 13 The current state of dementia diagnosis and care in England The current dementia care system remains fragmented, underfunded, and difficult to navigate, leaving many individuals and families unsupported. In response to these systemic challenges, Care England, in partnership with Dementia Forward and care providers, conducted a national survey in January 2025. This initiative aimed to capture the experiences of people living with dementia, their families, and care staff. The findings highlight significant gaps and inequalities in the dementia care pathway and inform a set of urgent policy recommendations. 14 Raising awareness of normal pressure hydrocephalus: an often misdiagnosed condition Normal pressure hydrocephalus (NPH) is a progressive neurological condition that comes under the dementia umbrella. In NPH, the cerebrospinal fluid-filled ventricles within the brain expand and distort the surrounding tissues. This process causes the neurological symptoms of NPH. Unlike other forms of hydrocephalus, NPH does not result in significantly raised intracranial pressure. NPH is often misdiagnosed as it is similar to neurodegenerative conditions such as Parkinson’s disease and other causes of dementia, such as Alzheimer's disease. However, unlike these other conditions, if diagnosed early there is an effective treatment that can significantly slow disease progression and potentially improve, or even reverse, symptoms in some people. 15 The training gap: a hidden injustice in dementia care and how to fix it This report from Alzheimer's UK reveals huge gaps in dementia training across social care: half of staff receive just one to two hours of dementia learning despite 70% of care home residents living with the condition. It argues that these shortfalls in training are leaving social care staff unprepared, unsupported, and putting people with dementia at risk of inadequate care. It calls on the government to build a bold and ambitious dementia plan, which includes mandatory dementia training for care staff. 16 Alzheimer's Society: Unlocking the door to dementia diagnosis and treatments Systems designed to diagnose and support people with dementia are struggling to keep pace, with delays, inequalities and missed opportunities far too common. Too many people have a poor experience, wait too long for a diagnosis and receive less treatment and support than clinical guidance says they should. Everyone with dementia has the right to an early and accurate diagnosis and the best available treatments. Alzheimer's Society’s two 'Unlocking the door' reports lay out a stark reality – and a clear programme of reform for England, Wales and Northern Ireland. For more resources, take a look at our Dementia area of the hub. Do you have a resource or story to share about dementia or a related condition? Could your insights or experiences help improve patient safety? Leave a comment below (join the hub for free first) or contact us at [email protected].

Nurses are at the forefront of health and social care delivery. Often they are also leading, championing and driving change for patient safety. In this edition of our ‘Top picks’ series we celebrate some of the amazing work nurses are doing to prevent avoidable harm and improve patient and staff experience. The examples below include blogs, interviews and practical improvement projects. They have been shared with us by members of the hub, a global community of people passionate about patient safety. You can sign up to the hub here, it’s free and easy to do.  Safety tools, approaches and insights Implementing the aSSKINg pressure ulcer care bundle – a blog by Susan Martins Nurse-led use of technology to enable better care - Homerton University Hospital Action Card App Yellow kits - an innovation to reduce the risk of falls in Accident and Emergency departments Friends of African Nursing: Training perioperative nurses across Africa Measuring standards of care, not negative outcomes Nobody left behind: Improving the health of people with learning disabilities and reducing inequalities across primary care Tackling antibiotic underdosing: Interview with Ruth Dando, Head of Nursing for Theatres, Critical Care and Anaesthetics at BHRUHT Insights from a reducing falls project at the University Hospital Southampton How a catheter removal project improved care for patients while saving money and carbon emissions Safety culture How a simple newsletter can improve culture and communication within teams It’s time to look beyond perceived barriers to Family Integrated Care in the NICU and create a culture for change Safety Incident Supporting Our Staff (SISOS) Safety Chats Interviews with nurses In our series of Patient Safety Spotlight interviews, we talk to different people about their role and what motivates them to make health and social care safer. Martin Hogan, Lead Professional Nurse Advocate at Central London Community Healthcare NHS Trust Kathy Nabbie, Theatre Scrub Nurse Practitioner and Non-medical Surgical First Assistant Angela Hayes and Caroline Morris, Palliative Care Nurse Specialists at The Christie NHS Foundation Trust In an episode of our Speaking up for patient safety interview series, we spoke to Rebecca Wight, a nurse consultant practitioner. Rebecca talks about what happened to her when she tried to raise patient safety concerns about a colleague. Speaking up for patient safety: Rebecca Wight in conversation with Peter Duffy and Helen Hughes Could you share for safety? Are you a nurse with a passion for patient safety? Do you have insights, projects or practical tools and resources that could be shared for wider benefit? Perhaps you’d like to feature in one of our Spotlight interviews? You can get in touch with our hub editorial team by emailing us at [email protected]

Mental Health Awareness Week is an annual event which aims to raise awareness and promote open conversations about mental health.  In this Top picks, we’ve pulled together resources, blogs and reports from the hub that focus on improving patient safety across different aspects of mental health services and also supporting staff with their own mental health and wellbeing. 1 World mental health today: latest data (WHO, 2025) This World Health Organization (WHO) document draws on the latest information available to outline the state of mental health and mental health systems in the world. It shows that mental health conditions remain highly prevalent, with more than a billion people worldwide living with a mental disorder. This report provides essential data to guide national and global dialogue. It highlights where progress is being made – and where critical gaps persist. This report should serve as a vital tool for policy-makers, implementers and advocates alike. 2 Jay’s Personalised Safety Planning Toolkit: A guide to support meaningful safety planning for self-harm and suicide This toolkit is a co‑designed set of materials created with researchers, people with personal experience of suicide and self-harm, and healthcare professionals. Inspired by the family of Jaymie Mart, known as Jay, who died by suicide in 2012 at the age of 32, the toolkit—which was funded by the National Institute for Health and Care Research (NIHR)—offers clear, practical guidance to help adults create and review personalised safety plans. 3 Harry’s story: Acute Behavioural Disturbance In December 2022, Harry Vass died after experiencing Acute Behavioural Disturbance (ABD) and a complex disturbance in normal physiology. Harry’s death was found to be avoidable as carers were not fully aware of this condition associated with acute psychosis. In this blog, Harry’s mother Julie describes the barriers they faced in getting the right support and care for Harry before he died and highlights the need for healthcare staff to have a greater awareness of ABD and the associated risks of a medical emergency. You can also read a second blog by Julie, where she explains more about Acute Behavioural Disturbance and the changes she believes are needed to make sure patients like Harry are cared for appropriately. 4 Life Beyond the Cubicle: eLearning to support working well with families during mental health crises A set of eLearning modules designed to educate and update clinicians on the importance of involving families wherever possible during mental health crises to improve patient care, avoid harm and reduce deaths. They were developed as a partnership between Oxford Health NHS Foundation Trust and Making Families Count, with funding from NHS England South East Region (HEE legacy funds). The resources have been co-produced by people with lived experience as patients, family carers and clinicians, supported by an Advisory Group drawn from a wide range of expertise, tested in eleven NHS Trusts and independently evaluated. 5 Mental health crises: how to improve care In May 2024, National Institute for Health and Care Research (NIHR) Evidence held a webinar on care for adults in mental health crisis. The webinar shared research findings on what works in community crisis care, how acute day units compare to crisis resolution teams and whether peer-supported self-management can reduce acute readmissions. This Collection summarises the 3 research projects presented at the webinar. It includes video clips from the speakers and incorporates quotes from the day. The information will be useful for anyone involved in commissioning or delivering mental health crisis services. 6 Self-harm: assessment, management and preventing recurrence This new guideline from the National Institute for Health and Care Excellence (NICE) covers assessment, management and preventing recurrence for children, young people and adults who have self-harmed. It includes those with a mental health problem, neurodevelopmental disorder or learning disability and applies to all sectors that work with people who have self-harmed. The guideline sets out some important principles for care and treatment. For example, it states that self-harming patients treated in primary care must receive regular follow-up appointments, regular reviews of self-harm behaviour and a regular medicines review. 7 Hope Virgo: What needs to happen to stop people with eating disorders being failed by the healthcare system? In this blog, Hope Virgo, author and Secretariat for the All Party Parliamentary Group (APPG) on Eating Disorders, examines the crisis that continues in eating disorder services in the UK and the devastating impact this is having on patients and their families. She highlights how failures in services lead to avoidable deaths. Hope shares the key recommendations from a new report by the APPG and calls for adequate funding and attention to ensure people with eating disorders receive the help they need to recover. 8 Designing paediatric wards to support mental health Blog from the Health Services Safety Investigations Board (HSSIB) authored by Saskia Fursland, Senior Safety Investigator. She talks about her visit to a newly opened paediatric ward where its design has carefully considered children and young people with mental health needs. Saskia reflects on the learning which could support other paediatric wards to improve their environments. 9 Zero Suicide Alliance training The Zero Suicide Alliance is a collaboration of NHS trusts, charities, businesses and individuals who are committed to suicide prevention in the UK and beyond. Their website offers free online training courses to teach people the skills and confidence to have potentially life-saving conversations with someone they’re worried about. They offer short online modules covering general suicide awareness, social isolation and suicide in veterans and university students. 10 How can our team move past a traumatic event? After an extreme traumatic event there are things that you can do to help yourself, and your colleagues, to move on. Fiona Day, medical and public health leadership coach and chartered coaching psychologist, Stacey Killick, consultant paediatrician at Glan Clwyd Hospital, and Lucy Easthope, professor in practice at Durham University’s Institute of Hazard, Risk, and Resilience and adviser on disaster recovery give their tips in this BMJ article. 11 Trusted information collection: severe mental illness (Patient Information Forum) The Patient Information Forum (PIF) have launched a series of new collections to help people find trusted resources. Each collection only features resources that have the PIF TICK. That means they are easy-to-read, evidence-based and easy to understand. Topics include: schizophrenia, bipolar disorder and psychosis. 12 Vicarious trauma: The invisible epidemic In healthcare, an insidious epidemic lurks beneath the surface, affecting the very individuals tasked with providing care: vicarious trauma by empathy. Despite its profound impact, this phenomenon remains largely unrecognised and under-discussed within the sector. As leaders, it is imperative that we shed light on this invisible trauma and acknowledge it as one of the greatest challenges facing our industry, as Margarida Pacheco explains in this blog. 13 Beyond stereotypes: A lived experience guide to navigating support for disordered eating Disordered eating can affect anyone, but it can be confusing to understand and recognise it in our own personal experiences. This guide, published by East London NHS Foundation Trust, is a snapshot of how adults in East London have navigated those experiences of uncertainty while seeking support for disordered eating. For many of the contributors, preconceptions about what an eating disorder is (or isn’t) have previously acted as a barrier to seeking or receiving support. It also contains advice on how to seek support for disordered eating. 14 “The alarming rate of suicide among healthcare workers should be a wake-up call in the urgent need to support them” Frontline19 was established at the start of the Covid pandemic as an urgent response to support frontline workers who were under extreme pressure and experiencing significant mental health challenges. Psychotherapist Claire Goodwin-Fee is the founder and CEO of Frontline19. In this blog, Claire explains how systemic pressures and stigma around mental health are continuing to leave healthcare staff extremely vulnerable. 15 Blog: Why harmful gender stereotypes surrounding men’s approaches towards their feelings need challenging This blog explores why men are reluctant to seek support when they are struggling with their mental health and why the suicide rate is so high. It looks at initiatives that exist to encourage men to seek help and highlights what more could be done to support mens’ mental health. 16 Time for a rebalance: psychological and emotional well-being in the healthcare workforce as the foundation for patient safety In this editorial for BMJ Quality and Safety, Kate Kirk explains why staff well-being is the foundation to improving patient safety. 17 Top tips and key actions for successful collaborative partnership working across mental health services These top tips and key actions have been co-developed to support effective collaborative partnership working in the planning and delivery of community mental health services. They recognise that every heath and care system will experience challenges in relation to partnership working given the statutory and cultural differences of organisations working across the mental health pathways and that there will be different arrangements to frame local partnership working, including for example a Section 75 agreement. 18 Balancing care: The psychological impact of ensuring patient safety In this blog, Leah Bowden, a patient safety specialist, reflects on the impact her job has on her mental health and family life. She discusses why there needs to be specialised clinical supervision for staff involved in reviewing patient safety incidents and how organisations need to come together to identify ways we can support our patient safety teams. 19 NHS England: Staying safe from suicide: Best practice guidance for safety assessment, formulation and management This guidance supports the government’s work to reduce suicide and improve mental health services. It promotes a shift towards a more holistic, person-centred approach rather than relying on risk prediction, which is unreliable because suicidal thoughts can change quickly. Instead, it recommends using a method based on understanding each person’s situation and managing their safety. 20 The Motherhood Group: Black maternal mental health report UK The Motherhood Group has launched a landmark report on Black maternal mental health in the United Kingdom, shining a light on the urgent need for safe spaces, culturally competent peer support, digital access, and community-driven, anti-racist solutions. This report centres the lived experiences of Black mothers and highlights systemic barriers to quality, affordable mental healthcare. By leading this research, The Motherhood Group places Black mothers’ voices at the forefront of national conversations, providing policy-makers, health services, and communities with the insights needed to drive meaningful change. 21 Mental Maintenance at NEAS: a proactive approach to staff mental health The North East Ambulance Service NHS Foundation Trust (NEAS) provides emergency medical and patient transport services to a population of 2.7 million people in the North East region, employing over 3,400 staff members. Exposure to traumatic events, the demands of shift working and an uncertainty of what’s in store each day, can impact ambulance staff mental health. Read how North East Ambulance Service NHS Foundation Trust created a campaign to provide proactive staff mental health support. 22 Mind: The big mental health report 2025 Mind’s 2025 Big Mental Health Report explores the state of mental health, and mental health services and support across England and Wales. It builds on the insights from their 2024 report and gives a comprehensive picture of mental health to date, serving as a crucial guide that anyone can use. It explores the latest evidence on the nation’s mental health including how well services are supporting mental health in England and Wales. 23 Making sense after a suicide: living with blame, uncertainty, and the need for answers. You are not alone Each year, more than 700,000 people die by suicide worldwide. In the UK, it is around 7,000 – making it the biggest cause of death for people aged 20–34 and for men under 50. Making Families Count have created this resource to offer some comfort, recognition, and companionship in the aftermath of bereavement by suicide, whether it seems the person intended to take their own life, or their intention was unclear. The resource consists of a booklet and three short films of people’s stories of their bereavement by suicide. Written by Dr Rachel Gibbons, with contributions from a group of bereaved families, Dr Karen Lascelles, and comments and suggestions from other affected people and those who work with them. 24 National Audit of Eating Disorders Service Mapping Report 2025 The National Audit of Eating Disorders (NAED) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and funded by NHS England as part of the National Clinical Audit and Patient Outcomes Programme. In 2025 the NAED team conducted a comprehensive mapping of eating disorder service provision across England. This report provides an in-depth overview of NHS-funded and independent sector services for children, young people, and adults. 25 Mental health crisis care: legislative challenges in emergency departments (HSSIB) The Health Services Safety Investigations Body (HSSIB) published two reports intended for healthcare organisations, policymakers and the public to help improve patient safety in relation to safety issues identified for people experiencing a mental health crisis who come into contact with urgent and emergency care services. This first report focuses on the significant legal, policy and safety gap in the care of people in emergency departments (EDs) in mental health crisis. During consultation on this report, concerns were shared with HSSIB about the current challenges in relation to the resourcing and configuration of mental health services that exacerbate challenges faced in the ED. 26 Mental health: attempted suicide while under the care of community services (HSSIB) The second HSSIB investigation used the patient safety incident investigation (PSII) report template and Patient Safety Incident Review Framework (PSIRF) tools to investigate an attempted suicide in the community mental health setting. Findings and areas for improvement are listed for the organisations that were involved in this incident. However, the learning may be relevant to other organisations. Have your say Do you have any stories, insights or resources related to mental health? We would love to hear from you! Comment below (register for free here first) Get in touch with us directly to share your insights.

