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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 Restraint Reduction Network: Supporting people with lived experience As all forms of restrictive practice can result in harm, it is important that people are able to identify restrictive practices and challenge their inappropriate use. The Restraint Reduction Network have a range of resources that people with lived experience, parents and carers may find helpful. The resources are designed to support people to understand what restrictive practices are, when and why they might be used, people’s rights, and how to identify and challenge unacceptable and unethical practices. 2 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. 3 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. 4 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. 5 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. 6 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. 7 Rethinking doctors’ mental health and the impact on patient safety: A blog by Ehi Iden This blog by Ehi Iden, hub topic lead for Occupational Health and Safety, reflects on the increasing workload and pressure healthcare professionals face, the impact this has on patient safety and why we need to start 're-humanising' the workplace. He highlights that, “It takes a safe healthcare worker to deliver safe healthcare to patients.” 8 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. 9 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. 10 Blog: Shifting the dial on mental health support for young black men In this blog for NHS Confederation, Kadra Abdinasir talks about how mental health services have failed to engage with young black men, and describes how services need to change to overcome the issue. She argues that delivering effective mental health support for young black men requires a move away from a crisis-driven response, to investment in system-driven, community-based projects. Kadra looks at learning from Shifting the Dial, a three-year programme recently piloted in Birmingham as a response to the growing and unmet needs of young black men aged 16 to 25. A recent report on the project found that most young men involved in Shifting the Dial reported good outcomes related to their wellbeing, confidence, sense of belonging and understanding of mental health. 11 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. 12 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. 13 “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. 14 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. 15 Learning how to protect the health system by protecting the caregivers This commentary in JAMA Network Open looks at the increasingly recognised problem of burnout among US healthcare professionals. General Social Survey data suggest that almost one-half of US health care workers experienced symptoms of burnout often or very often in 2022, up from less than one-third in 2018. The article explores research that demonstrates the extent of the issue and highlights studies looking at ways to reduce burnout. The authors conclude that systemic change will be required to tackle the issue. 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. 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.