The UK Council on Deafness created Deaf Awareness Week to increase the visibility of challenges the deaf community face and educate others on how they can support them. Patient Safety Learning has pulled together 9 useful resources shared on the hub to help healthcare professionals, friends and family communicate and support people with hearing loss or deafness. 1 Royal College of General Practitioners: Deafness and hearing loss toolkit This educational kit, developed by Royal College of GPs (RCGP) in collaboration with RNID and NHS England, aims to support GPs to consult effectively with deaf patients by offering tips on how to communicate during face to face and remote appointments. It offers guidelines on how to recognise early symptoms of hearing loss and how to refer patients for a hearing assessment. 2 Communicating with patients with hearing loss or deafness—Can you hear me? The authors of this JAMA article describe the experience of a family member who was in critical care, and who is deaf. They outline a lack of awareness amongst healthcare professionals about their relative's deafness and highlight the lack of understanding in how to communicate with her. They go on to outline a number of approaches to communicating with patients who are deaf or hard of hearing. 3 Inequalities and unreasonable adjustments: are D/deaf women being given a detrimental care pathway in the name of risk assessment? In this article, published in The Practising Midwife, Rachel Crowe argues that in the UK, pregnant women who are hearing impaired or D/deaf (sign language users) and deaf (who are hard of hearing but who have English as their first language and may lipread and/or use hearing aids) are often labelled as high risk and offered a care pathway that is unsuitable and detrimental to their care. This article provides an overview to the needs of D/deaf birthing people with a number of recommendations and tools for use in clinical practice. 4 Blog - 12 tips for communicating with deaf patients Communication barriers are the number one reason deaf people have poorer health compared to hearing people. This blog by the organisation SignHealth gives 12 tips for healthcare workers and non-clinical staff on how to communicate with deaf people. It also describes the difficulties deaf people face when booking appointments and describes why remote consultations are problematic for deaf people. 5 CardMedic: Empowering staff and patients to communicate across any barrier In this interview, anaesthetist Rachael Grimaldi tells us about CardMedic, the organisation she founded to empower staff and patients to communicate across any barrier. Rachael explains how their tools can be used to support vulnerable groups and reduce inequalities. 6 Accessible and inclusive communication within primary care: What matters to people with diverse communication needs The primary care team have an important role in making people feel welcomed, listened to and taken seriously. Yet we often hear examples about people who have not had their communication needs met within primary care. This includes people with sensory impairments. This report from National Voices sets out the key issues faced by people with specific communication needs within primary care and what they feel would make the biggest difference, as well as key actions primary care leaders and teams can take to support inclusive communication. 7 Independent Review of Audiology Services in Scotland In January 2022 the Scottish Government asked for an independent review of the audiology services in Scotland in the context of failings in the standards of care provided in the NHS Lothian Paediatrics Services and made a series of recommendations. 8 The Safety Gap: Safety and accessibility of medicines and medical devices for people with sensory impairment This report for the Patient Safety Commissioner for England, commissioned from Professor Margaret Watson, highlights serious gaps and deficiencies in the way that people with visual and/or hearing impairment or loss (referred to as sensory impairment) are able to access and use medicines and medical devices safely. The report presents the results of a short-term study to explore the challenges experienced by patients with sensory impairment in relation to their safe and effective access to and use of medicines and medical devices and offers a number of recommendations. 9 Kingdon review: terms of reference Dr Camilla Kingdon has been appointed by the Secretary of State to chair an independent review of children's hearing services. The review will consider NHS England’s response to the service failures in paediatric audiology; how the relevant governance arrangements between NHS England and the Department of Health and Social Care could be improved and identify lessons learned; and how NHS England’s handling of any future service failures in similar services could be improved and identify lessons learned. Do you have a resource you'd like to share? We’d love to hear about it - leave a comment below or join the hub to share your own post.

Good hand hygiene in healthcare is essential to reduce the spread of healthcare associated infections (HAIs), which are the most frequent adverse event in healthcare globally. Although progress has been made in improving hand hygiene, there is still a pressing need to give healthcare professionals around the world the necessary knowledge and facilities to achieve effective infection control. The latest World Health Organization (WHO) data shows that globally, half of healthcare facilities do not have basic hand hygiene services, one in five facilities have no water services and one in ten have no sanitation services. We've pulled together useful resources about hand hygiene that have been shared on the hub. They include advice on effective handwashing, resources for healthcare professionals on how to promote hand hygiene and a global tool for monitoring hand hygiene interventions. 1. Scientia potentia est—Why sharing knowledge about hand hygiene remains important In this blog, hub topic leader Julie Storr looks at the question of why it's still so important to share knowledge about hand hygiene. She highlights the power of sharing knowledge to save lives, the need to address research gaps and that hand hygiene should be integrated into all aspects of frontline care. She also shares tools and resources that can be used to help train and equip frontline healthcare professionals. 2. Health Education for Scotland - Hand hygiene learning resources Resources by Health Education for Scotland to support their e-learning modules on hand hygiene. You will need an account to access the e-learning modules, but the supporting resources are available to download. 3. Improving hand hygiene in the anesthesia workspace: The importance, opportunities, and obstacles Anaesthesia professionals have consistently been leaders in patient safety and have long recognised the importance of hand hygiene in the anaesthesia workspace. Hand contamination is associated with pathogen transmission across multiple anaesthesia workspace reservoirs, and genome analysis of bacteria cultured from provider hands and infection causing pathogens have confirmed that providers transmit pathogens that result in patient infections. These findings should provide the impetus for widespread improvements in hand hygiene compliance for all intraoperative personnel, with anaesthesia professionals taking the lead. 4. WHO: Your 5 moments for hand hygiene This poster summarises WHO’s ‘Five moments for hand hygiene’ model, which WHO released in 2006 in collaboration with the infection prevention and control (IPC) research group at the University of Geneva. The approach aims to facilitate behavioural change and prioritise hand hygiene action at the right time to prevent infection transmission and avoid harm to patients and healthcare workers during care delivery. 5. Hand hygiene acceleration framework tool The Hand Hygiene Acceleration Framework Tool (HHAFT) has been developed by The Global Handwashing Partnership. It tracks the process that governments have taken to develop and implement a plan of action for hand hygiene improvement, and assesses the quality of that plan. It helps identify barriers, opportunities and priority actions for accelerating progress towards hand hygiene and drive investment to these plans. Use of this common framework allows countries to share learning and helps direct and coordinate global action. The webpage includes a dashboard that presents the latest data from different countries. 6. Supporting you to talk about hand hygiene: A primer for those in health care As a champion for hand hygiene, feeling empowered to talk about the topic to a range of colleagues is important. WHO has collated a number of hand hygiene improvement tools to help anyone working in healthcare promote good hand hygiene within their organisation. 7. Video: How to wash your hands Patients can contribute to infection prevention and control by making sure they wash their hands effectively—it’s one of the easiest and most important ways for patients to protect themselves and others from infectious illnesses. This NHS video demonstrates the best way to wash your hands and describes when you should do it. 8. WHO global taskforce on WASH in health care facilities: synthesis 2022-2023 The Global Taskforce on WASH in healthcare facilities aims to provide global strategic direction and coordination to WHO and UNICEF, and to promote information sharing and dialogue. It evolved from a series of think tanks convened by WHO. This webpage links to a summary of their work in 2022-23. 9 WHO Hand Hygiene Self-Assessment Framework 2010 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. 10 Implementation of a quality improvement project using the patient as the observer to improve hand hygiene compliance in ambulatory care practices This study published by the Journal of Hospital Infection, evaluated using patients as hand hygiene observers in an outpatient setting. It demonstrated that the implementation of a hand hygiene compliance improvement programme using the patient as the observer can be adopted successfully in the ambulatory setting. 11 e-Bug: Resources for children and young people about infection control and AMR (UKHSA) e-Bug, operated by the UK Health Security Agency, is a health education programme that aims to promote positive behaviour change among children and young people to support infection prevention and control efforts, and to respond to the global threat of antimicrobial resistance. e-Bug provides free resources for educators, community leaders, parents, and caregivers to educate children and young people and ensure they are able to play their role in preventing infection outbreaks and using antimicrobials appropriately. 12 World Hand Hygiene Day 2026 resources (Australian Commission on Safety and Quality in Health Care) This stakeholder kit supports the promotion of World Hand Hygiene Day, a WHO global initiative, on 5 May. Have your say Do you have any stories, insights or resources related to hand hygiene? We would love to hear from you! Comment below (register for free here first) Get in touch with us directly to share your insights

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

Parkinson’s is the fastest growing neurological condition in the world. It can affect young or old, and in the UK, around 153,000 people are living with the condition. With population growth and ageing, this figure is estimated to increase by 20%, within the next ten years. At the moment, there is no cure for Parkinson’s, but medication plays a vital role in managing symptoms and preventing deterioration. People with Parkinson’s face a number of specific patient safety issues when accessing healthcare including communication difficulties and risks associated with medication delays. In this blog, Patient Safety Learning has pulled together 14 useful resources about Parkinson’s shared on the hub. They include guidance for patients and their families about hospital stays and medication, and awareness-raising resources for healthcare professionals about the patient safety issues people with Parkinson’s face. 1. Keeping patients with Parkinson’s safe in hospital: 4 key actions for staff Dr Rowan Wathes, Associate Director of the Parkinson's Excellence Network at Parkinson's UK, recommends four key actions that healthcare workers can take to improve safety for people with Parkinson’s while they are in hospital. 2. Parkinson's UK: Parkinson's Away-From-Home Kit This kit from the Parkinson's UK Excellence Network comes from 3 years of collaboration with people with Parkinson’s and carers to understand the challenges they face when going into hospital and how we can help. People with Parkinson’s can choose from a range of tools to create a kit that works for them. Every item is designed to support them, and those who care for them, to advocate for their Parkinson's medications to be administered on time, every time. 3. Nurses leading the way: enhancing Parkinson's care in nursing homes In this blog published by the Royal College of Nursing, Jean Almond, Programme Manager at Parkinson's UK, discusses improving the delivery of time critical Parkinson’s medication to care home residents. 4. Preparing to go into hospital – tips for people with Parkinson's and their carers In this blog, Laura Cockram, Head of Policy and Campaigning at Parkinson's UK, talks about how people with Parkinson’s can prepare their medication to go into hospital. 5. Time-critical Parkinson’s medication: the human cost of delays and mistakes In this blog, Joanne explains how delays to her mother’s time-critical medication in hospital led to her condition deteriorating. 6. Time critical medication guides for health professionals The Parkinson’s Excellence Network has produced three practical guides to support UK health professionals to deliver time critical Parkinson’s medication on time in hospital: a guide for NHS ward staff, a guide for hospital pharmacists and a swallowing guide for the nurse in charge and ward staff. 7. Electronic prescribing: how it can improve the delivery of time critical medications This resource describes how NHS Ayrshire & Arran hospitals improved their rates for administering patients' Parkinson's medications on time, sharing case studies and tips on how other hospitals might be able to replicate their successful e-prescribing system. 8. Improving the delivery of time critical medications at Bradford Teaching Hospitals NHS Foundation Trust A best practice case study showcasing a quality improvement project at Bradford Teaching Hospitals NHS Foundation Trust. 9. Ask the expert: How to spot fake Parkinson’s medicines online Falsified, fake or counterfeit medicines are medicines disguising themselves as authentic, and they can pose significant health risks. This blog highlights the issue of counterfeit Parkinson's medications being sold illegally online. Mike Isles, Executive Director of the Alliance for Safe Online Pharmacy in the EU describes their high prevalence and gives tips for people with Parkinson's on how to stay safe when buying medicines online. 10. My Parkinson's passport This tool from the Parkinson's Association of Ireland allows people with Parkinson's to record their essential medical information in an easy to access format, should they need assistance or medical treatment. 11. Parkinson's awareness: a 15-minute online presentation for ward staff This 15-minute training video by the Parkinson's Excellence Network pulls together the key symptoms and issues that can affect a person with Parkinson's and their care when admitted to a hospital ward. It aims to help ward staff understand the most important considerations when caring for people with Parkinson's. 12. Medication delays: A huge risk for inpatients with Parkinson’s This blog examines the serious health implications of delayed medication in people with Parkinson’s. It highlights evidence that this is a widespread safety issue and outlines the challenges, barriers and solutions to ensuring patients receive their medication on time. 13. Parkinson’s UK Tech Guide Parkinson’s UK created the Tech Guide so that people with Parkinson’s, and their families, friends and carers, can make the right decisions for themselves about all the devices and apps that claim to be able to help improve their quality of life. To do this, they provide trusted reviews based on the lived experience of people with Parkinson’s, and maintain a catalogue of the various products that are on the market. This is backed up with information about Parkinson’s and evidence-based articles that will help you decide what’s right for you, in your unique circumstances. 14. NHS Northumbria Healthcare: Improving the care in hospital for people with Parkinson’s In this blog, consultant geriatrician, Dr James Fisher, talks about a project at NHS Northumbria Healthcare to improve the experience of Parkinson’s patients by focusing on medication. Have your say Are you a healthcare professional who works with people with Parkinson’s? We would love to hear your insights and share resources you have developed. Do you have, or do you care for someone with Parkinson’s? Please share your experience of health and care services with us. We would love to hear from you! Comment below (register for free here first). Get in touch with us directly to share your insights.

Patient and family voices play a critical role in understanding patient safety issues, learning from incidents and managing risk. In this Top picks, we’ve pulled together resources from the hub that highlight the value in involving patients and the public in patient safety.  Using patient stories to create significant impact and improve cancer patient experience The Cheshire and Merseyside Cancer Alliance (CMCA) were finalists in the 'Partnership Working to Improve the Experience' category at the Patient Experience Network 2025 Awards. In this blog, CMCA explain how patient stories are deliberately integrated into their governance, learning and pathway redesign, and how this approach transforms storytelling from passive listening into active improvement. Why the patient voice matters when things go wrong Risa Mallory is a retired psychotherapist from Canada. After a serious cardiovascular event in 2018 she became a patient advocate, collaborating with organisations across the globe. In this blog, Risa describes why patient involvement is critical when things go wrong in healthcare The role of simulation-based education, co-design and co-delivery in improving patient safety Dr Kirsten Howson, Specialist Education Lead at SimComm Academy, discusses the role Simulation-Based Education (SBE) can have in patient safety. Kirsten highlights some of the techniques used in SBE, the benefits for staff and patients, and the importance of involving people with lived experience in the design and delivery of SBE. Working with bereaved parents for safer and more equitable care Julia Clark and Mehali Patel from the Sands Saving Babies’ Lives research team, draw on their recent Listening Project to illustrate the value of working with bereaved parents. Julia and Mehali argue that hearing and amplifying these unique insights is vital to developing safer, more equitable neonatal and maternity care. Integrating patient and public involvement into co-design of healthcare improvement: a case study in maternity care (March 2025) Despite recognition of the importance of patient and public involvement (PPI) in healthcare improvement, compelling examples of “what good looks like” for PPI in co-design of improvement efforts, how it might be done, and formalisation of methods and reporting are lacking. The authors of this study sought to address these gaps through a case study. Patient safety and lived experience Anthony O'Connor works primarily in the areas of lived experience and in co-production and strives to have both of these concepts better understood, and more effectively utilised wherever possible. In this blog he focuses on lived experience, its definition, its usage, and its impact. Patient safety and co-production Anthony O’Connor talks about the benefits of co-production and why it is essential to patient safety. Anthony gives examples of how co-production can be used more in healthcare and encourages everyone to develop their knowledge of co-production and start embedding it into their work. Providing patient-safe care begins with asking and listening... really listening! Dan Cohen talks about how patient-safe care is all about collaborating and listening to your patients to find out what really matters to them. He illustrates this in a case study of his own personal experience whilst working as a clinician in the USA. Catching cancer early: what more can we do as GPs? GP, Amelia Randle sets out a number of ways clinicians can develop their daily practice to improve cancer diagnosis at an early stage. Amelia talks about involving patients in questioning symptoms, deep listening and learning from patients and families. “Listening to a patient’s history for longer can help doctors make the right diagnosis” Mary Dahm and Carmel Crock tell us more about their research to explore the relationship between communication and diagnostic accuracy. The findings highlight how critical it is to spend time listening to the patient, and for doctors to communicate uncertainties well. Share your insights Have you been involved in safety improvements as a patient? Or perhaps you’re a healthcare professional who has made safety improvements that were informed by the patient voice? Could you share your insights on the value of the patient voice in patient safety? You can comment below (sign up first for free) or email our editorial team at [email protected].

Over the years, we have worked with many amazing women who share our aim of reducing avoidable harm in health and social care. In this blog, to mark International Women’s Day, we are celebrating women who campaign for patient safety.  These articles, interviews and resources from the hub shine a light on just some of the women who are working hard to prevent avoidable harm and strengthen patient safety. Often informed by lived experience, their insights, expertise and tenacity have helped shape conversation and change. Click on the titles to read each one in full. Interview with Kath Sansom, Founder of Sling the Mesh Kath talks to us about why she set up Sling the Mesh and the significant impact that campaigning has on her life. She also highlights the need to establish systems that will identify and prevent avoidable harm, including long term tracking to investigate trends of harm, reporting of industry payments to clinicians and making logging side effects mandatory for healthcare professionals. Patient Safety Spotlight interview with Rosi Reed, Development and Training Coordinator at Making Families Count Making Families Count is an organisation that offers practical training based on lived experience to healthcare professionals. Rosi Reed became involved in Making Families Count after the death of her son Nico. In this Patient Safety Spotlight interview, Rosi outlines the vital importance of seeing patient and family voices as equal to those of people working for healthcare organisations. Rosi talks to us about how MFC training benefits patient safety and improves the way in which patients and families are involved in incident investigations. Campaigning for safety as a patient, family member or advocate In this video we hear from campaigners Sandra Igwe, CEO of the Motherhood Group, and Soojin Jun, co-founder of Patients for Patient Safety US. They talk about their experiences of engaging with the system, the challenges they have faced and offer advice for others seeking to campaign for change in healthcare. Interview with Charlet Crichton, founder of UKCVFamily UKCVFamily was set up in November 2021 to support patients in the UK who have had an adverse reaction to a Covid-19 vaccination. The group provides help and advocacy as well as raising awareness amongst healthcare professionals, the media and the Government. In this video, founder of UKCVFamily Charlet Crichton talks to us about the side effects she experienced after having the AstraZeneca Covid vaccine. She outlines why she established the group and describes the support it offers to patients. People with eating disorders should not face stigma in the health system and barriers to accessing support In this blog, Hope Virgo, an eating disorder survivor and mental health campaigner, looks at the barriers people face when they try to access support, and talks about her own experience of being told she was ‘not thin enough for support’. She calls for long-overdue action on funding, training and awareness of eating disorders within the NHS. Interview with Isabela Castro, patient advocate Isabela shares how her experience of losing her baby daughter to avoidable harm in 2006 led to her involvement in patient safety advocacy. She talks to us about the vital role of patient campaigners in driving the movement to reduce avoidable harm, and why we need to shift from patient inclusion to belonging in order to improve patient safety. When will the Government take responsibility and meet the needs of all mesh patients? A blog by Paula Goss Paula Goss had surgery to implant rectopexy and vaginal meshes which left her with severe pain and other serious complications. In this blog, Paula talks about why she set up Rectopexy Mesh Victims and Support to campaign for adequate treatment, redress and justice for people injured by surgical mesh. She outlines the need for greater awareness of mesh injuries amongst both healthcare professionals and the public and talks about what still needs to be done to enable people to access the treatment and support they need. Leading for safety: A conversation with Jane Plumb, Founder of Group B Strep Support Jane Plumb is the Co-Founder of Group B Strep Support and the Women's Voices Lead for the Royal College of Obstetricians & Gynaecologists. In this interview, she emphasises the importance of actively involving patients and families in patient safety discussions so that improvements can be informed by their insights and experiences. Interview with Marie Lyon, chair of the Association for Children Damaged by Hormone Pregnancy Tests In this interview, Marie Lyon talks about her campaign for justice for families affected by hormone pregnancy tests, why she is passionate about reforming medicines regulation and the important role patient campaigners play in improving patient safety. The question that will save lives: Interview with Katinka Blackford Newman, founder of Antidepressant Risks Antidepressant medications are taken by millions of people globally. A small percentage of people who take them will experience rare but dangerous adverse reactions. In this interview, Katinka Blackford Newman tells us about her personal experience of antidepressant-induced psychosis and how this led her to campaign for increased awareness about side effects. She highlights a widespread lack of education and awareness about the risks associated with antidepressants and outlines why she is asking suicide prevention charities to ask callers one simple question about their medication. Women’s heart health - a patient safety priority hub Topic lead Risa Mallory is a retired psychotherapist from Canada. After a serious cardiovascular event in 2018 she became a patient advocate, collaborating with organisations across the globe. In this blog Risa talks about her experience and the patient safety issues she's observed as a woman with a heart condition. House of Lords roundtable on Independent National Maternity and Neonatal Investigation: reflections from The Motherhood Group Sandra Igwe MBE is the Founder and CEO of The Motherhood Group and a Topic leader for the hub. In this blog, she talks about The Motherhood Group’s involvement in a recent roundtable event to discuss the Independent National Maternity and Neonatal Investigation. Thrush and vulval nerve damage: lack of information and knowledge puts patients at risk Philly Baines is a patient advocate and Founder of Thrush Support. She is living with chronic pain following recurrent thrush infections and vulval nerve damage. In this opinion piece, Philly shares her experience and calls for action to make sure patients and healthcare professionals are more aware of the risk of thrush-associated nerve damage. She highlights the devastating impact chronic vulval pain has on people’s lives and why prevention is key. Enhancing patient safety through effective communication in clinical trials and cancer care: a blog by Tambre Leighn In this blog, patient advocate and healthcare communications consultant, Tambre Leighn, discusses how effective communication is essential for ensuring patient safety in clinical trials and cancer care, and why poor communication can lead to negative outcomes. She shares her strategies to improve patient safety through communication. Do you campaign for patient safety? Are you involved in a campaign that has patient safety at its heart? Would you like to tell us more about your work and the changes you’d like to see? Perhaps you are a patient or relative with lived experience that you would like to share? Or a healthcare professional with insights around the patient safety challenges and potential solutions? Get in touch with us at [email protected]

Over 6,000 rare diseases are characterised by a wide range of conditions and symptoms that can vary not only between diseases but also among individuals with the same condition. 72% of rare diseases are genetic, and nearly one in five cancers is classified as rare. Some common symptoms may overlap with those of rare diseases, which can make diagnosis challenging and delay access to appropriate care. These conditions can impact daily life due to their long-term, evolving nature. At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. To support Rare Disease Day, we have pulled together 16 resources, including reports, guidelines and blogs, to raise awareness of the challenges faced by people with a rare disease, and to support healthcare professionals and patients and their carers. 1 England Rare Diseases Action Plan 2025 The UK Rare Diseases Framework, published in January 2021, set out a shared vision for addressing health inequalities and improving the lives of people living with rare diseases across the UK. This is the fourth action plan setting out how the Department of Health and Social Care and delivery partners will implement the UK Rare Diseases Framework in England. 2 How one woman’s missed referrals exposed a systemic gap in hereditary cancer care: Why I'm campaigning for Rachel's Rule When Stuart Ball's wife Rachel passed away in August 2025, she was just 47 years old. Her death was not inevitable. It was the result of years of missed opportunities—signs that were there in plain sight but never joined together. What happened to Rachel should never happen to another family. Stuart shares Rachel's story and tells us why he is campaigning for Rachel's Rule—a call for a system safeguard that ensures hereditary risks are not missed. 3 National Organization for Rare Disorders: Rare Disease Database for patients and families The National Organization for Rare Disorders (NORD)’s Rare Disease Database provides brief introductions for patients and caregivers to specific rare diseases. 4 OrphanAnesthesia: Patient Safety Card OrphanAnesthesia offers a Patient Safety Card for all hospitals, patients, and support groups. The patient or the physician fills in the name of the rare disease to notify the anaesthesiologist/ emergency personnel of the rare disease, and of the recommendation for the anaesthetic management. The card should be given to the anaesthesiologist before anaesthesia. It should be carried by the holder in case of emergency. 5 Highlighting Loeys-Dietz syndrome and the need for awareness Loeys-Dietz syndrome (LDS) is a genetic disorder affecting connective tissue, which supports, protects and gives structure to various tissues and organs. This article tells the story of Sharon, a 53-year-old woman from Bristol, who died in December 2022. Her family now advocates for greater awareness of LDS to prevent similar tragedies. Sharon’s death, attributed to natural causes compounded by neglect, highlights systemic failures in promptly recognising and treating her aortic dissection. 6 Rare care matters: The struggle to access diagnosis and care for rare autoimmune rheumatic disease patients The Rare Autoimmune Rheumatic Disease Alliance (RAIRDA) has launched a report revealing that individuals living with rare autoimmune rheumatic diseases (RAIRDs) experience stark variations in their care and treatment. The report paints a concerning picture: nearly one in three respondents waited more than five years for a diagnosis, with the average wait time standing at two and a half years. 7 “No one would believe me”: A common feeling for people living with a rare disease Having a diagnosis can be very important, not only in order to consider medical needs, but sometimes it can also come as proof that something is happening to the body, proof to others that there is something going on. Several people across the globe, with different rare diseases, have shared their story, telling us about needing to be heard and understood. 8 GIRFT - Spinal surgery: National suspected cauda equina syndrome (CES) pathway Cauda Equina Syndrome (CES) is a rare but serious spinal condition and if not diagnosed and treated swiftly, it can result in lifechanging injury. Nearly a quarter of compensation claims for spinal surgery in England relate to CES. This CES pathway and accompanying guidance by the Getting It Right First Time (GIRFT) programme, aims to provide healthcare professionals working in all care settings with the ability to effectively diagnose and care for patients presenting with suspected Cauda Equina Syndrome. 9 Sickle Cell Society: Standards for the clinical care of adults with sickle cell disease in the UK These standards for the clinical care of adults with sickle cell disease were produced by the Sickle Cell Society in collaboration with a broad multi-disciplinary group of healthcare providers, patients and support groups. 10 HSIB: Management of sickle cell crisis In this investigation, the Health Services Safety Investigation Body (HSSIB) used a real patient safety incident to explore how sickle cell crises are managed within hospital settings. In particular, the investigation considered: the knowledge nursing staff may have about the care of patients in sickle cell crisis how patient-controlled analgesia (PCA) – where a patient can use a device to give themself doses of pain relief medication – is considered holistically, such as monitoring the patient and staff workload. 11 Medication supply issues: Mast cell activation syndrome (MCAS) Joy Mason is the Director of Operations, Services and Engagement at Mast Cell Action. In this blog, Joy tells us more about Mast Cell Activation Syndrome and how medication supply issues are impacting people’s lives and causing avoidable harm. 12 Neonatal herpes – more common than you think? Neonatal herpes is a rare, and potentially fatal, disease which usually occurs in the first four weeks of a baby's life. It is caused by the same virus that causes cold sores and genital infections – the herpes simplex virus (HSV). Early recognition and treatment has been shown to significantly improve babies' chances of making a full recovery. Sarah de Malplaquet, Chief Executive and Founder of the Kit Tarka Foundation, explains why they are joint-funding new research into neonatal herpes, and how the findings could help save many lives. 13 What can I do to prevent my baby getting neonatal herpes? (Kit Tarka Foundation) There are some simple things you can do to help prevent babies from catching herpes infections. These include regular hand washing, covering cold sores and not kissing babies who are not your own. The Kit Tarka Foundation provide information on neonatal herpes and how to keep your baby safe. 14 Creon shortages: “It’s just another thing patients with cystic fibrosis could do without” There is a current shortage of Creon, a pancreatic enzyme replacement therapy. Sophie, a patient with cystic fibrosis, tells us about her experience of trying to get hold of Creon and the challenges she has faced. 15 From diagnosis to system change: what rare disease is teaching us about safety, bias and AI Professor Rob Galloway is an Emergency Medicine Consultant and Founder of the charity Rare People. In this article, Rob talks about his daughter’s recent diagnosis of a rare genetic condition. He describes the barriers to safe and equitable care for people with rare diseases, and his hopes for future treatment development, supported by AI. 16 Equity for Rare: Delivering fair healthcare systems for people affected by rare conditions The Genetic Alliance UK 'Equity for Rare' report highlights the inequities the rare conditions community experiences, and found that equity broadly means ensuring that people with rare conditions can navigate the healthcare system with the same dignity and efficacy as those with common conditions. It's gives five recommendations for the Government. For more resources, take a look at our Rare diseases area of the hub. Do you have a resource or story to share about rare diseases? Could your insights or experiences help improve patient safety? Leave a comment below (join the hub for free first) or contact us at [email protected].