Race and ethnic inequalities in health are widely recognised, with much work needed to improve care, diagnosis and treatment, and outcomes for patients. Racism is also evident within healthcare organisations and the impact on staff can be devastating.  In this blog, we’ve collated a wide range of resources, including the latest research, the barriers patients face, improvement initiatives, health inequalities in maternity, and staff discrimination to evidence some of the key patient safety issues and the need for greater investment in this area. Barriers to diagnosis and treatment 1 Perceived barriers to accessing mental health services among black and minority ethnic communities: a qualitative study In most developed countries, substantial disparities exist in access to mental health services for black and minority ethnic populations. This study sought to determine perceived barriers to accessing mental health services among people from these backgrounds to inform the development of effective and culturally acceptable services to improve equity in healthcare. 2 ‘Mistreatment’ due to the colour of your skin A blog highlighting the barriers in healthcare faced by patients due to the colour of their skin. Impacting factors can include explicit racial bias, which includes discrimination and prejudice; implicit racial bias; missing data; lack of trust; and reduced access. These can lead to misdiagnoses and delays in treatment, which can ultimately cause harm and preventable death. 3 95% of healthcare professionals do not feel confident diagnosing dermatology conditions across skin tones This blog by Pastest, a provider of medical exam preparation resources, explores how different organisations are developing transformative initiatives to diversify clinical practice. It highlights the results of a global survey that reveals a critical gap in dermatological diagnosis across skin tones and explores the need for a multifaceted approach to anti-racist medicine. 4 Equity in medical devices: independent review A core responsibility of the NHS is to maintain the highest standards of safety and effectiveness of medical devices available for all patients in its care. Evidence has emerged, however, about the potential for racial and ethnic bias in the design and use of some medical devices commonly used in the NHS, and that some ethnic groups may receive sub-optimal treatment as a result. In response to these concerns, the UK Government commissioned this independent review on equity in medical devices. In its final report, the Review sets out the need for immediate action to tackle the impact of ethnic biases in the use of medical devices. 5 Skin assessment in patients with dark skin tone This article in the American Journal of Nursing provides basic information about the assessment of dark skin tone and calls for action in academia and professional practice to ensure the performance of effective skin assessments in all patients. 6 “We’re not taken seriously”: Describing the experiences of perceived discrimination in medical settings for Black women Cervical cancer disparities persist for Black women despite targeted efforts. Reasons for this vary; one potential factor affecting screening and prevention is perceived discrimination in medical settings. Inequalities in maternity 1 For black women in the UK, a fear of pregnancy is far from irrational In this blog for Refinery 29, journalist L'Oréal Blackett discusses the additional risk and associated worries faced by black pregnant women in the UK. With black women four times more likely to die in childbirth than white women, and 40% more likely to suffer a miscarriage, she examines what action the government is taking to improve outcomes for black women and their babies. She speaks to a number of campaigners who highlight the importance of including black women at every stage of research and policy to tackle race-based health inequalities. 2 Five X More campaign: Improving maternal mortality rates and health outcomes for black women In this interview, Patient Safety Learning talks to Tinuke, co-founder of the Five X More campaign and founder of the mothers group, Mums and Tea. Tinuke started the Five X More campaign as a response to the MBRRACE 2018 report which highlighted that black women in the UK are five times more likely to die in pregnancy and childbirth in comparison to a white woman. 3 Review of neonatal assessment and practice in Black, Asian and minority ethnic newborns: Exploring the Apgar score, the detection of cyanosis, and jaundice The results of a commissioned review undertaken by Sheffield Hallam University highlights a number of ‘reliability concerns’ around three current neonatal assessments and perinatal practices – the Apgar score and the detection of cyanosis and jaundice. It calls for immediate update of maternity guidelines that refer to assessments by skin colour and the increased use of screening tool devices, including oximeters and bilirubinometers. Urgent research is also needed which focuses on enhancing the reliability of these tools especially for darker skinned babies. 4 Addressing critical gaps in Black maternal mental healthcare: a new partnership project is launched Sandra Igwe is the Founder and CEO of The Motherhood Group. In this interview Sandra tells us about a new partnership project, bringing together The Motherhood Group, Centre for Mental Health, and the Maternal Mental Health Alliance to address critical gaps in Black maternal mental healthcare. Staff discrimination 1 NHS Confederation - Shattered hopes: black and minority ethnic leaders’ experiences of breaking the glass ceiling in the NHS This report by NHS Confederation looks at the lived experience of senior black and minority ethnic leaders in the NHS. The report highlights that more than half of those surveyed considered leaving the health service in the last three years because of their experience of racist treatment while performing their role as an NHS leader. Colleagues, leaders and managers seemed to be a particular source of racist treatment, more so than members of the public. This suggests that more focused efforts are required at every level to reduce the incidence of racist behaviour and to improve awareness among all staff of the impact of this type of discrimination. 2 Resource for nursing and midwifery professionals to combat racial discrimination against minority ethnic nurses, midwives and nursing associates Racism is unacceptable and it has no place in health and care. But we know that it exists and that the impact on staff can be devastating. All registered professionals have responsibility under the Nursing and Midwifery Council (NMC) Code to challenge discriminatory behaviour, creating an environment where people are treated as individuals and with dignity and respect. This resource is designed to support nurses, midwives and nursing associates, providing advice on the action you can take if you witness or experience racism. It also supports those in leadership roles to be inclusive leaders. 3 Too hot to handle? Why concerns about racism are not heard... or acted on This report aims to understand the NHS response to racism, what trusts and healthcare organisations do about it and how effective they are at addressing it. It brings together key learning from a number of significant tribunal cases and responses from 1,327 people to a survey about their experiences of raising allegations of racism within their organisations. 4 Closing the gap: A guide to addressing racial discrimination in disciplinaries A guide from NHS Providers to help health service trusts tackle racial discrimination in disciplinary procedures and promote inclusivity. 5 Nursing narratives: Racism and the pandemic This report describes the findings of a study that collected stories of the working lives of Black and Brown healthcare staff during the Covid-19 pandemic. The study asked them to reflect on their experiences and highlight the changes they would like to see. It highlights a number of issues around victimisation, access to PPE, speaking up and risk assessments. 6 Racism which impacts healthcare staff endangers patient care As well as a moral issue, tackling racism affecting NHS staff is a crucial part of improving patient safety and care, says MDX Research Fellow Roger Kline. In this blog, Roger looks at the risks of racism on patient safety. Improvement initiatives 1 How Lambeth is closing the health inequality gap for Black and minority ethnic patients with high blood pressure Black and minority ethnic patients with high blood pressure have benefited from a project which was run by two Lambeth GP practices. The project aimed to reduce the very significant difference in blood pressure control (hypertension) between Black and minority ethnic patients and white patients. The year-long project resulted in the two practices achieving some of the best outcomes ever seen in South East London for overall hypertension control, with a 12% inequality gap for blood pressure control between black and white patients completely eradicated. In addition, over 300 patients from the local community were newly diagnosed with hypertension. 2 Patient and Carer Race Equality Framework - community This video provides an introduction to Sheffield Health and Social Care NHS Foundation Trust's (SHSCFT's) Patient and Carer Race Equality Framework (PCREF). The PCREF aims to help the Trust's staff and communities understand how to have sensitive conversations with patients and carers and to get better information from them. This will mean the Trust is more culturally aware and able to offer culturally appropriate care by understanding the barriers ethnic minority communities face in getting healthcare services for diagnosis and treatment. 4 Excellence through equality: Anti-racism as a quality improvement tool This report from the BME Leadership Network comprises examples of anti-racist initiatives from BME Leadership Network members, to help advance equality within the workforce and for service users. 5 Be the Change: How to tackle racial inequalities in health and care charities A few years ago, National Voices created an inclusion action plan to try to narrow the gaps in racial inequalities by driving improvements in their recruitment practices, organisational culture, influencing activities and work with people with lived experience. A key part of that plan was convening their members to learn from each other, so they organised a series of four members-only roundtables for focused, pragmatic and open discussion. This report, highlights the main learnings in each of the areas, and draws out general advice from all these conversations. They hope it will give colleagues in the health and voluntary sectors ideas for what they could do, alongside practical tools to take action. 6 Mind the Gap: A handbook of clinical signs in Black and Brown skin Mind the Gap is a Handbook to raise awareness of how symptoms and signs can present differently on darker skin as well as highlighting the different language that needs to be used in descriptors. The aim of this booklet is to educate students and essential allied health care professionals on the importance of recognising that certain clinical signs do not present the same on darker skin. 7 The Health Foundation: Bringing an anti-racism approach to quality improvement in maternity care Black Maternity Matters is a collaboration supporting perinatal staff to reduce the inequitable maternity outcomes faced by Black mothers and their babies. Through a ground-breaking programme of training, including anti-racist education, peer support, and quality improvement, it supports maternity systems to provide safer, equitable care. In a recent episode of the Leading Improvement in Health and Care podcast, Penny Pereira, Q Managing Director, spoke to three improvement leaders from the Black Maternity Matters programme. Structural racism 1 Institute of Health Equity: Structural racism, ethnicity and health inequalities in London Racism in London is widespread and persistent causing damage to individuals, communities and society as a whole. Its impacts are experienced in different ways and to varying levels of intensity related to individual experiences, socioeconomic position and other dimensions of exclusion such as disability, age and gender. The intersections with other dimensions of exclusion can amplify the effects of racism. The focus of this review is on the effects of racism on health and its contribution to avoidable inequalities in health between ethnic groups – a particularly unacceptable form of health inequity. It is urgent that society tackle the damage to health and wellbeing as a result of racism. 2 Structural racism as a contributor to lung cancer incidence and mortality rates among Black populations in the United States Although racial disparities in lung cancer incidence and mortality have diminished in recent years, lung cancer remains the second most diagnosed cancer among US Black populations. Many factors contributing to disparities in lung cancer are rooted in structural racism. To quantify this relationship, Robinson-Oghogho et al. examined associations between a multidimensional measure of county-level structural racism and county lung cancer incidence and mortality rates among Black populations, while accounting for county levels of environmental quality. 3 Interrogating and uprooting systemic racism in the emergency department Systemic racism refers to systems in which norms and practice patterns reinforce racial and ethnic inequalities even in the absence of individual intentions to do so. Uncovering subtle, overt and pervasive instances of racism that influence and change the trajectory of patient care is important. Emergency departments (EDs) offer a distinct environment where equity is not just a concept, but a fundamental practice that should be woven through all interactions between the patient, healthcare professionals and the system. For this reason, EDs are poised to lead health equity advocacy in the delivery of high-quality care. This JAMA Health Forum viewpoint article looks at evidence relating to ED systems’ vulnerability to systemic racism and maps a path forward to dismantle racism in the ED. 4 Women from ethnic minorities face endemic structural racism when seeking and accessing healthcare Women from ethnic minorities are voicing their concerns that they face endemic structural racism when seeking and accessing healthcare, and they feel that their symptoms and signs are more often dismissed. It is vital that patients are listened to when they say that they feel this is also due to structural racism in healthcare. 5 Structural racism — A 60-year-old Black woman with breast cancer This study uses the case study of a 60-year-old Black woman with breast cancer as an example of structural racism and propose three critical strategies for addressing structural racism in health care. These strategies hinge on shifting the focus of work on racial differences in health outcomes from biologic or behavioural problems to the design of health care organisations and other social institutions. Research 1 Language-based exclusion associations with racial and ethnic disparities in thyroid cancer clinical trials Racial and ethnic disparities in thyroid cancer care may be reduced by improving enrolment of more diverse patient populations in clinical trials. This study in the journal Surgery looked at trial eligibility criteria and enrolment to assess barriers to equitable representation. 2 Differences in care team response to patient portal messages by patient race and ethnicity The use of patient portals to send messages to healthcare teams is increasing. This JAMA Network Open cross-sectional study of nearly 40,000 US patients aimed to find out whether there are differences in how care teams respond to messages from Asian, Black and Hispanic patients compared with similar White patients. The authors found that messages asking for medical advice sent by patients who belong to minoritised racial and ethnic groups were less likely to receive a response from doctors and more likely to receive a response from registered nurses. This suggests these patients receive lower prioritisation during triaging. The differences observed were similar among Asian, Black and Hispanic patients. 3 Racial implicit bias and communication among physicians in a simulated environment This JAMA Network Open study aimed to explore whether standardised patients in a simulated environment can be effectively used to explore racial implicit bias and communication skills among doctors. For this cross-sectional study, 60 doctors were placed in an environment calibrated with cognitive stressors common to clinical environments. The results reflected expected communication patterns based on prior research (performed in actual clinical environments) on racial implicit bias and physician communication. The authors believe that this simulation and the process of its development can inform interventions that provide opportunities for skills development and assessment of skills in addressing racial implicit bias. 5 Racial differences in shared decision-making about critical illness This US study looked at how critical care doctors approach shared decision-making with Black compared with White caregivers of critically ill patients. The authors found that racial disparities exist in critical care clinicians' approaches to shared decision-making and suggest potential areas for future interventions aimed at promoting equity. 6 Impact of healthcare algorithms on racial and ethnic disparities in health and healthcare This systematic review conducted for the Agency for Healthcare Research and Quality (AHRQ) aimed to examine the evidence on whether and how healthcare algorithms exacerbate, perpetuate or reduce racial and ethnic disparities in access to healthcare, quality of care and health outcomes. The results showed that algorithms potentially perpetuate, exacerbate and sometimes reduce racial and ethnic disparities. Disparities were reduced when race and ethnicity were incorporated into an algorithm to intentionally tackle known racial and ethnic disparities in resource allocation (for example, kidney transplant allocation) or disparities in care (for example, prostate cancer screening that historically led to Black men receiving more low-yield biopsies). 7 Characteristics of publicly available skin cancer image datasets: a systematic review Artificial intelligence (AI) is increasingly being used in medicine to help with the diagnosis of diseases such as skin cancer. To be able to assist with this, AI needs to be ‘trained’ by looking at data and images from a large number of patients where the diagnosis has already been established, so an AI programme depends heavily upon the information it is trained on. This review, published in The Lancet Digital Health, looked at all freely accessible sets of data on skin lesions around the world. These are just a selection of the resources we have on the hub, read more in the health inequalities section of the hub. Share your insights We'd like to hear from patients about your experiences and how it has impacted your care. Or perhaps you are clinician or researcher with a perspective to share on health inequalities? Please leave a comments below (sign up here first for free), or contact us directly at [email protected].