Eating Disorders Awareness Week takes place 23 February - 1 March 2026 Eating disorders are complex mental health conditions that affect an estimated 1.25 million people in the UK. There are many unhelpful myths about who eating disorders affect, what the symptoms are and how to support people in recovery. Alongside a current lack of appropriately trained staff and capacity in mental health services, this can make it challenging for people with eating disorders to access the help and support they need. Patient Safety Learning has pulled together 15 useful resources shared on the hub to help healthcare professionals, friends and family support people with eating disorders. They include awareness-raising blogs, practical tips for patients and their loved ones, and clinical guidance for primary, secondary and mental health providers. 1 Hope Virgo: What needs to happen to stop people with eating disorders being failed by the healthcare system? In this blog, Hope Virgo, author and Secretariat for the All Party Parliamentary Group (APPG) on Eating Disorders, examines the crisis that continues in eating disorder services in the UK and the devastating impact this is having on patients and their families. She highlights how failures in services lead to avoidable deaths. Hope shares the key recommendations from a new report by the APPG and calls for adequate funding and attention to ensure people with eating disorders receive the help they need to recover. 2 Beyond stereotypes: A lived experience guide to navigating support for disordered eating Disordered eating can affect anyone, but it can be confusing to understand and recognise it in our own personal experiences. This guide, published by East London NHS Foundation Trust, is a snapshot of how adults in East London have navigated those experiences of uncertainty while seeking support for disordered eating. For many of the contributors, preconceptions about what an eating disorder is (or isn’t) have previously acted as a barrier to seeking or receiving support. It also contains advice on how to seek support for disordered eating. 3 ARFID: A brief evidence review Avoidant/restrictive Food Intake Disorder (ARFID) is a severe feeding and eating disorder marked by food avoidance and/or restricted food intake. Individuals with ARFID can restrict the amount of food eaten, and therefore do not get enough calories, or they can restrict the range of foods eaten and therefore do not get all the nutrients needed for maintaining health. The charity Beat has produced an evidence review on ARFID. 4 Leaflet - Seeking treatment for an eating disorder If someone suspects they may have an eating disorder, their first step in getting treatment is often a visit to their GP. This leaflet contains guidance for people who have, or suspect they may have, an eating disorder, as well as information for GPs and other people who may be supporting them. It’s based on the guideline on eating disorders from the National Institute for Health and Care Excellence (NICE), which GPs should use when making decisions about patients’ healthcare. 5 Feeding or eating disorders hub (NHS England) The NHS England MindEd all-age eating disorders hub is aimed at all professionals, from universal to specialist. It contains key trusted evidence-based learning, curated and approved by an expert panel. You can find information on NHS policy guidance, professional bodies' guidance, professional associations' reports, charities, NHS learning and good practice, legislation and reports, and key and influential texts. 6 People with eating disorders should not face stigma in the health system and barriers to accessing support - a blog by Hope Virgo People with eating disorders often find it difficult to get help and treatment from the health system because of pervasive stigma, misinformation and stereotypes around eating disorders. This blog by eating disorder survivor and mental health campaigner, Hope Virgo, looks at the barriers people face when they try to access support for eating disorders in the UK. She talks about her own experience of being told she was ‘not thin enough for support’ and calls for long-overdue action on funding, training and awareness of eating disorders within the NHS. 7 Medical emergencies in eating disorders (MEED): Guidance on recognition and management To tackle the serious harms, up to and including death, associated with eating disorders it is crucial that more is done to identify them at the earliest stage possible so that the appropriate care and treatment can be provided. This guidance by the Royal College of Psychiatrists provides a comprehensive overview of the latest evidence associated with eating disorders, including highlighting the importance and role of healthcare professionals from right across the spectrum recognising their responsibilities in this area. 8 I survived diabulimia, the world’s most dangerous eating disorder Sarah Rainey talks about her experience of type 1 diabetes with disordered eating (T1DE), which is thought to affect up to 40% of women and 15% of men with type 1 diabetes. People with T1DE, sometimes also called diabulimia, limit their insulin intake to control their weight, which can have life-threatening consequences. Olivia describes how the stress of living with type 1 contributed to her developing T1DE, and how when she finally received treatment and support in her 30s, she was able to deal with her disordered eating and see her health and wellbeing improve. 9 London Assembly Health Committee: Eating Disorders in London In June 2023, the London Assembly Health Committee launched an investigation into eating disorders in London, following reports that referrals for eating disorder services have increased in recent years and performance against waiting time standards dropped during the COVID-19 pandemic. The aim of this investigation was to understand what is driving the increase in referrals, how services are responding to this additional demand and to explore people’s access to, experiences of, and outcomes from treatment services. The report makes 12 recommendations for change. 10 SAPHNA - Eating disorder toolkit This toolkit was co-produced by the School and Public Health Nurses Association (SAPHNA) with school nursing services, mental health campaigners, eating disorder experts, education colleagues and young people with lived-experience of eating disorders. It provides information and guidance for school nurses on how to identify and support students with eating disorders and their families, addressing issues such as consent, confidentiality and referral to specialist services. 11 Tips poster: First signs of symptoms of an eating disorder When someone has an eating disorder, getting early support and treatment can make a huge difference to their recovery. That’s why it's important that everyone can spot the first signs and symptoms of an eating disorder. This poster by the charity Beat Eating Disorders offers tips to help you spot the very first signs of an eating disorder. 12 Eating disorders: a guide for friends and family This booklet from Beat Eating Disorders is for anyone supporting someone with an eating disorder. It covers information about eating disorders and treatment, and offers guidance on how you might approach the subject if you’re worried about someone you know and how to support them after diagnosis, as well as looking after yourself. 13 Medical emergencies in eating disorders: Guidance on recognition and management People with eating disorders can reach a crisis point where their condition becomes a medical emergency resulting in serious harm or even death. This guidance from the Royal College of Psychiatrists makes a series of recommendations for primary care, secondary care and mental health services that aim to make preventable deaths due to eating disorders a thing of the past. There are specific recommendations focused on the needs of children with eating disorders, recognising the physiological differences between adults and children. 14 In conversation with Hope Virgo: “The withdrawal of treatment from people with eating disorders is a national crisis that’s being ignored.” A growing number of patients with eating disorders are reporting having treatment withdrawn by services, often without notice and without their consent. We spoke to eating disorder campaigner Hope Virgo about how pressures on services, enduring stigma around eating disorders and dangerous new narratives are leading to the practice of treatment withdrawal. Hope explains how this is affecting vulnerable patients and highlights that as the number of people developing eating disorders increases, the risks to patient safety will only get worse. 15 National Audit of Eating Disorders Service Mapping Report 2025 The National Audit of Eating Disorders (NAED) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and funded by NHS England as part of the National Clinical Audit and Patient Outcomes Programme. In 2025 the NAED team conducted a comprehensive mapping of eating disorder service provision across England. This report provides an in-depth overview of NHS-funded and independent sector services for children, young people, and adults. Have your say Are you a healthcare professional who works with people with eating disorders? We would love to hear your insights and share resources you have developed. Perhaps you have received treatment for an eating disorder—what was your experience of healthcare services? We would love to hear from you! Comment below (register for free first) Get in touch with us directly to share your insights

Our free platform for patient safety – the hub – was launched in 2019 with the aim of sharing learning for safer care. We now have members from all around the world, and many are helping to shape the hub by sharing their patient safety insights through blogs, interviews, tools and practical examples.  In this Top picks, we showcase some of our international contributions, and celebrate our ever-growing network of people who are passionate about reducing avoidable harm. From the United States 1. Diagnostic errors and delays: why quality investigations are key Dan Cohen, international consultant in patient safety and clinical risk management, and Trustee for Patient Safety Learning, looks at the challenges around diagnostic error and delay, 3. A complex adaptive systems approach to patient safety Kumar Subramaniam, CEO at SafeTower, argues that it is time to reimagine safety event reporting and management solutions that guide, not prescribe, investigations and improvement actions. 4. Patient Safety Spotlight interview with Soojin Jun, Co-founder of Patients for Patient Safety US Soojin Jun talks explains how her personal experience of harm motivated her to work in healthcare and campaign for patient safety, the power of collaboration in improving healthcare safety and how healthcare workers can take steps to improve their own patient interactions. 5. Harmful attitudes towards gynae surgery as a discipline – a risk to patient safety An interview with US-based gynaecology surgeon Jocelyn Fitzgerald, looking at the knock-on patient safety issues caused by negative attitudes towards her specialty. 6. Enhancing patient safety through effective communication in clinical trials and cancer care: a blog by Tambre Leighn Tambre discusses how effective communication is essential for ensuring patient safety in clinical trials and cancer care, and why poor communication can lead to negative outcomes. 7. Now is not soon enough: Patients, families and the general public have much to gain from the US National Patient Safety Board Act Olivia Lounsbury, Committee Lead for Patients for Patient Safety US's National Patient Safety Oversight committee, looks at a new Bill calling for the creation of a US National Patient Safety Board (NPSB). From Africa 1. The 'Minutes of the Minute': a blog by Ehi Iden - OSHAfrica Ehi Iden discusses the importance of documenting and learning from patient safety incidences. Using a fictional story to draw parallels from, Ehi highlights how accountability, leadership and reporting incidences will help us keep staff and patients safe. 2. Friends of African Nursing (FoAN): Training perioperative nurses across Africa FoAN's Chair of Trustees Kate Woodhead describes the challenges facing nurses working in perioperative care in many African countries. 3. 'Mind the Implementation Gap': the challenges facing Ethiopia Yakob Seman Ahmed reflects on Patient Safety Learning's recent report 'Mind the implementation gap: The persistence of avoidable harm in the NHS' and the similar challenges Ethiopia faces in implementing its own standards and policies. 4. Patient Safety Spotlight interview with Chidiebere Ibe, medical illustrator and medical student Chidiebere Ibe is passionate about increasing representation of Black people in all forms of medical literature. In this interview, he explains how lack of representation at all levels of the healthcare system leads to disparities in healthcare experiences and outcomes. 5. Spotlight on Sudan: How can we improve healthcare services during war? From his observations of healthcare conditions in Sudan, Dr Ahmed Khalafalla presents some ideas on how we can improve healthcare services during times of war and uncertainty to make healthcare services accessible for those who need them. 6. Preventing patient falls in healthcare settings: The need for fall risk assessment Patient falls are a significant concern in healthcare settings, often leading to severe injuries, prolonged hospital stays and increased healthcare costs. This blog from Augustine Kumah, Deputy Quality Manager at The Bank Hospital, Accra, Ghana, explores the significance of fall risk assessment, its implementation and its role in reducing fall-related incidents in healthcare settings. 7. Putting patients at the centre of antimicrobial stewardship in Uganda: Why meaningful patient engagement is essential to beating antimicrobial resistance Across Uganda, patients are increasingly experiencing infections that no longer respond to commonly used antibiotics. Conditions that were once easily treatable now require longer hospital stays, repeated courses of treatment and higher out-of-pocket expenditure. In this blog, Annet Naguudi, Regina Kamoga and Joshua Wamboga from the Uganda Alliance of Patients’ Organizations (UAPO) argue that strengthening AMS in Uganda requires placing patients at the centre of the response and highlights the strategic positioning of the UAPO to lead this shift in line with national and global priorities. From Australia 1. #NavigatingHealth—Enabling every patient, every time, system-wide In this blog, Siân Slade shares how, through her research interest into the difficulties of navigating the healthcare system in Australia, she created a policy and advocacy project: #NavigatingHealth. The aims of the project are to streamline the silos and address the fragmentation of healthcare by bringing together all those who are developing solutions to enable patients and carers to better navigate healthcare journeys. 2. “Listening to a patient’s history for longer can help doctors make the right diagnosis” Mary Dahm and Carmel Crock tell us more about their research to explore the relationship between communication and diagnostic accuracy. 3. Professional regulation and patient safety systems: parallel planets or partners in improvement? Martin Fletcher has been part of transformational change in professional regulation through his tenure as Chief Executive of the Australian Health Practitioner Regulation Agency (Ahpra). Martin shares Australia's regulatory journey and reflects on the UK's more gradual path to reforming their legislative frameworks. He highlights both countries' shared common goals and the challenges faced along the way. He ends the blog with three priorities for future action: integrating professional regulation into system safety, better use of data to anticipate risk and embedding equity and cultural safety. More international insights… 1. ‘Knowledge is the driver of change and will make a difference': a blog from Peter Lachman Peter, Lead of the Faculty Quality Improvement Programme, Royal College of Physicians of Ireland, explains why safety must be embedded into what we do every day, not what we do only after harm has occurred, and why we need to constantly ask ourselves “what do we need to do to be safe?” 2. Patient Safety Spotlight interview with Isabela Castro, patient advocate Isabela is from Brazil and in this interview shares how her experience of losing her baby daughter to avoidable harm in 2006 led to her involvement in patient safety advocacy, and talks about the vital role of patient campaigners in driving the movement to reduce avoidable harm. 3. Patient Safety Spotlight interview with Roohil Yusuf, Global Pharmacy Adviser at Save the Children international Roohil talks to us about the vital role of pharmacists in making sure medications help patients, rather than causing harm and highlights the global threat of substandard and counterfeit medicines. 4. Mother knows best – a blog by Dr Abha Agrawal Dr Abha Agrawal shares with the hub her family's experience of going into hospital in India, and demonstrates how patients and families can be true partners in patient safety. 5. The patient's chair: a blog by Dr Faisal Saeed Dr Faisal Saeed, a doctor in the Maldives, talks about the patient-provider power imbalance using an AI generated image of two chairs to illustrate his points. 6. Patient Safety Spotlight interview with Josie Gilday, Global Medical Adviser at Save the Children International Josie tells us about the nursing error that first sparked her interest in patient safety, how a just culture helps healthcare workers and systems learn from their mistakes, and how her love of skiing has inspired her to think differently about risk in healthcare. 7. Treading around level 3: Time for a paradigm shift in patient safety? Dr Abdulelah Alhawsawi, Abdominal Organs Transplant and Hepato-biliary Surgeon, and Director General of the Saudi Patient Safety Center, discusses why hospitals are falling short of safe care levels. He believes healthcare continues to be structurally weak when it comes to the safety conditions and suggests that there is an urgent need for a paradigm shift in the way we think about patient safety and how we implement it while providing healthcare. In his essay, Dr Alhawsawi proposes four practical solutions. 8. The power of being heard in healthcare (a blog by Risa Mallory) Risa Mallory, a retired psychotherapist from Canada, talks about the importance of listening in healthcare, and how patient voices play a critical role in ensuring safety, quality and fairness. 9. Patient safety in humanitarian settings This blog describes the challenges faced in assuring patient safety in humanitarian settings and offers suggestions for how international medical aid organisations can build patient safety systems. 10. How a charity in France is supporting intensive care units: An interview with Anne-Sophie Debue In this interview, Anne-Sophie Debue tells us about the 101 Fund in France, a charity that develops projects to support intensive care units, and a tool that they have developed, LifeMapp, which supports patients and their families during and after intensive care. 11. Can systems modelling help generate safer and faster morbidity and mortality conference preparation? Reflections from a pilot study on coronary angiography Stefan Peil, a healthcare consultant in Germany, summarises a pilot study he has done to see whether a structured systems model can support the preparation of a morbidity and mortality (M&M) conference discussion. 12. The ant that moves the elephant: a lesson in building safer reporting cultures Saed Saleh Abed, a risk management supervisor at the Royal Commission Health Services Program (RCHSP) in Jubail, Saudi Arabia, discusses how a single report—no matter how minor—can challenge an assumption and shift an entire system toward safer care. Join the hub Do you have insights to share around patient safety? Are you a member of the hub? Why not join our global community today (it’s free and easy to sign up) and submit an article or share a resource? You can also contact the editorial team at [email protected]. Could you be an international Topic leader for the hub? We are looking for someone based outside of the UK, with expertise in an area of patient safety to join our team of volunteer Topic leaders. Our topic leaders are an integral part of ensuring the value of content on the hub. We want to ensure that quality content is published on the hub and that we have credible experts in specific topic areas to contribute personal blogs sharing expertise and insights advise us on the validity of posted content suggest areas to develop content in lead and respond to discussions within our communities. If you’d like to apply to become a topic please visit our Topic leader page where you’ll find a job description and application form.

NHS England has set a target that cervical cancer will be eliminated in England by 2040. Although progress has been made in detecting and treating cervical cancer, there are still many women who are reluctant to go for cervical screening, or who face barriers to accessing screening. These barriers include perceived discrimination, lack of understanding the risk of cervical cancer and unmet access needs. This contributes to persistent health inequalities amongst particular groups. Patient Safety Learning has pulled together 13 useful resources shared on the hub about how to improve access and overcome barriers to cervical screening. 1. Cervical screening, my way: Women's attitudes and solutions to improve uptake of cervical screening This research by Healthwatch explored why some women are hesitant to go for cervical screening. Based on the findings of a survey of more than 2,400 women who were hesitant about screening, it makes recommendations to policymakers on how to improve uptake, including: improvements to the way data about the disability and ethnicity of people attending screening. producing an NHS-branded trauma card for affected women to bring to appointments. ensuring staff are effectively trained on accessibility and adjustments to care. looking at the possibility of home-based self-screening. 2. Facing a smear test after my trauma In this BMJ article, Ruth Ajayi shares her experience of cervical screening after a traumatic childbirth, and how healthcare professionals could offer more compassionate, flexible care. 3. Exploring the inequalities of women with learning disabilities deciding to attend and then accessing cervical and breast cancer screening, using the Social Ecological Model Women with learning disabilities are less likely to access cervical and breast cancer screening when compared to the general population. In this study, the Social Ecological Model (SEM) was used to examine the inequalities faced by women with learning disabilities in accessing cervical and breast cancer screening in England. The study highlights key barriers to access for women with learning disabilities. 4. “We’re not taken seriously”: Describing the experiences of perceived discrimination in medical settings for Black women Black women continue to experience disparities in cervical cancer despite targeted efforts. One potential factor affecting screening and prevention is discrimination in medical settings. This US study in the Journal of Racial and Ethnic Health Disparities describes experiences of perceived discrimination in medical settings for Black women and explores the impact of this on cervical cancer screening and prevention. The authors suggest that future interventions should address the poor quality of medical encounters that Black women experience. 5. Top tips for healthcare professionals: Cervical screenings This article by the Royal College of Obstetricians & Gynaecologists and the My Body Back Project offers tips for healthcare professionals to make cervical cancer screening attendees feel as comfortable as possible during their appointments. Cervical screening can be very daunting for some women, and for those who have experienced sexual violence it can be triggering and cause emotional distress. The article provides tips on communication, making the environment calm and safe, sharing control and building trust with women. 6. Cervical screening uptake: supporting positive patient experiences is key In this blog, Steph explains why Cervical Cancer Prevention Week is an opportunity to validate and help improve patient experiences. She calls for more information to be shared with both patients and doctors that helps to increase compassion, understanding and accessibility. 7. Cervical screening for people with learning disabilities: Learning resource for sample takers This learning resource from the NHS Wessex Cancer Alliance explains the misconceptions and barriers to cervical screening, the consent and best interest decisions, and the role of the sample taker and the reasonable adjustments that can be made. 8. The Eve Appeal: What adjustments can you ask for at your cervical screening? The Eve Appeal want to raise awareness of what adaptations women and people with a cervix can ask for during their screening to make the appointment more comfortable. 9. How can reframing women’s health improve outcomes? An interview with Dr Marieke Bigg Dr Marieke Bigg is the author of a 2023 book, This won’t hurt: How medicine fails women. In this interview, Marieke discusses how societal ideas about the female body have restricted the healthcare system’s approach to women’s health and describes the impact this has had on health outcomes. She also highlights areas where the health system is reframing its approach by listening to the needs of women and describes how simple changes, such as allowing women to carry out their own cervical screening at home, can make a big difference. 10. Having a smear test. What is it about? This download A4 Easy Read booklet from Jo's Cervical Cancer Trust uses simple language and pictures to talk about smear tests. It explains what a smear test is, has tips for the person having the test and has a list of words they might hear at their appointment. 11. Health Improvement Scotland: Cervical screening standards 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. 12. Cervical cancer screening in women with physical disabilities This US study explored how the cervical cancer screening experiences of women with physical disabilities (WWPD) can be improved. Interviews with WWPD indicated that access to self-sampling options would be more comfortable for cervical cancer screening participation. The authors highlight that these findings that can inform the promotion of self-sampling devices for cervical cancer screening. 13. Cervical screening - a guide for survivors of rape, sexual assault and sexual abuse This guide by The Eve Appeal and The Survivors Trust gives information about attending cervical screening for survivors of rape, sexual abuse or assault. It offers tips that may help patients feel more comfortable about their appointment. It is part of the #CheckWithMeFirst campaign to help raise awareness of the challenges survivors of rape, sexual abuse and sexual violence may face when accessing cervical screening. Have your say Are you a healthcare professional who works in women’s health or cancer services? We would love to hear your insights and share resources you have developed. Perhaps you have an experience of cervical screening or cervical cancer that you would like to share? We would love to hear from you! Comment below (register as a hub member for free first) Get in touch with us directly to share your insights

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. In healthcare, developing a culture of psychological safety is essential to ensuring patient safety. It helps to create and maintain an environment where patient safety issues can be raised, discussed and resolved. A psychologically safe environment supports incidents of avoidable harm being responded to with empathy, respect, rigour and action for improvement. Whilst the first priority after any incident of avoidable harm will be to support patients and their families, staff directly and indirectly involved should also be provided with the support they need following an incident. Organisations should have a support structure in place to look after their staff’s mental health and wellbeing. At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples.  In this ‘Top picks’, we have pulled together resources, blogs and tools from the hub to support staff and organisations in developing a culture where everyone feels psychologically safe. 1 Paul O’Neill: A psychological safety success story We often talk about failures of psychological safety – what happens when, in an absence of psychological safety, concerns are not raised, questions remain unasked, mistakes are hidden and no one shares their improvement ideas. Unsurprisingly, the consequences can be catastrophic. But what happens when leaders prioritise psychological safety, and how can it transform their organisations? Paul O’Neill at Alcoa was one such example and highlights that cultures can change, with leadership and commitment to psychological safety and addressing the ‘work as done'. 2 Speak Up for Safety: A new workshop for healthcare staff about the importance of Just Culture The culture of a healthcare organisation can determine how safe its staff members feel to raise concerns about patient safety. Bella Knaapen, Surgical Support Governance & Risk Management Facilitator and Sarah Leeks, Senior Health & Wellbeing Practitioner at Norfolk and Norwich University Hospitals NHS Foundation Trust, have developed ‘Speak Up For Safety’, a Just Culture training workshop that aims to help staff, at all levels, understand the importance of creating an environment that encourages people to share concerns and feedback. 3 Amy Edmondson: The importance of psychological safety As a leader how can you foster a work environment where people feel safe to speak up, share new ideas and work in innovative ways? In this video from the Kings Fund, Amy Edmondson, Novartis Professor of Leadership and Management at the Harvard Business School, talks about the importance of psychological safety in health and care and what leaders can do to create it. 4 Staff Support Guide: a good practice resource following serious patient harm This guide from Patient Safety Learning and the Safer Healthcare Biosafety Network, as part of the Safety for All campaing, outlines what good practice support looks like for a staff member following a serious safety incident, and through the subsequent investigation and aftermath. 5 System-level changes are essential to improve the psychological wellbeing of NHS staff In this study, researchers reviewed literature on the causes of stress and anxiety among nurses, midwives and paramedics. They recommended that senior leaders, managers and clinicians improve working conditions and shift from individual interventions only (such as mindfulness or resilience training) to include a focus on system-level culture change. 6 Key themes emerging from our ‘Speaking up for patient safety’ interview series At the beginning of 2025 we launched our video interview series Speaking up for patient safety. The series is hosted by Peter Duffy, NHS whistleblower and Chair of the Healthcare Working Group at WhistleblowersUK, and Helen Hughes, Patient Safety Learning’s Chief Executive. In each interview we hear from someone who has raised concerns about patient safety in healthcare, often at great cost to their own career and personal life. They share their story and their reflections on what needs to be done to improve organisational cultures so that when staff raise patient safety issues, their concerns are responded to appropriately and not dismissed because they are inconvenient to address. Alongside the thread of bravery and tenacity that runs through each contributor, a number of common themes come up time and again as people share their experiences. In this blog, Helen and Peter look at some of these themes and outline their implications for people who speak up or whistleblow. 7 The whistleblower playbook 'The whistleblower playbook' infographic illustrates how some organisations respond to staff raising concerns about patient safety. 8 Royal Society of Medicine: Aware to Care resource pack Psychological safety resource pack for all staff on a wide range of topics, including improving team communication and dynamics, tools to build awareness of current state of mind and behaviour, moving from reacting to responding, building and balancing compassion between others and self. 9 Trust talk! The language of leaders who create psychologically safe teams Language is powerful. Our words are important. Few things are likely to have a more frequent or profound impact on the trust (or mistrust) levels of our teams than the words we speak on a daily basis. Our words can influence our teams to frame events in positive or negative, helpful or hindering, and trusting or fearful ways. Psychologist Clive Lloyd looks at how the language we use can create psychologically safe teams. 10 Vicarious trauma: The invisible epidemic In healthcare, an insidious epidemic lurks beneath the surface, affecting the very individuals tasked with providing care: vicarious trauma by empathy. Despite its profound impact, this phenomenon remains largely unrecognised and under-discussed within the sector. As leaders, it is imperative that we shed light on this invisible trauma and acknowledge it as one of the greatest challenges facing our industry, as Margarida Pacheco explains in her blog. 11 How can our team move past a traumatic event? After an extreme traumatic event there are things that you can do to help yourself, and your colleagues, to move on. Fiona Day, medical and public health leadership coach and chartered coaching psychologist, Stacey Killick, consultant paediatrician at Glan Clwyd Hospital, and Lucy Easthope, professor in practice at Durham University’s Institute of Hazard, Risk, and Resilience and adviser on disaster recovery give their tips in this BMJ article. 12 Strategies for improving clinician psychological safety in reporting and discussing diagnostic error One of the best ways to collect information about diagnostic errors is through self-reporting by patients and healthcare professionals. This issue brief from the Agency for Healthcare Research and Quality looks at how to foster psychological safety and organisational safety culture in order to reduce harm from diagnostic error. 13 Safety Incident Supporting Our Staff (SISOS): A second victim support initiative at Chase Farm Hospital Suicide rates for doctors, nurses and allied healthcare workers are rising and being involved in a safety incident increases this risk. The need to support staff when things go wrong is evident. We come to work to do the very best we can for our patients, often ignoring and at the cost of our own health. Most adverse incidents happen, not because we are bad at what we do, but because of system failure. As professionals who care passionately about our work, we blame ourselves when things go wrong. In a series of blogs. Carol Menashy shares her experiences of setting up and developing Safety Incident Supporting Our Staff (SISOS). 14 Pyschological safety videos This channel is dedicated to useful, entertaining and informative content about psychological safety, human organisational performance, and organisational learning. 15 What can the NHS do to help staff speak up about concerns? How do you ensure staff’s concerns are voiced and heard in a complex system like the NHS? A recent decline in doctor’s confidence to raise concerns about patient safety has led to renewed calls for stronger regulation of managers – but a broader approach is likely to be vital to encouraging staff to speak up writes Professor Graham Martin, Director of Research at THIS. 16 Balancing care: The psychological impact of ensuring patient safety In this blog, Leah Bowden, a patient safety specialist, reflects on the impact her job has on her mental health and family life. She discusses why there needs to be specialised clinical supervision for staff involved in reviewing patient safety incidents and how organisations need to come together to identify ways we can support our patient safety teams. 17 “The alarming rate of suicide among healthcare workers should be a wake-up call in the urgent need to support them” Frontline19 was established at the start of the Covid pandemic as an urgent response to support frontline workers who were under extreme pressure and experiencing significant mental health challenges. In this blog, psychotherapist Claire Goodwin-Fee, founder and CEO of Frontline19, explains how systemic pressures and stigma around mental health are continuing to leave healthcare staff extremely vulnerable. 18 How fostering empathy and psychological safety makes healthcare safer: An interview with Carolyn Cleveland Carolyn Cleveland has delivered training on empathy and compassion to healthcare organisations for many years. In this interview, she describes how she came to develop her training approach and outlines how creating a psychologically space environment for individuals to engage with the practice of empathy contributes to safer organisational cultures. 19 How to foster psychological safety: Behaviours Psychological safety is a belief that the group is safe for interpersonal risk taking. There are many ways we can help to foster these environments, but it’s important to remember that we must walk the walk as well as talk the talk! In this article in Psych Safety, Tom Geraghty looks comprehensively at behaviours that build psychological safety and enhance group performance, inclusion, resilience and happiness. 20 What people get wrong about psychological safety Amy C. Edmondson and Michaela J. Kerrissey describe six misconceptions about psychological safety, explaining why each gets in the way and how to counter it, and then offer a blueprint for building the kind of strong, learning-oriented work environment that is crucial for success in an uncertain world. 21 Beyond “being nice”: What does an effective team really look like? This article looks at what effective teams actually look like, not just how they feel. It explores why a little tension, when handled well, isn’t a sign of dysfunction but a sign of health. It breaks down how leaders can move from nice-but-ineffective to respectful-and-productive, where debate is welcome, and performance improves because of it. 22 Top 10 ways to foster psychological safety in the workplace Tom Geraghty shares ten approaches that he's found most effective in fostering psychological safety and enabling people to speak up (and backed up by empirical evidence). 23 When psychological safety fails, patient safety follows The NHS has served millions of people over decades. It stands as a symbol of collective care, public service and professional commitment. That history matters. It deserves respect. But patient safety does not rest on history alone. It rests on people. And people need safe systems to do safe work. Today, those systems are under strain in ways that should concern us all. This piece is not about blame. It is about learning, and about starting a conversation that is long overdue. 24 Power and the sound of silence—A blog by Roger Kline In a review shared on the hub, Roger Kline, Research Fellow at Middlesex University Business School, explored the literature on patient safety and speaking up, arguing that staff being able to raise concerns safely and effectively is essential for patient safety, but the NHS continues to struggle with creating a culture where this happens reliably. In this blog, Roger reflects on some of the findings of his review. Do you have a resource or an example of how your organisation supports staff psychological safety to share? We’d love to hear about it – leave a comment below or join the hub to share your own post.