Swarm is one of the learning tools that can be used for the Patient Safety Incident Response Framework (PSIRF). A Swarm is designed to start as soon as possible after a patient safety incident occurs. Immediately after an incident, staff ‘swarm’ to the site to quickly analyse what happened and how it happened and decide what needs to be done to reduce risk. Swarms enable insights and reflections to be quickly sought and generate prompt learning. In this Top picks, we’ve pulled together 8 hub resources on Swarm, including a number of templates organisations have shared with us. 1 NHS England: Swarm huddle This swarm tool provided by NHS England integrates the SEIPS3 framework and swarm approach to explore in a post-incident huddle what happened and how it happened in the context of how care was being delivered in the real world (ie work as done). 2 PSIRF templates - AAR, Swarm, Rapid Review These templates were developed by Liverpool Heart and Chest Hospital for use in After Action Review, Swarm and Rapid Review toolkit responses. 3 Swarm debrief guide (Epsom and St Helier Hospital) Epsom and St Helier Hospital have developed a Swarm guide and fictional example video, for use by those who wish to use the Swarm debrief learning response as part of their PSIRF work. 4 Swarm video (Epsom and St Helier Hospital) This Swarm fictional example video was developed by Epson and St Helier Hospital to demonstrate how you can carry out a Swarm debrief using the Swarm guide. 5 Four PSIRF learning response tools (iTS Leadership) In this article, Judy Walker compares the four tools that can be used for PSIRF, including Swarm, explaining what they are and their strengths and weaknesses. 6 Swarm: a quick and efficient response to patient safety incidents Two years ago, a patient safety incident at North Bristol Trust led to the introduction of Swarm – a step change in how the trust responds to safety incidents. This article in the Nursing Times describes how Swarm works, its advantages over root cause analysis, and how it is being embedded in the safety culture of North Bristol Trust. 7 Yorkshire Ambulance Service: Swarm huddle tool This infographic from the Yorkshire Ambulance Service explains what Swarm is, when you would use it, who should be involved in it and who should lead it, and it's strengths and weaknesses. 8 SpaMedica: Swarm templates At a recent Patient Safety Management Network meeting, SpaMedica shared insights into their PSIRF journey, offering a unique perspective on how the independent sector implements PSIRF. They have shared their SWARM templates, including one for falls, and Swarm Charter with the hub. Share your SWARM resources If you have insights, tools or knowledge to share relating to SWARM why not comment below (you will need to be a member of the hub and sign in) or get in touch with us at [email protected]. At Patient Safety Learning we are also always keen to share good practice, challenges and training resources that could help support safe care more widely.

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.  1. 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. 2. 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. 3. 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. 4. 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. 5. 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. 6. 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. 7. 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. 8. “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].

Healthcare Science Week, 10–16 March 2025, brings together over 50 scientific specialisms and professional groups to celebrate and raise awareness of this diverse NHS workforce. These experts play a crucial role in diagnosing diseases, developing treatments and ensuring the effectiveness of medical technologies. Their work is essential for patient care. To celebrate Healthcare Science Week, Patient Safety Learning has pulled together 13 blogs and interviews published on the hub showcasing the important work healthcare professionals, scientists and researchers are doing to improve patient safety. 1. Decoding diabetes research – an innovative approach that makes scientific knowledge accessible to everyone D-Coded is an online resource that presents easy-to-understand summaries of diabetes research studies. It aims to make the latest knowledge and developments accessible to people who don't have a medical or scientific background. 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. 2. WireSafe®: Designing a new patient safety solution WireSafe® is an innovative solution designed to prevent retained guidewires during central venous catheter (CVC) insertion. Retained guidewires are never events that require urgent removal if accidentally left in. They occur in about 1 in 300,000 procedures. We interviewed Maryanne, who developed the WireSafe®, on the innovation, the human factor considerations in designing it and the difficulties she faced getting a new product into the NHS. 3. Using barcode scanning technology to improve blood group testing in unborn babies In this blog, 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. This technology has made the process more efficient, reduced errors and improved patient experience. 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. He outlines the importance of speaking openly about how racial bias affects patient safety, and argues that dispelling damaging myths about particular patient groups starts with equipping people with accurate health knowledge from a young age. 5. Applying a robust approach to digital clinical safety in diagnosis Diagnostics and digital go hand in hand. Digital healthcare has brought so many advancements in diagnostics and we are at the point of another paradigm shift with the advancements in artificial intelligence (AI), with some early and convincing diagnostic-use cases. New things also bring (new) risks. Some we can predict and plan for, perhaps some we haven’t, and some we can’t yet. In this blog, Ben Jeeves, Associate Chief Clinical Information Officer and Clinical Safety Officer, looks at the digital clinical safety aspects in relation to diagnostic safety. 6. Lost tissue samples a thing of the past with new innovative tracking system? The stress and anxiety felt by patients awaiting a potential cancer diagnosis can be made much worse if they are told their sample has been lost. Delays can impact treatment options and patient outcomes. Dil Rathore is a Biomedical Scientist and Pathology Innovation Lead at Leeds Teaching Hospitals NHS Trust. In this interview, he tells us about a new tracking system he’s developed to reduce the number of patient tissue samples going missing. 7. Medical device safety: effective testing is key In this blog, University of Sheffield based researcher Dr Nicholas Farr explains why investing in the development of testing methods is key to ensuring medical devices are safe to use. Nicholas and colleagues at the University of Sheffield have developed innovative testing methods that mimic key features of the human body within the lab. He believes this will improve our understanding of the materials being used in the development of medical devices at an early stage in the process – saving time and money, and reducing the risk of patient harm. 8. “Our message about public involvement is don’t be afraid to start.” Interview with Barbara Molony-Oates from the NHS Health Research Authority In this interview, we speak to Barbara Molony-Oates, public involvement manager at the Health Research Authority about why it's important to involve patients and members of the public in health research. Barbara tells us about the Shared Commitment to Public Involvement, a partnership of research organisations working together to promote, support and improve public involvement in health and social care research. She describes how the Shared Commitment was developed and how it is helping researchers involve individuals and communities who have never before considered taking part in research. 9. Coil procedures: Exploring negative experiences through qualitative research Trainee Clinical Psychologist, Sabrina Pilav tells us about her latest research project exploring negative experiences of coil/ intrauterine device (IUD) procedures. Sabrina explains how their in-depth qualitative methodology could contribute to improvements in the future. 10. Patient Safety Spotlight interview with Mark Sujan, Chartered Ergonomist and Human Factors Specialist Mark talks to us about how he came to work in healthcare, the vital role of safety scientists and human factors specialists in improving patient safety, and the challenges involved in integrating new technologies into the health system. 11. Improving diagnostic safety in surgery: A blog by Anna Paisley Safe diagnosis requires the gathering of information from multiple sources, including clinical history, examination, and laboratory and radiological tests. This information must then be distilled and interpreted to form a working diagnosis for treatment or further investigation. In this blog, 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. 12. 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. 13. Implementation of bedside electronic transfusion checks at Barts Health Trust: Quantifying benefits In this blog, Laura Green, Consultant Haematologist at NHS Blood and Transplant and Barts Health NHS Trust, describes how a new electronic process to improve the safety of blood transfusions was implemented across all four Barts Health sites. She explains why the new system was needed, outlines the benefits for staff and patients and highlights the role of project governance and staff training in successful implementation. Can we help you with your research? Where the topic is relevant to patient safety, we can work with researchers in a number of ways: To help recruit participants To share links to published papers via the hub and through our social media. To create content (blogs, interviews, videos) that help provide context around findings or research projects. Contact the hub team at [email protected] to discuss further.

Cervical Cancer Prevention Week takes place 20-26 January 2025 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 seven 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 (September 2024) 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. Exploring the inequalities of women with learning disabilities deciding to attend and then accessing cervical and breast cancer screening, using the Social Ecological Model (18 March 2024) 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. 3. “We’re not taken seriously”: Describing the experiences of perceived discrimination in medical settings for Black women (3 March 2022) 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. 4. Top tips for healthcare professionals: Cervical screenings (17 January 2022) 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. 5. 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. 6. 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. 7. 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. 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 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. 7 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. 8 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. 9 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. 10 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. 11 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). 12 Pyschological safety videos This channel is dedicated to useful, entertaining and informative content about psychological safety, human organisational performance, and organisational learning. 13 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. 14 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. 15 “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. 16 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. 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 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.

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, 2. 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. 3. 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. 4. 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. 5. 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. 6. 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. More international insights… 1. ‘Knowledge is the driver of change and will make a difference': a blog from Peter Lachman Peter 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 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. “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. 5. Mother knows best – a blog by Dr Abha Agrawal Dr Abha Agrawal shares with the hub her family's experience of going into hospital and demonstrates how patients and families can be true partners in patient safety. 6. The patient's chair: a blog by Dr Faisal Saeed Dr Faisal Saeed talks about the patient-provider power imbalance using an AI generated image of two chairs to illustrate his points. 7. 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. 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.

Anaesthetic techniques and equipment have greatly improved over the last 60 years, as has the training and safety equipment to protect patients. If you are in good health modern anaesthetics are really very safe. However, all procedures have some risks and it is important that patients are fully informed and that the anaesthetist discusses the procedure and the risks with the patient, taking into account the patient's medical history. 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 9 useful resources about anaesthesia that have been shared on the hub. They include insights from anaesthetists and examples of good practice. 1 Patient Safety Spotlight interview with Annie Hunningher, Consultant Anaesthetist at the Royal London Hospital, Barts Health In this interview, Annie talks to us about her work training teams in safety behaviours, why productivity and safety must go hand-in-hand, and how working on patient safety is like running a marathon. 2 Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals Human factors is an evidence-based scientific discipline used in safety critical industries to improve safety and worker wellbeing; implementing human factors strategies in anaesthesia has the potential to reduce the reliance on exceptional personal and team performance to provide safe and high-quality patient care. A three-stage Delphi process was used to formulate a set of 12 recommendations: these are described using a ‘hierarchy of controls’ model and classified into design, barriers, mitigations and education and training strategies. 3 Reviewing ‘work as done’ to prevent wrong site anaesthetic blocks: An interview with Marsha Jadoonanan, HCA Healthcare UK Marsha Jadoonanan, nurse and Head of Patient Safety and Learning at HCA Healthcare UK (HCA UK), shares a recent opportunity to learn from patient safety incidents involving wrong site anaesthetic blocks. She describes the new learning approach she and her colleagues used, which focused on engaging staff working in a variety of roles to create a safe space to focus on identifying ‘work as done’. 4 Hysteroscopy pain: A discussion with anaesthetists. A blog by Helen Hughes In this blog, Patient Safety Learning’s Chief Executive, Helen Hughes, reflects on a recent discussion about hysteroscopy and patient safety at a conference in January 2023, hosted by the Association of Anaesthetists. 5 Reducing intubation errors: A simple, accessible checklist to improve safety and support staff Sam Goodhand is a registrar in the Sussex region, specialising in anaesthetics and intensive care medicine. In this interview for Patient Safety Learning he tells us how and why he developed an accessible checklist for staff involved in intubation processes. 6 Handling injectable medications in anaesthesia: Guidelines from the Association of Anaesthetists These guidelines from the Association of Anaesthetists aim to provide pragmatic safety steps for the practitioner and other individuals within the operative environment, as well as short- to long-term goals for development of a collaborative approach to reducing errors. 7 RCOA infographic - Common events and risks for children and young people having a general anaesthetic This infographic by the Royal College of Anaesthetists shows some of the common events and risks that healthy children and young people of normal weight face when having a general anaesthetic (GA) for routine surgery. It highlights that modern anaesthetics are very safe and that most common side effects are usually not serious or long lasting. It also outlines the conversations children and their families should expect to have with their anaesthetist prior to their procedure. 8 Association of Anaesthetists case reports: Invaluable learning from mistakes In this clinical case report for the Association of Anaesthetists, the authors reflect on the importance of error reporting and implementing learning from clinical mistakes. They look at several error-related incidents and examine key learning points. They highlight that cases that do not result in serious harm to the patient are not prioritised for entry into databases or national audits, meaning they are less likely to be the subject of system-based improvement projects when compared with more ‘serious’ events. They identify that this may cause gaps in clinicians' awareness of potential risks and error traps. 9 The normalisation of patient care: Developing global guidance on securing an airway In this blog, Dawn Stott discusses the importance of consistency in care delivery, why healthcare systems must continue to develop and refine strategies for normalising care, and how she and her colleagues are developing global guidance on securing an airway when delivering anaesthesia. Do you have a resource or story about anaesthesia to share? We’d love to hear about it - leave a comment below or join the hub to share your own post.