At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. Since launching in 2019, the hub now has over 19,000 resources, 8000 members from 98 countries, and we have had over 1.7million visits and over 3 million page views. In this blog, the hub's Editor, Samantha Warne, reflects on our most popular pieces of original content published on the hub in 2025. These are a mix of our original blogs, interviews and resources shared by patients, frontline staff and leaders in patient safety. It shows the breadth of content we have on the hub, including collaborations we have with other organisations and people, patient stories, the challenges healthcare staff face and insights from an international perspective. Keep an eye out for more end of year content from our team at Patient Safety Learning, including a policy roundup. 1 Speaking up for patient safety: A new interview series about raising concerns and whistleblowing At the beginning of 2025, we launched our video interview series Speaking up for patient safety. The series is hosted by Peter Duffy, NHS whistleblower and Chair of the Healthcare Working Group at WhistleblowersUK, and Helen Hughes, Patient Safety Learning’s Chief Executive. In each interview we hear from someone who has raised concerns about patient safety in healthcare, often at great cost to their own career and personal life, or from those who work to help staff raise concerns through their own experience and advice. Alongside the thread of bravery and tenacity that runs through each contributor, a number of common themes come up time and again as people share their experiences. One thing that we often hear is the common tactics that some organisations use when dealing with people who speak up or blow the whistle. To highlight these tactics we created 'The whistleblower playbook' infographic, illustrating how some organisations respond to staff raising concerns about patient safety. 2 Patient Safety Learning: World Patient Safety Day 2025 The theme of this year’s World Patient Safety Day was ‘Safe care for every newborn and every child’. In a blog to mark the day, Patient Safety Learning reflected on this theme, highlighting the World Health Organization goals for this event and shared a series of guest blogs from healthcare professionals, patient campaigners, organisation leaders and safety experts on the hub, each exploring a different aspect of the theme. 3 Duty of Candour: Frequently Asked Questions Through the joint efforts of the Patient Safety Management Network in collaboration with experts from the Care Quality Commission (CQC) and NHS Resolution, these FAQs were produced to address the most pressing concerns about Duty of Candour. The collaborative approach ensured that the FAQ tool reflects the insights and expertise of those actively engaged in the regulation, implementation and oversight of candour practices. This is an example of the ‘how to’ resources that Patient Safety Learning, the networks and partners are developing to guide the implementation of good practice in patient safety. 4 Working in a toxic culture: Doing the right thing is often the least popular and hardest thing to do… In this blog, Clare Wade, Patient Safety Learning's Director, draws attention to the impact toxic cultures have on staff and how, sadly, most often nothing is done about it. Clare shares her own personal reflections from past experiences in her career. There is a clear link between toxic cultures and patient safety, and while there are no easy answers these behaviours must be acknowledged, challenged and cured if the NHS is to survive. 5 Top 10 priorities for patient safety in surgery Patient Safety Learning asked the Patient Safety Group (PSG) of the Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top tips for patient safety in surgery to share on the hub. They came up with three useful resources for surgeons and surgical trainees: Top 10 priorities for patient safety in surgery Top 10 tips for surgical safety: Think Safety, think SEIPS Top 10 patient safety tips for surgical trainees These resources are an example of the effectiveness of collaborating with partners such as the RCSEd to develop resources that will help practitioners better understand patient safety and how they can access resources to help reduce avoidable harm. 6 What do Patient Safety Incident Response Plans tell us about how the NHS is approaching safety investigations? From Autumn 2023, NHS organisations in England began to change the way they investigated cases of avoidable patient harm and near misses, introducing the Patient Safety Incident Response Framework (PSIRF). As part of PSIRF, organisations are required to create and publish a Patient Safety Incident Response Plan. Drawing from a sample of 13 Patient Safety Incident Response Plans, Patient Safety Learning considers what they can tell us about the implementation of PSIRF. This is intended to support organisations who are currently reviewing their PSIRPs to ensure that their prioritisation of investigations and reviews meets national guidance and provides an evidence based rationale to inform patients, families and staff. 7 Post-SSRI Sexual Dysfunction: After 30 years, why is the health system still failing to recognise this life-limiting adverse effect? Post-SSRI Sexual Dysfunction (PSSD) is a long-term adverse effect of Selective Serotonin Reuptake Inhibitors (SSRIs), a type of antidepressant medication. In this opinion piece, Harriet Vogt, Patient Safety Partner at NHS Sussex Integrated Care Board, outlines the need for recognition and research into PSSD to allow patients to make truly informed choices when considering SSRIs. She argues that while the health system is beginning to recognise the value of placing patients at the heart of efforts to improve safety, this focus on listening is rarely given to individual patients who express concern about the impact of their medication or treatment. 8 SEIPS in action In this blog, Patient Safety Learning’s Associate Director Claire Cox shares a video with associated training resources developed for the Patient Safety Management Network Symposium. Claire explains how they used it to facilitate an interactive workshop, bringing SEIPS (Systems Engineering Initiative for Patient Safety) to life. It's now available as a resource for you to use in your own organisation. It is simple to set up, highly engaging, and encourages teams to think beyond individuals and see the wider system in action. 9 Balancing care: The psychological impact of ensuring patient safety In this blog, Leah Bowden, a patient safety specialist working in an ambulance service, reflects on the impact her job has on her mental health and family life. She discusses why there needs to be specialised clinical supervision for staff involved in reviewing patient safety incidents and how organisations need to come together to identify ways we can support our patient safety teams. 10 Exploring the barriers that impact access to NHS care for people with ME and Long Covid For healthcare to be safe it needs to be accessible. But what does this look like for people with ME (myalgic encephalomyelitis) and Long Covid? This blog from #ThereForME explores the barriers that impact access to NHS care for people with ME and Long Covid. 11 Bridging the gap between policy and practice: A Safety-II approach to patient transfers In this anonymous blog, a patient safety lead shares how they implemented a Safety-II approach to patient transfers, highlighting the disconnect between 'work as imagined' and 'work as done', and the importance of listening to frontline voices. The author worked with subject matter experts to develop a visual, easy-to-use risk stratification tool designed to support decision making on the appropriate level of clinical escort required for safe transfer. While the tool is applicable to most adult acute settings, certain areas—such as maternity, paediatrics, and specialist theatres—require their own local adaptations. This could have wider applicability to a range of different clinical settings. 12 Evidencing the impact of culture on patient safety – a new tool from MNSI In this interview, Chris McQuitty, a clinical fellow at the Maternity and Newborn Safety Investigation (MNSI) programme, talks us through a new patient safety tool. COMPASS (Culture of Organisations and its iMpact on PAtientS’ Safety) is currently being piloted to help understand the impact organisational culture may have on patient safety in maternity settings. 13 Improving safety in healthcare—is quality improvement the answer? 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. Claire reflects on the need for a safety management systems approach, as highlighted in Healthcare Safety Investigation Branch (HSSIB) reports, essential to embedding a proactive, system-wide perspective on patient safety. 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. 14 Preventing patient falls in healthcare settings: The need for fall risk assessment Patient falls are a significant concern in healthcare settings, often leading to severe injuries, prolonged hospital stays and increased healthcare costs. This blog from Augustine Kumah, Deputy Quality Manager at The Bank Hospital, Accra, Ghana, explores the significance of fall risk assessment, its implementation and its role in reducing fall-related incidents in healthcare settings. 15 Patient barcode scanning in NHS hospitals: safety, snags and workarounds. A nurse’s perspective As a nurse working in the NHS for over 25 years, Claire Cox has seen first-hand how technology has transformed patient care. One of the biggest changes in recent years has been the introduction of electronic scanning. In this blog, Claire talks about the opportunities to improve patient safety and the risks associated with the use of barcode technology in healthcare. 16 Corridor care and patient safety Corridor care can broadly be defined as care being provided to patients in corridors, non-clinical areas or unsuitable clinical areas because of a lack of hospital bed capacity. It is increasingly being used in the NHS as demand for emergency care grows and hospital departments struggle with patient numbers. In a series of blogs for the hub, we shine a light on some of the key patient safety issues surrounding corridor care. Share your experiences on the hub I would like to take this opportunity to thank everyone who has contributed to the hub this year. the hub is a platform for everyone with a professional or personal interest in patient safety to share and learn from one another. Have you implemented a new initiative in your organisation? Have you improved patient safety where you work? Or are you a patient and would like to share your experience to improve patient safety? We would love to hear from you and share on the hub your stories. This can be done anonymously if you prefer. If you are a member, you can share directly on the hub or please contact [email protected] to discuss further. See all our 'Top picks' Our ‘Top picks’ are collections of resources, blogs and tools around a specific topic or theme. You can view them all here: Top picks.