Blood clots, particularly deep vein thrombosis (DVT) and pulmonary embolism (PE), together venous thromboembolism (VTE), pose a significant health threat to patients. These potentially life-threatening conditions can manifest silently and without warning, making vigilance and knowledge crucial. In this Top picks, we’ve pulled together resources, blogs and reports from the hub for patients and healthcare professionals, which focus on how to recognise venous thromboembolism and how to improve patient safety. 1. Deep vein thrombosis: understanding and managing your risk In this blog, Jo Jerrome, CEO of Thrombosis UK, explains the dangers of DVT and why it is important for patients and staff to be aware of the risk factors. Jo offers advice on how we can all manage our risk of DVT. 2. HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments This investigation by the Healthcare Safety Investigation Branch (HSIB) explores the timely recognition and treatment of suspected pulmonary embolism in emergency departments. 3. Jenny, and why we must learn from her misdiagnosis of pulmonary embolism Jenny Edwards died in February 2022 from pulmonary embolism, following misdiagnosis. In this blog, her son Tim introduces us to Jenny, illustrating the deep loss felt following her premature passing. He talks about the care she received and argues that there were multiple points at which pulmonary embolism should have been suspected. 4. Venous thromboembolism (VTE): deep vein thrombosis and pulmonary embolism VTE is a significant cause of mortality, long-term disability and long-lasting ill-health problems – many of which are avoidable. 1 in 20 people will have a VTE at some time in their life and the risk increases with age. This NHS Resolution guide provides more information about the risks of VTE and how to spot the common signs and symptoms. 5. HSIB - The assessment of venous thromboembolism risks associated with pregnancy and the postnatal period final report This investigation by the HSIB explores the issues associated with the assessment of risk factors for venous thrombosis in pregnancy and the first six weeks after birth. 6. NHS Resolution: Working to prevent avoidable venous thromboembolism VTE is an international patient safety issue and a clinical priority for the NHS. Around half of all cases of VTE are associated with hospitalisation, with many events occurring up to 90 days after admission. It is a leading and preventable cause of death in an estimated 25,000 of hospitalised patients each year. This information leaflet highlights the cost of VTE claims and what you can do in your organisation to prevent VTE. 7. Pulmonary embolism misdiagnosis – a systemic problem Tim Edwards is a risk management expert and son of Jenny, who passed away in February 2022 from pulmonary embolism, following a misdiagnosis. Frustrated by the quality of the initial investigation that followed her death and the lack of assurance that learning would take place, Tim conducted an independent review. In this opinion piece, Tim draws on his research to highlight the key patient safety issues, and to encourage further dialogue around the topic. 8. Let's Talk Clots! Help reduce your risk of DVT and PE in hospital with this simple app Download the free Let’s Talk Clots patient information app from Thrombosis UK, and help reduce your risk of DVT and pulmonary embolism in hospital. 9. Patient Safety Spotlight Interview with Beverley Hunt, Professor of Thrombosis and Haemostasis and founder of Thrombosis UK In this interview, Beverley Hunt talks about setting up Thrombosis UK and how it has grown to have a national impact on patient safety in hospitals. She also describes the value of combining policy work with seeing patients face-to-face, and explores the need to find new ways of working to deal with the pressures facing the healthcare system. 10. Risk assessment models for venous thromboembolism in medical inpatients This cohort study in JAMA Network Open aimed to determine the prognostic performance of the simplified Geneva score and other validated risk assessment models (RAMs) to predict VTE in medical inpatients. The study provided a head-to-head comparison of validated RAMs among 1352 medical inpatients. It found that sensitivity of RAMs to predict 90-day VTE ranged from 39.3% to 82.1% and specificity of RAMs ranged from 34.3% to 70.4%. The authors concluded that the clinical usefulness of existing RAMs is questionable, highlighting the need for more accurate VTE prediction strategies. 11. HSIB: Investigation into management of venous thromboembolism risk in patients following thrombolysis for an acute stroke This HSIB investigation focused on the management of VTE risk in inpatients following thrombolysis for an acute stroke detection of medical problems (that impact on VTE risk) occurring in inpatients following thrombolysis for an acute stroke. Do you have a resource or story to share? We’d love to hear about it - leave a comment below or join the hub to share your own post.

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.

According to the UK Sepsis Trust, sepsis affects 245,000 people every year in the UK alone, and 48,000 people die of sepsis-related illnesses. Sepsis arises when the body’s response to an infection injures its own tissues and organs. It may lead to shock, multi-organ failure, and death – especially if not recognised early and treated promptly. Dr Ron Daniels, Founder & Joint CEO of the UK Sepsis Trust, and Topic Lead for the hub, said: “During the Covid-19 pandemic, attention to sepsis care understandably diminished, leading to gaps in timely and effective treatment. As we emerge from the pandemic, it’s crucial to refocus our efforts on this life-threatening but often treatable condition. We’re calling on the government to commission clear and efficient pathways within the NHS, supported by integrated care boards, to ensure that suspected sepsis is taken seriously – every time – in Accident & Emergency (A&E) departments nationwide.” 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 10 useful resources about sepsis that have been shared on the hub. They include advice on recognising and managing sepsis along with educational materials. 1 THINK SEPSIS THINK SEPSIS is a Health Education England programme aimed at improving the diagnosis and management of those with sepsis. Prompt recognition of sepsis and rapid intervention will help reduce the number of deaths occurring annually. The resources that are available on their website support the early identification and management of sepsis. It includes a film and a wide range of learning materials for primary care, secondary care and paediatrics. 2 Dr Ron Daniels: Recognising sepsis Dr Ron Daniels, Chief Executive of the Global Sepsis Alliance, has filmed a short video for the hub on the importance of recognising sepsis quickly and acting early to not only save lives but also to improve the quality of the lives we do save. He highlights the tools available to recognise and manage sepsis, the Red Flag Sepsis start bundle, and discusses why it is important to know when to act and what to do, and why healthcare professionals and the public need to work collaboratively. 3 UK Sepsis Trust: Get Sepsis Savvy video Five-minute video to help protect yourself and your loved ones against sepsis. 4 Patient Safety Learning interview with double sepsis survivor, Dave Carson, and his wife Margaret A Patient Safety Learning interview with sepsis survivor, Dave Carson, and his wife, Margaret Carson, who tell us how things have improved and what more still needs to be done for sepsis. 5 Managing deterioration using NEWS A series of videos from NHS England Workforce, Training and Education on managing deterioration. 6 Sepsis: National Education Scotland resources Some of NHS Education for Scotland (NES) sepsis educational resources, including NHS Scotland National Early Warning Score (NEWS) and Sepsis Screening Tool, and the Maternal Sepsis e-Learning Package. 7 NHS England: Improving the blood culture pathway NHS England’s report into blood culture practices outlines key improvement steps in the pre-analytical phase of the blood culture pathway. Through targeted recommendations to trust chief executives, clinical and pathology staff, there's an opportunity to improve the blood culture pathway, antimicrobial stewardship and patient outcomes from sepsis. 8 Spotlight on sepsis: your stories, your rights This report from the Parliamentary and Health Service Ombudsman(PHSO) looks at some of the sepsis complaints people have brought to PHSO, to shine a light on their experiences and encourage others to let their voices be heard. It shares case summaries and guidance to help people complain and help NHS organisations understand and learn from the issues raised 9 Sepsis alert systems, mortality, and adherence in emergency departments: a systematic review and meta-analysis Early detection and management of sepsis is an important patient safety target. This systematic review included 22 studies and examined the use of sepsis alert systems in the Emergency Department (ED) on patient outcomes. The researchers found that sepsis alert systems were associated with reduced risk of mortality and decreased length of stay, as well as increased adherence to sepsis management guidelines, such as timely administration of antibiotics. 10 Improving sepsis compliance with Human Factors interventions in a community hospital emergency room Adherence to best practices for sepsis management at a small community hospital was below system, state and national benchmarks and affected vital indicators, including mortality. This study aimed to improve sepsis best practice compliance by implementing human factors–influenced interventions. Do you have a resource or story about sepsis to share? We’d love to hear about it - leave a comment below or join the hub to share your own post.

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.

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 12 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: 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”. 2 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. 3 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. 4 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. 5 Shifting the dial on mental health support for young black men In this blog, Kadra Abdinasir talks about how mental health services have failed to engage with young black men, and describes how services need to change to overcome the issue. She argues that delivering effective mental health support for young black men requires a move away from a crisis-driven response, to investment in system-driven, community-based projects. Kadra looks at learning from Shifting the Dial, a three-year programme recently piloted in Birmingham as a response to the growing and unmet needs of young black men aged 16 to 25. 6 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. 7 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. 8 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. 9 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. 10 Prostate cancer: getting information and support This leaflet helps signpost people to support and information about prostate cancer, both nationally and regionally. 11 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. 12 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. 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].

World Hospice and Palliative Care Day takes place on 12 October 2024.  Patient safety in hospice and palliative care involves ensuring that every patient is able to access the services, support and pain relief that they need when they reach the end of life. It is also vital that families and carers are given relevant and timely support and information by healthcare services during their loved one’s hospice or palliative care, and following their death. Patient Safety Learning has pulled together 12 useful resources shared on the hub about hospice and palliative care. They include reports into the current state of hospice and palliative care in the UK, families’ reflections on how end of life care can be improved and resources related to palliative care for people with learning disabilities. 1. A manifesto for palliative and end of life care The charities Sue Ryder, Marie Curie, Together for Short Lives, National Bereavement Alliance and Hospice UK have produced this joint manifesto that calls on all political parties and candidates to commit to policies that ensure everyone affected by dying, death and bereavement receives the best possible care and support, both now and in the future. 2. The Worldwide Hospice and Palliative Care Alliance The Worldwide Hospice and Palliative Care Alliance (WHPCA) is an international non-governmental organisation focusing exclusively on hospice and palliative care development worldwide. The WHPCA website hosts a wide variety of resources relating to hospice and palliative care including advocacy resources, standards and clinical guidelines and country reports. 3. Dying well at home: commissioning quality end-of-life care (King's Fund) This King’s Fund report explores what we know about commissioning end-of-life care, the inequalities experienced by particular groups, and how NHS and social care commissioners in England are measuring and assuring the quality of care people receive. 4. Seeking Excellence in End of Life Care UK (SEECare UK): a UK multi-centred service evaluation The Association of Palliative Medicine coordinated the first ever prospective evaluation of end of life care against set standards in 88 hospitals across the UK. It found that people dying in UK hospitals without specialist palliative care input frequently have “significant and poorly identified unmet needs” —93% of people assessed having demonstrable unmet need. 5. Interview with Dr Elena Mucci, Consultant Geriatrician at East Sussex Healthcare NHS Trust In this video interview, consultant geriatrician Dr Elena Mucci talks about patient safety in geriatrics and end of life care. She describes the importance of taking a whole-person approach to caring for older people, reviewing medications regularly, equipping patients to manage their own health, and engaging patients and their families in planning for end of life care at an early stage. 6. Palliative Care for People with Learning Disabilities Network (PCPLD Network) The Palliative Care for People with Learning Disabilities (PCPLD Network) is a charity created to ensure that patients with learning disabilities receive the coordinated support they need throughout their life. The PCPLD Network website has some interesting webinars on a range of different topics which have already taken place for you to watch as well as useful resources. 7. Sarcoma UK: Family insights from Dermot’s experience This article from Sarcoma UK was written by the family of Dermot, who was diagnosed aged 77 with myxofibrosarcoma in March 2020. They reflect on the issues Dermot faced in accessing effective palliative care and make recommendations linked to the recent publication of the Healthcare Safety Investigation (HSIB) report, Variations in the delivery of palliative care services to adults. 8. Mind the gaps: understanding and improving out-of-hours care for people with advanced illness and their informal carers For patients living at home with advanced illness, deterioration in health can happen at any time of the day or night. This research report funded by the charity Marie Curie looks at issues faced by people with advanced illness and their informal carers in accessing out-of-hours care. 9. "We were completely unprepared for the challenges and disruption that lay ahead" — A family share their experience of taking a loved one home for end of life care In this anonymous blog, a hub member shares how unprepared she and her family were for the challenges and disruption that lay ahead when her husband was discharged from hospital for end of life care at home. 10. "What matters to you today?" How this simple question can improve patient care Physiotherapist Ann Bryan and occupational therapist Ines Brito are part of the therapy team working at the Marie Curie hospice in Hampstead. In this blog, they look at how asking a simple yet powerful question: "what matters to you?" can give healthcare professionals vital insights into the lives of patients that aren't always captured in routine assessments. 11. Lessons not learned: A family's lengthy efforts to turn complaints into improvements In this blog, a family describe the lengthy efforts they had to take to try to ensure their complaints about their loved one's end of life care would result in improvements at the hospital. 12. Final guidance on visiting and accompanying in care homes, hospitals and hospices - Care Quality Commission (CQC) Following consultation, the Care Quality Commission have now published final guidance to help providers understand and meet the new fundamental standard on visiting and accompanying in care homes, hospitals, and hospices. The guidance (on Regulation 9A: visiting in care homes, hospitals, and hospices) also sets out what people using health and social care services and their families, friends or advocates can expect. Have your say Are you a healthcare professional who works in hospice or palliative care? We would love to hear your insights and share resources you have developed. Perhaps a family member or someone you care for has received palliative care - what was your experience like? We would love to hear from you! Comment below (register for free first) Get in touch with us directly to share your insights