Pressure ulcers, or bed sores as they are often called, can affect people of all ages. They can lead to serious complications and immense pain for patients, so prevention and awareness is key. Patients with mobility difficulties, conditions affecting blood flow (such as Type 2 Diabetes), and those over 70 are particularly vulnerable.  Stop Pressure Ulcer Day is organised annually by the European Pressure Ulcer Advisory Panel and aims to bring knowledge to a wider audience to reduce the harm caused by pressure ulcers.  In support of the campaign, we're shining a spotlight on a selection of fantastic resources that have been shared with us via our patient safety platform - the hub.  Click on the headings below to read more about each resource. 1. Conducting a systems review of pressure ulcers in the intensive care unit Pressure ulcers within the intensive care unit have long been recognised as a persistent and complex patient safety issue. In this blog, Patient Safety Learning's Associate Director Claire Cox shares how she adopted a systems approach using the Systems Engineering Initiative for Patient Safety (SEIPS) model to review pressure ulcers. 2. Implementing the aSSKINg pressure ulcer care bundle – a blog by Susan Martin In this blog, Susan Martin, a Tissue Viability Specialist Nurse at East Sussex, describes how she implemented the aSSKINg model (assess risk; skin assessment and skin care; surface; keep moving; incontinence and moisture; nutrition and hydration; and giving information or getting help) for pressure ulcer prevention into her Trust. 3. Skin Assessment: Assessing skin on patients with darker skin tones in relation to PU prevention In this 56 minute presentation by The Society of Tissue Viability, Jacqui Fletcher looks at how wound care and pressure ulcer prevention can be improved for patients with darker skin tones. 4. PURPOSE-T (Pressure Ulcer Risk Primary or Secondary Evaluation Tool) PURPOSE-T (Pressure Ulcer Risk Primary or Secondary Evaluation Tool) is an evidence-based pressure ulcer risk assessment instrument that was developed by the University of Leeds using robust research methods. PURPOSE-T identifies adults at risk of developing a pressure ulcer and supports nurse decision‐making to reduce that risk (primary prevention), but also identifies those with existing and previous pressure ulcers requiring secondary prevention and treatment. It uses colour to indicate the most important risk factors and forms a three‐step assessment process. 5. PSIRF planning – Pressure ulcer example scenario The Patient safety incident response framework (PSIRF) represents a new approach to responding to incidents. Under PSIRF, those leading the patient safety agenda within provider organisations, together with internal and external stakeholders (including patient safety partners, commissioners, NHS England, regulators, Local Healthwatch, coroners etc), decide how to respond to patient safety incidents based on the need to generate insight to inform safety improvement where it matters most. Key issues must first be identified and described as part of planning activities before an organisation agrees how it intends to respond to maximise learning and improvement. This guidance has been developed collaboratively between Stop the Pressure Programme, National Wound Care Strategy leads and members of the Patient Safety Team, with the support from the Patient Safety Incident Response Framework (PSIRF) Implementation and Working Groups. 6. Embedding skin tone diversity into undergraduate nurse education: Through the lens of pressure injury This study, published by the Journal of Clinical Nursing, explores health disparity in on-campus undergraduate nurse education through the analysis of teaching and teaching material exploring pressure injuries. 7. Measuring standards of care, not negative outcomes (Interview with Head of Nursing Quality) In this interview, Head of Nursing Quality Gavin Porter talks about his positive, team-focused approach to improving pressure ulcer outcomes. "Counting the number of pressure ulcers doesn’t really tell you about the standards of pressure ulcer care. I wanted to look at things differently; to focus more on the interventions and good practice that helps keep patients safe." 8. Sign up to safety - pressure ulcers (Barts Health NHS Trust) In this six minute video, Barts Health NHS Trust explains the measures frontline medical staff can take to help avoid the risk of pressure ulcers using the SSKIN acronym. 9. This Is Nursing podcast: We don't want a good wound. We want to prevent them! Alison Schofield, Tissue Viability Clinical Nurse Specialist, discusses the challenges facing her role in this current world of nursing, the impact of COVID-19 has had on the delivery of community tissue viability services and on people in receipt of the services in care homes and in their own homes. 10. Incidence of hospital-acquired pressure injuries and predictors of severity in a paediatric hospital Hospital-acquired pressure injuries (HAPIs) pose significant challenges in healthcare and cause increased patient suffering, longer hospital stays and higher healthcare costs. Children in hospital face unique risks, but evidence about this remains scarce. This study in the Journal of Advanced Nursing aimed to identify and describe HAPI admission incidence and severity predictors in a large Australian children's hospital. The authors found that HAPI injuries in paediatric patients are unacceptably high. They argue that prevention should be prioritised and the quality of care improved globally. They also call for further research to develop targeted prevention strategies for these vulnerable populations. 11. Reducing hospital-acquired pressure injuries in a cardiothoracic intensive care unit Hospital-acquired pressure injuries are a significant patient safety concern. The US Centers for Medicare & Medicaid Services tracks hospital-acquired pressure injuries as a patient safety indicator. Healthcare organisations with higher-than-expected rates may incur penalties. The aim of this study was to reduce the prevalence and incidence of hospital-acquired pressure injuries in the cardiothoracic intensive care unit. 12. Safeguarding adults protocol: pressure ulcers and raising a safeguarding concern Pressure ulcers are a significant challenge for the patients who develop them and the healthcare professionals involved in their prevention and management. They can result in serious complications and avoidable harm, with patients with mobility difficulties at particularly risk from this. This guidance from the Department of Health and Social Care is designed to help practitioners and managers across health and care organisations to provide caring and quick responses to people at risk of developing pressure ulcers. For more resources, see our dedicated Pressure ulcer section of the hub. Do you have a resource or story to share on pressure ulcer care or prevention? the hub is designed for frontline staff, patients, managers, and anyone else else with an interest in patient safety, to come together and share their insights. You can sign up today for free for full access to our library of resources and all of the benefits on offer to our members.

At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That’s why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples. To mark World Antimicrobial Awareness Week, which takes place every year in November, we’ve selected 18 resources related to antimicrobial resistance. Shared with us by hub members and patient safety advocates, they provide valuable insights and practical guidance about AMR. 1 Global antibiotic resistance surveillance report 2025 Antimicrobial resistance (AMR) is a growing threat to global health, undermining the effectiveness of life-saving treatments and placing populations at heightened risk, whether from common infections or routine medical interventions. This new World Health Organization (WHO) report presents a global analysis of antibiotic resistance prevalence and trends, drawing on more than 23 million bacteriologically confirmed cases of bloodstream infections, urinary tract infections, gastrointestinal infections, and urogenital gonorrhoea. 2 Short-term intermittent IV antibiotics – Understanding the issue of under delivery In this blog, Claire Davies, Clinical Therapy Manager at B. Braun Medical Ltd., explores the issue of under delivery and provides essential insights for clinicians to optimise their antibiotic therapy. 3 Tackling antibiotic underdosing: Interview with Ruth Dando, Head of Nursing for Theatres, Critical Care and Anaesthetics at BHRUHT In this video interview, Ruth Dando, Head of Nursing, Theatres, Critical Care and Anaesthetics at Barking, Havering and Redbridge University Hospitals Trust (BHRUHT) explains why antibiotic underdosing is a risk to patient safety and describes how she has implemented a change in practice to tackle the issue across BHRUHT. 4 Tackling antimicrobial resistance: How to keep antibiotics working for the next century The first WISH report on antimicrobial resistance, 'Antimicrobial Resistance: In search of a collaborative solution', was published in 2013. This report takes stock of what has emerged from the United Nations (UN) General Assembly High-Level Meeting on tackling AMR and makes six recommendations. 5 Silent Pandemic – The global fight against antimicrobial resistance (film) The film Silent Pandemic shows how countries, scientists and private initiatives around the world are networking and forming alliances, and what strategies and measures they are using to counter the advance of antibiotic resistance. 6 Why won’t my doctor give me antibiotics? Ron Daniels explains Ron Daniels, a Consultant in Critical Care, Vice President of the Global Sepsis Alliance and Chief Medical Officer of the United Kingdom Sepsis Trust, explains why doctors have to carefully manage the use of antibiotics in order to protect patients, now and in the future. 7 My involvement with Commonwealth Partnerships for Antimicrobial Stewardship Scheme (CwPAMS) in Zambia In this blog, Fiona Rees, who worked in the NHS as a hospital pharmacist for 13 years, shares her experience of working with colleagues in Zambia to improve the use of antimicrobials by using the expertise of pharmacists to help tackle AMR. 8 Reform - Powering the UK's approach to AMR: the future of AMR policy This report draws on the expert input of a roundtable held by public service think tank Reform in October 2022, to assess progress made against proposals published by Reform in 2020. It recommends actions for NHS England, the Department of Health and Social Care (DHSC) and public health departments to address the threat of AMR. 9 Antimicrobial resistance survivors: calling the world to action This Lancet article was written by a group of AMR survivors and their caregivers in order to share individual stories and perspectives on the impact of AMR. The authors highlight challenges in raising the profile of AMR, including insufficient funding, research, motivation and knowledge. They also call for meaningful patient engagement in the AMR agenda. 10 WHO: How vaccines can help prevent antibiotic resistance – Zimbabwe’s response to drug resistant outbreaks of typhoid and cholera This case study focuses on large outbreaks of antibiotic resistant strains of both cholera and typhoid in Zimbabwe and the steps taken to tackle them. It looks at a mass typhoid Vi-conjugate vaccine (TCV) vaccination campaign from February to March 2019 in nine suburbs of Harare that were severely affected by the outbreaks. 11 British Society for Antimicrobial Chemotherapy: Antimicrobial stewardship: From principles to practice This e-book provides an extensive overview of the day-to-day challenges posed by AMR, tools for setting up stewardship programmes and guidance on how to make the most of existing programmes. Its resources apply the principles of antimicrobial stewardship to a wide range of professions, populations and clinical/care settings. 12 How antibiotic underdosing affected my mum’s end of life care: An interview with Ashleigh Hughes In this interview, senior sister Ashleigh Hughes shares her personal story about the impact of antibiotic underdosing on her Mum’s end of life care. Antibiotic underdosing is a medication safety issue that has profound implications for the health service as well as individual patients, but there is currently a lack of understanding and recognition of the issue. 13 Strengthening primary health care-oriented health systems to address antimicrobial resistance: policy brief WHO policy brief on antimicrobial resistance with an emphasis on primary care. It is noted that ‘Most patient interactions occur in primary care and in the community, where an estimated 80–90% of antibiotics are prescribed. Effective primary care plays a vital role in improving the management of infectious diseases and in reducing overuse and inappropriate use of antibiotics, thus slowing the emergence of antimicrobial resistance (AMR) and ensuring the continued effectiveness of antimicrobials.’ 14 Reducing hospitalizations and multidrug-resistant organisms via regional decolonisation in hospitals and nursing homes Infections due to multidrug-resistant organisms (MDROs) are associated with increased morbidity, mortality, length of hospitalisation, and health care costs. Regional interventions may be advantageous in mitigating MDROs and associated infections. This study evaluated whether implementation of a decolonisation collaborative is associated with reduced regional MDRO prevalence, incident clinical cultures, infection-related hospitalisations, costs, and deaths. 15 What factors in the workplace enable success in antimicrobial stewardship in paediatric intensive care? Efforts to mitigate AMR prioritise antimicrobial stewardship (AMS) interventions. These interventions typically focus on deficiencies in practice and providing negative or normative feedback. This approach may miss opportunities to learn from success. In this study, the authors aimed to identify factors that enable success in AMS practices in the paediatric intensive care unit (PICU) by analysing the data obtained from interviews with staff members who had achieved success in AMS. 16 WHO: The case for investment and action in infection prevention and control 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. This WHO 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. 17 NHS England: Digital vision for antimicrobial stewardship in England Effectively tackling the challenge of AMR requires a co-ordinated and strategic approach across healthcare settings. Antimicrobial stewardship is an important element of this work. This publication outlines the functionalities that clinical digital systems need to support optimal antimicrobial stewardship in primary and secondary care. 18 Putting patients at the centre of antimicrobial stewardship in Uganda: Why meaningful patient engagement is essential to beating antimicrobial resistance Although antimicrobial stewardship (AMS) has traditionally focused on prescribers, laboratories and health facilities, evidence from Uganda demonstrates a critical reality: a large proportion of antibiotic use occurs at community and household level. Without engaging patients and communities as partners, stewardship efforts remain incomplete and unsustainable. Annet Naguudi, Regina Kamoga and Joshua Wamboga from the Uganda Alliance of Patients’ Organizations (UAPO) argue that strengthening AMS in Uganda requires placing patients at the centre of the response and highlights the strategic positioning of the UAPO to lead this shift in line with national and global priorities. #Share4safety Are you a healthcare professional looking to share your frontline insights to help improve patient safety? Have you developed a resource or tool locally that others could benefit from? Or perhaps you have an experience to share around antimicrobial resistance? Get in touch with us by emailing [email protected] Join our global patient safety community the hub is an award winning platform, bringing together people from around the world who are passionate about patient safety and reducing unsafe care. It's free and easy to join so why not sign up today and join a growing community helping to drive safer care.

Unsafe medication practices and medication-related harm are one of the leading causes of avoidable harm in health and care. This year’s #MedSafetyWeek focuses on the theme “we can all help make medicines safer”. We have collated patient interviews and blogs shared on the hub that raise awareness of medication adverse reactions, and resources on how you can report a problem. 1 MHRA: The Yellow Card Scheme The Yellow Card Scheme helps the Medicines and Healthcare products Regulatory Agency (MHRA) monitor the safety of all healthcare products in the UK to ensure they are acceptably safe for patients and those who use them. On the Yellow Card Scheme website you can report a suspected incident or problem. 2 The question that will save lives: Interview with Katinka Blackford Newman, founder of Antidepressant Risks Antidepressant medications are taken by millions of people globally. A small percentage of people who take them will experience rare but dangerous adverse reactions. In this interview, Katinka Blackford Newman tells us about her personal experience of antidepressant-induced psychosis and how this led her to campaign for increased awareness about side effects. She highlights a widespread lack of education and awareness about the risks associated with antidepressants and outlines why she is asking suicide prevention charities to ask callers one simple question about their medication. 3 Patient Safety Spotlight interview with Marie Lyon, chair of the Association for Children Damaged by Hormone Pregnancy Tests In this interview, Marie Lyon talks about her campaign for justice for families affected by hormone pregnancy tests, why she is passionate about reforming medicines regulation and the important role patient campaigners play in improving patient safety. 4 USA: FDA Adverse Event Reporting System (FAERS) public dashboard FAERS is the U.S. Food and Drug Administration (FDA) primary database for collecting and analysing adverse event reports, serious medication errors, and product quality complaints for prescription drugs and therapeutic biologics, containing reports submitted by healthcare professionals, consumers, and manufacturers. 5 Recognising adverse events and using the yellow card system Despite the role of the MHRA’s Yellow Card reporting system in pharmacovigilance in the UK, understanding and uptake of the scheme remains limited. East London NHS Foundation Trust share how they designed a survey to explore healthcare professionals’ awareness, usage and perceptions of the Yellow Card Scheme for reporting adverse drug reactions. 6 Post-SSRI Sexual Dysfunction: After 30 years, why is the health system still failing to recognise this life-limiting adverse effect? Post-SSRI Sexual Dysfunction (PSSD) is a long-term adverse effect of Selective Serotonin Reuptake Inhibitors (SSRIs), a type of antidepressant medication. In this opinion piece, Harriet Vogt, Patient Safety Partner at NHS Sussex Integrated Care Board, outlines the need for recognition and research into PSSD to allow patients to make truly informed choices when considering SSRIs. She looks at the impact PSSD has on the sexual and emotional lives of thousands of people and highlights a new research study analysing the obstacles to quantifying its incidence and prevalence. Harriet argues that while the health system is beginning to recognise the value of placing patients at the heart of efforts to improve safety, this focus on listening is rarely given to individual patients who express concern about the impact of their medication or treatment. 7 MHRA: Reporting a possible side effect to a medicine – a guide for Children and Young People The MHRA has produced a guide to download and share to help children and young people learn why it's important to report possible side effects of medication. 8 Sodium Valproate: The Fetal Valproate Syndrome Tragedy In this article, Sharon Hartles, member of the Open University’s Harm and Evidence Research Collaborative, reflects upon the use of Sodium Valporate, marketed as Epilim, to treat patients at risk of epilepsy and the subsequent harms in fetal development and birth defects that arose from its use. ‘ 9 Interview with Charlet Crichton, founder of UKCVFamily UKCVFamily was set up in November 2021 to support patients in the UK who have had an adverse reaction to a Covid-19 vaccination. The group provides help and advocacy as well as raising awareness amongst healthcare professionals, the media and the Government. In this video, founder of UKCVFamily Charlet Crichton talks to us about the side effects she experienced after having the AstraZeneca Covid vaccine. She outlines why she established the group and describes the support it offers to patients. She outlines some of the issues people face when trying to access diagnosis and treatment, and discusses the limitations of the MHRA's Yellow Card scheme in collecting data about adverse reactions. She also describes how healthcare professionals can support people with adverse reactions by taking their concerns seriously and investigating symptoms thoroughly. Share your stories Have you had an adverse reaction to medication? What do you think of the Yellow Card reporting system? Share your thoughts and experiences with us on the hub. You can comment below (you will need to be signed in first; sign up is free and easy) or email us at [email protected].