NHS England is introducing a new approach to investigating patient safety incidents, called the Patient Safety Incident Response Framework (PSIRF). Members of our online patient safety platform, the hub, have been sharing their insights, opinions and reflections around PSIRF to support one another at this time of transition.   In this ‘Top picks’, we’ve selected ten to share with you.*  In this ‘Top picks’, we’ve selected ten to share with you.* 1. Is the NHS ready for PSIRF? A blog by Chris Elston Chris, a patient safety education lead, discusses whether the NHS is ready for PSIRF, looking at the role leaders will play in implementing it and how we need to change the mindset and the culture within organisations. 2. Reflections on PSIRF, patient engagement and why we investigate: a recent discussion at the Patient Safety Management Network This blog captures a recent discussion at a Patient Safety Management Network (PSMN) meeting, where members of the network raised a number of important questions and issues relating PSIRF. 3. Going forward with PSIRF – overcoming the challenges by Judy Walker Written for all those involved in implementing PSIRF, this article describes some of the reasons behind the challenges being faced and suggests three principles to help navigate through this complex process and offers practical ideas to help. 4. 'The PSIRF Hollywood collaborative': a blog from Jane Carthey, Tracey Herlihey, Claire Cox, Maureen Bankole-Allibay and Helen Hughes ‘PSIRF: The Hollywood Edit'. Unifying key messages from NHS England’s PSIRF guidance (NHS England, August 2022) with Hollywood movie titles and a bit of shared learning along the way. 5. Making a positive difference to patient safety – Preparing for PSIRF Linda Jones, Head of Patient Safety & Quality Governance at Independent Healthcare Providers Network (IHPN), writes about the significant changes that introducing a new approach to managing risk and patient safety will entail for the independent sector, and how they are supporting members to be ready. 6. The Patient Safety Incident Response Framework (Bevan Brittan) Mark Amphlett, clinical negligence specialist, looks at the aims of moving away from the Serious Incident Framework, and the challenges of implementation. 7. Mind the potholes! Implementing After Action Reviews: A blog by the National AAR Reporting Template Team Using the potholes metaphor, the National After Action Review (AAR) Reporting Template Team share their reflections on implementing AAR and its challenges. Although the focus of this blog is on AAR, its messages are pertinent to other learning response tools, including the SWARM huddle, multidisciplinary team review and the horizon scanning tool. 8. Patient Safety Spotlight interview with Lucy Winstanley and Rebecca Gibson, PSIRF leads at West Suffolk NHS Foundation Trust Lucy and Rebecca talk to us about their experience as Patient Safety Incident Response Framework (PSIRF) early adopters. They discuss how PSIRF puts patients at the centre of incident investigations, and the challenges and opportunities they have faced in implementing PSIRF at West Suffolk NHS Foundation Trust. 9. Patient Safety Spotlight Interview with Tracey Herlihey, Head of Patient Safety Incident Response Policy at NHS England Tracey talks to us about the importance of putting users at the centre of developing PSIRF, and what we can learn from magicians about patient safety. 10. Shared insights: The Patient Safety Incident Response Framework Summary of a presentation given by NHS England's Lauren Mosley and Tracey Herlihey. The session covered key elements of PSIRF and, what it means for coroners, litigation and trusts. There was also feedback from an early adopter trust. 11. NHS England - PSIRF Early Adopter interview: Patient safety incident investigator perspective (15 August 2022) In this video, Megan Pontin, Patient Safety Incident Investigator at West Suffolk NHS Foundation Trust, describes the process of engaging staff, patients and families in incident investigations, and how PSIRF enables people to share what happened from their perspective. *PSIRF is continuously developing and these are the opinions and reflections from those working with it at the time of publication. Related content Top picks: PSIRF tools, templates and examples PSIRF Risk Register and Risk Management Plan: Free tool to help you transition. Join our community If you would like to join our hub community or become a member of the Patient Safety management Network, you can register for free here. Read our '7 reasons to join the hub' to get a flavour of how our community might help you. Share your views If you have insights, tools or knowledge to share relating to PSIRF why not comment below or get in touch with us at [email protected]. At Patient Safety Learning we are also always keen to share good practice, challenges and training resources that could help support safe care more widely. If you sign up to become a member of the hub, you can upload resources to the site, receive our monthly newsletter and engage with other members.