At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. Since launching in 2019, the hub now has over 19,000 knowledge resources, 6900 member from 95 countries and over 1 million unique users. In this blog, the hub's Editor, Samantha Warne, reflects on the top 10 most popular pieces of content on the hub in 2024. It showcases the breadth of original content shared on the hub from patients, frontline staff and leaders in patient safety. 1 Covid-19 : A risk assessment too far? A blog by David Osborn In a series of blogs for the hub, David Osborn, a health and safety practitioner has explored the way Government departments have handled healthcare worker safety during the Covid-19 pandemic. In this blog from September, David reflects on the misuse and abuse of ’risk assessment’, the very cornerstone of workplace health and safety. David explains how this left hundreds of thousands of healthcare workers at risk of catching Covid-19 as they provided close-quarter care to infectious patients. As the narrative unfolds, David introduces new information evidenced by emails and other correspondence obtained through Freedom of Information (FOI) requests. 2 A simple guide to the Patient Safety Incident Response Framework (PSIRF) NHS organisations in England are changing the way they investigate patient safety incidents with the introduction of the Patient Safety Incident Response Framework (PSIRF). NHS England has produced detailed resources for patient safety leaders and policy makers about the purpose of PSIRF and what organisations are expected to do to deliver this part of the NHS Patient Safety Strategy. Our discussions with frontline clinicians, patient safety managers, educators and Patient Safety Partners have highlighted the need for a simple guide that helps communicate PSIRF to a wide range of stakeholders, including those who do not work in healthcare. This guide provides information about what PSIRF is and why it’s been introduced. 3 Patient Safety Incident Response Plan (PSIRP) finder As part of PSIRF, every NHS trust is required to create and publish a Patient Safety Incident Response Plan (PSIRP). Patient Safety Learning is compiling PSIRPs from all NHS trusts in England in our PSIRP finder. Making these documents accessible in one central place will make them easy to find, allow trusts to compare ways of working and highlight variation in how trusts are approaching PSIRF implementation. We will continue to add links to plans as they become available. 4 Application of SEIPS and AcciMap to a patient safety incident At the first Patient Safety Education Network meeting of the year, Chris Elston, a patient safety education lead, shared with the group a patient safety incident that happened at this trust. In this blog he describes how he used Safety Engineering Initiative for Patient Safety (SEIPS) and Accident Mapping (AcciMap) to learn from it. 5 Electronic patient record systems: Putting patient safety at the heart of implementation Electronic patient record (EPR) systems have the potential to improve patient treatment, increase efficiency and reduce the costs of healthcare. However, it has become increasingly evident that introducing EPR systems comes with serious patient safety risks. In the report 'Electronic patient record systems: Putting patient safety at the heart of implementation', Patient Safety Learning looks at this in depth. Drawing on a recent roundtable event, it considers how patient safety can, and must, be put firmly at the heart of the design, development and rollout of EPR systems. This blog gives a summary of the report and the 10 principles it sets out for safe EPR system implementations. 6 My experience of an outpatient hysteroscopy procedure Studies indicate that some women do not find hysteroscopy procedures painful. However, it is now widely recognised that many women experience severely painful and traumatic hysteroscopies. At Patient Safety Learning, we have worked with patients, campaigners, clinicians and researchers to understand the barriers to safe care and call for improvements. We believe that no woman should have to endure extreme pain or trauma when accessing essential healthcare. We invited women to share their hysteroscopy experiences with us, and this blog is one of many stories shared on the hub. We’d like to thank all the patients for to sharing their experiences to help raise awareness of the patient safety issues surrounding outpatient hysteroscopy care. 7 Patient Safety: Emerging Applications of Safety Science There are few resources and books for professionals within the patient safety sector that use case studies to model the practical application of theories of patient safety incident investigation. Exploring these theories, this book, published earlier this year, brings together contributors from a variety of academic and healthcare professions, alongside those with lived experience, to help you understand some of the emerging theories of safety science and their practical application. 8 A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift Corridor nursing has featured heavily in the media this year as it is increasingly being used in the NHS as demand for emergency care grows and A&E departments struggle with patient numbers. In this anonymous account, a nurse shares their experience of corridor nursing, highlighting that corridor settings lack essential infrastructure and pose many safety risks for patients. They also outline the practical difficulties providing corridor care causes for staff, as well as the potential for moral injury. Using the System Engineering Initiative for Patient Safety (SEIPS) framework, they describe the work system, the processes and how that influences the outcomes. 9 The hospital told me to GO HOME, but my daughter was critically sick. A bereaved mother’s 11 patient safety lessons It was a beautiful sunny summer’s day. Twenty-five year old Gaia Young had been out for a gentle bike ride to do some shopping, came home and had an ice cream in the garden in north London that afternoon. Just hours later she was dead. Gaia, the only daughter of Dorit Young, died of an unexplained brain condition after an emergency admission to a London teaching hospital on a Saturday night in July 2021. This is Dorit's story, as a bereaved mother, about lessons she has learnt following the unexpected death of her previously well daughter Gaia. Dorit has written 11 patient safety lessons in the hope this helps other families be more assertive if they have a critically sick relative in hospital. 10 World Patient Safety Day 2024 The theme of this year's World Patient Safety Day was 'Improving diagnosis for patient safety'. In this blog for World Patient Safety Day, Patient Safety Learning sets out the scale of avoidable harm in health and care and highlights the need for a transformation in our approach to patient safety. We reflect on the theme of this year’s event and our World Patient Safety Day blogs shared on the hub, drawing out some key areas, including rapid and timely diagnosis; improving investigations into diagnostic error and the importance of listening to patients. Share your experiences on the hub the hub is a platform for everyone with a professional or personal interest in patient safety to share and learn from one another. Have you implemented a new initiative in your organisation? Have you improved patient safety where you work? Or are you a patient and would like to share your experience to improve patient safety? We would love to hear from you and share on the hub your stories. This can be done anonymously if you prefer. If you are a member, you can share directly on the hub or please contact [email protected] to discuss further.

In this 'Top picks', we've selected a number of key blogs from the hub relating to diagnostic safety. These have been shared with us by patients, healthcare professionals, researchers, third sector organisations and more. The insights captured help show the complexity of diagnostic safety and offer up ways to make improvements to prevent diagnostic delay or error.  Clink on the titles to access the blogs in full. 1. Using barcode scanning technology to improve blood group testing in unborn babies The NHS Blood and Transfusion (NHSBT) and the Scan4Safety Team in the NHS England National Patient Safety Team explore how barcode scanning technology has improved testing for the D blood group in unborn babies. 2. Pancreatic Cancer: striving for early, fast and accurate diagnosis Alfie Bailey-Bearfield from Pancreatic Cancer UK, explains the challenges associated with diagnosing pancreatic cancer, why fast and accurate diagnosis is so important, and why increased funding is vital to improving outcomes for patients. 3. Catching cancer early: what more can we do as GPs? In this blog, GP, Amelia Randle sets out a number of ways clinicians can develop their daily practice to improve cancer diagnosis at an early stage. 4. Diagnostic errors and delays: why quality investigations are key Dan Cohen, international consultant in patient safety and clinical risk management, looks at the challenges around diagnostic error and delay, compounded by human factors, cognitive bias and the Covid-19 pandemic. Ending with a case study, he illustrates how high-quality investigations, that delve deeply into human factors and focus less on blame, are key to reducing harm. 5. Diagnostic safety: accessibility and adaptations– a (un)reasonable adjustment? Pavi Brar from National Voices, explains why accessibility needs and adaptations must be taken into account and addressed to enable everyone to access diagnostic services. 6. How early diagnosis saves lives: case study on aortic dissection The Aortic Dissection Charitable Trust explains why timely and accurate diagnosis of aortic dissection is critical for saving lives. By sharing Martin’s recovery story, they illustrate the positive impact of prompt testing and treatment. 7. Rheumatoid arthritis: would my life be different if I had been diagnosed sooner? A patient explains how her experiences of pain were dismissed after the birth of her first baby. Although her own research indicated she had rheumatoid arthritis, she had to battle misinformed and unhelpful doctors to get a referral to a specialist. 8. “Listening to a patient’s history for longer can help doctors make the right diagnosis” Maria Dahm and Carmel Crock tell us more about their research to explore the relationship between communication and diagnostic accuracy. The findings highlight how critical it is to spend time listening to the patient, and for doctors to communicate uncertainties well. 9. Digital diagnosis—what the doctor ordered? Clive Flashman, Patient Safety Learning's Chief Digital Officer, looks at some of these new digital tools that are becoming increasingly available not only to clinicians but also for patients, and highlights some of the risks that they bring and considerations that need to be thought through. 10. Improving diagnostic safety in surgery: A blog by Anna Paisley Anna Paisley, a Consultant Upper GI Surgeon, talks about the challenges to safe surgical diagnosis and shares some of the strategies available to mitigate these challenges and aid safer, more timely diagnosis. 11. Applying a robust approach to digital clinical safety in diagnosis Ben Jeeves, Associate Chief Clinical Information Officer and Clinical Safety Officer, looks at the digital clinical safety aspects in relation to diagnostic safety. Share your experiences on the hub We would welcome your views on improving diagnosis for patient safety. Are you a patient who has been affected by a delayed, incorrect or missed diagnosis? Or perhaps a healthcare professional with an example of an improvement project that aims to reduce diagnostic error and improve outcomes? You can share your experience in our community forum (sign up here for free first), submit a blog, or email us at [email protected]. You can also find a number of existing resources, tools and stories relating to diagnosis and patient safety on the hub here.

The 3 December is International Day of Persons with Disabilities. More than 1.3 billion people experience significant disability today, which represents 16% of the global population. Many persons with disabilities die earlier, are at increased risk of developing a range of health conditions, and experience more limitations in everyday functioning than the rest of the population. To mark International Day of Persons with Disabilities, we are sharing 10 resources, blogs and reports from the hub on improving care, treatment and outcomes for people with disabilities. 1. Learning from safety incidents issue 13: Protecting people using wheelchairs 'Learning from safety incidents' resources are published by the Care Quality Commission (CQC). Each one briefly describes a critical issue—what happened, what the CQC and the provider have done about it, and the steps you can take to avoid it happening in your service. This edition is about ensuring the safety of people using wheelchairs in health and social care. 2. Tommy Jessop: Why I investigated hospital care for people like me People with a learning disability are more than twice as likely to die from avoidable causes than the rest of the population. Actor Tommy Jessop and BBC Panorama investigated some of the stories of families who say they were let down by their medical care. 3. WHO - Global report on health equity for persons with disabilities People with disabilities have the right to the highest standard of health, however, this report by the World Health Organization (WHO) demonstrates that while some progress has been made in recent years, many people with disabilities continue to die earlier and have poorer health than others. The report demonstrates how these poor health outcomes are due to unfair conditions faced by people with disabilities in all areas of life, including in the health system itself. 4. Towards a social model approach? : British and Dutch disability policies in the health sector compared This study looked at nursing within the UK and The Netherlands' health sectors, which are both highly regulated with policies to increase inclusiveness. It aimed to investigate the interplay between employment conditions and policy measures at sectoral level, in order to identify how these both facilitate and limit employment participation for disabled workers. 5. Tanni Grey-Thompson: NHS leaves the disabled feeling ‘they don’t count When the Paralympian and television presenter Tanni Grey-Thompson found she was pregnant in 2001, she went to see her doctor. “The first thing I was offered was a termination,” she says, “because people like me shouldn’t be allowed to have children.” In this Times article, she says that for disabled people, “the relationship with the NHS can be quite mixed”. 6. My Involvement Profile (Shaping Our Lives) Shaping Our Lives is a non-profit, user-led group, led by disabled people and service users. They want to make sure everyone can have their say, especially those from marginalised groups who often face barriers to getting involved. The My Involvement Profile was designed by disabled people. Involvement activities enable people to influence and improve policies and services that affect their lives, like health or social care. Involvement can mean sharing your experiences and opinions in a focus group, a patient involvement forum, or a research study. It’s made up of two simple template forms and can help you keep a record of your involvement activities, keep a list of your access and support requirements so you don’t have to keep repeating them, and each section has help notes to assist you in completing it if you need them. 7. NHS England Learning Disability Improvement Standards project This national data collection project has been commissioned by NHS England (NHSE) and is run by the NHS Benchmarking Network (NHSBN). The aim of the project is to understand the extent to which organisations are complying with the NHSE Learning Disability Improvement Standards, and to identify improvement opportunities. 8. The King's Fund: Towards a new partnership between disabled people and health and care services getting our voices heard Disabled people's voices need to be valued and prioritised in the planning and delivery of health and care services. This long read sets out the findings of research carried out by The King's Fund and Disability Rights UK into how disabled people are currently involved in health and care system design, and what good might look like. 9 Self-advocacy and barriers for young people accessing health care in the Scottish Highlands Self-advocacy is an individual's ability to communicate their own needs and is an important skill for patients. However, medical self-advocacy can be challenging, especially when there is a power imbalance between people in positions of authority and patients, who are often in a more vulnerable position. This power imbalance can be even more difficult to navigate for children and young people. In this personal account, Hannah Eaton describes her experiences as a disabled young person attempting to get support for diagnoses relating to chronic illness and neurodivergence. 10 Diagnostic safety: accessibility and adaptations– a (un)reasonable adjustment? Pavi Brar is Senior Policy Advisor at National Voices, a coalition of over 200 health and care charities. In this blog, Pavi explains why accessibility needs and adaptations must be taken into account and addressed to enable everyone to access diagnostic services.