NHS England is introducing a new approach to investigating patient safety incidents, called the Patient Safety Incident Response Framework (PSIRF). Members of our online patient safety platform, the hub, have been sharing PSIRF resources, tools and templates to support one another as the approach is implemented. In this ‘Top picks’, we’ve selected some to share with you.*  Click on the title to access each full content piece. 1. NHS England: Patient safety incident response standards NHS England has provided a complete list of patient safety incident response standards that organisations need to uphold to ensure they meet the minimum expectations of PSIRF, which cover policy, planning and oversight; competence and capacity; engagement and involvement of those affected by patient safety incidents; and proportionate responses. 2. PSIRF templates: AAR, SWARM, Rapid Review (Liverpool Heart and Chest Hospital, 2023) Three templates developed by Liverpool Heart and Chest Hospital for use in After Action Review, SWARM and Rapid Review toolkit responses. 3. PSIRF infographic: A new era in patient safety for the NHS and healthcare A simple, eye-catching poster to explain PSIRF, created by Stephen Ashmore and Tracy Ruthven. 4. Four PSIRF learning response tools Judy Walker, iTS Leadership, summarises four tools that can be used for PSIRF, explaining what they are and the strengths and weaknesses of each. 5. Suffolk and North East Essex's SOP – Patient Safety Incident Response Framework (PSIRF) ICB sign off process for smaller independent providers Suffolk and North East Essex NHS Foundation Trust share their Standard Operating Procedure on PSIRF Integrated Care Board sign-off process. 6. Applying the After Action Review for the PSIRF – some real life examples Judy Walker describes some real-life examples of After Action Reviews to illustrate some of its many applications. 7. PSIRF planning – Pressure ulcer example scenario 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. 8. Example of a PSIRF preparation guide A Patient Safety Specialist in the North East of England has shared their 'plan on a page’ with the hub to help others prepare for the implementation of PSIRF. 9. PSIRF tool: Themed review template (August 2022) Dr Sam Machen shares her thematic review template. 10. Learn Together - Supporting involvement after safety events in healthcare Learn Together is a resource website that equips patients and families with the knowledge and resources to be involved effectively in patient safety investigations. 11. HSIB: Learning Response Review and Improvement tool Development of this tool was informed by a research study from Paul Bowie, Programme Director for Safety & Improvement at NHS Education for Scotland (NES), identified ‘traps to avoid’ in safety investigations and report writing. The 'Learning Response Review and Improvement Tool' is intended to be used by those writing learning response reports following a patient safety incident or complaint, to inform the development of the written report; and peer reviewers of written reports to provide constructive feedback on the quality of reports and to learn from the approach of others. 12. PSIRF Risk Register and Risk Management Plan: Free tool to help you transition To help organisations develop their plans and transition to this new way of working, Patient Safety Learning has published a template PSIRF Risk Register and Risk Management Plan. *Please note, that many of these will be under continuous development so please check with the related organisation or individual if you require the latest version. 13 NHS England: Applying the Patient Safety Incident Response Framework outside of NHS trusts NHS England has provided FAQs based on the questions that have been asked about applying PSIRF in non-NHS trust organisations. They should be read in conjunction with the wider PSIRF guidance and help clarify how PSIRF principles can be applied proportionately across the variety of services and commissioning structures within the NHS. 14 Self-Assessment Framework for Event Response (SAFER) Oversight: A tool for effective Patient Safety Incident Response Framework (PSIRF) governance The introduction of the Patient Safety Incident Response Framework (PSIRF) has removed traditional oversight targets, requiring practitioners to take a flexible, improvement-focused approach. While this shift is intended to improve patient safety, it has also created uncertainty for those in oversight roles, who must navigate new responsibilities without the comfort of prescriptive performance metrics. This article provides practical guidance on PSIRF oversight and introduces the Self-Assessment Framework for Event Response (SAFER) Oversight tool. The article outlines the mindset and functions needed to support effective, improvement-focused governance. It explores three aspects of oversight mindset: systems thinking, improvement focus, and compassion - as well as three oversight functions: demonstrating and assuring improvement, supporting and collaborating, and facilitating learning across the system. Related content Top picks: PSIRF insights and opinions Top picks: 8 Swarm resources Join our community If you would like to join our hub community or become a member of the Patient Safety management Network, you can register for free here. Read our '7 reasons to join the hub' to get a flavour of how our community might help you. Share your views If you have insights, tools or knowledge to share relating to PSIRF why not comment below or get in touch with us at [email protected]. At Patient Safety Learning we are also always keen to share good practice, challenges and training resources that could help support safe care more widely. If you sign up to become a member of the hub, you can upload resources to the site, receive our monthly newsletter and engage with other members.

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 eight 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. 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

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 15 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, 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. 3. 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. 4. Professionals with Parkinson’s tackle time critical patient safety issue Sam Freeman Carney, Health Policy and Improvement Lead at Parkinson's UK, explains how critical it is that people with Parkinson’s get their medication on time and how, on World Parkinson’s Day in 2022, a group of healthcare professionals who live with Parkinson’s themselves decided to take action. 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: Involving everyone in improving management of inpatients in Leeds Inspired by a letter from the wife of a patient with Parkinson’s, Consultant Neurologist Jane Alty and colleagues started the 'Improving care of patients with Parkinson’s quality improvement project' at Leeds Teaching Hospitals NHS Trust. In this article, Jane talks about the successes and challenges of the project and the value of involving staff from across the organisation and carers to make services better. 14. 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. 15. 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.

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.  the hub's Content and Engagement Manager, Steph O'Donohue, has hand-picked 15 resources, particularly relevant for patient safety managers working in hospital settings. Shared with us by hub members and patient safety advocates, they are jam-packed with practical tools and rich insights.  1 D1abasics: Equipping staff to care safely for inpatients with diabetes The inpatient diabetes team at University Hospital Southampton NHS Foundation Trust 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. 2 Yellow kits - an innovation to reduce the risk of falls in Accident and Emergency departments In this blog, Jayne Flood, Falls Prevention Practitioner at East Kent Hospitals NHS Foundation Trust, describes how her team introduced ‘yellow kits’* to assist patients at high risk of falls in A&E, and evaluated their impact. 3 A simple guide to the Patient Safety Incident Response Framework (PSIRF) This guide provides information about what PSIRF is and why it’s been introduced. It also outlines what patients, carers and family members can expect from an investigation if they are involved in a patient safety incident. 4 National campaign aims to reduce patient harm from infiltration and extravasation Infiltration is when fluid or intravenous drugs administered to a patient (which are given to patients into a vein through a cannula or other device) inadvertently leak into the tissue surrounding a vein by mistake. Extravasation is when infiltration occurs but the drugs involved are called vesicants which can damage the tissue and cause serious harm to the patient. The National Infusion and Vascular Access Society (NIVAS) are leading a campaign to improve awareness of infiltration and extravasation and reduce avoidable harm. In this interview Andrew Barton, Chair of NIVAS, explains why this is such an important issue and what needs to happen to improve patient safety. 5 Infiltration and Extravasation: A toolkit to improve practice This toolkit, developed by the National Infusion and Vascular Access Society (NIVAS), is intended to enable local services and healthcare organisations to implement polices, protocols and guidelines that will increase awareness about non-chemotherapy extravasations. 6 Medication delays: A huge risk for inpatients with Parkinson’s In this blog, Laura Cockram, Head of Policy and Campaigning at Parkinson's UK talks about the serious health implications of medication delays for people living with Parkinson's disease. She also offers recommendations for how hospitals can reduce the risk of harm. 7 Application of SEIPS and AcciMap to a patient safety incident Chris Elston, a patient safety education lead, shares how he used Safety Engineering Initiative for Patient Safety (SEIPS) and Accident Mapping (AcciMap) to learn from a patient safety incident at his Trust. 8 Improving safety for diabetic inpatients: 4 key steps In this short film, National Specialty Advisor for Diabetes, Partha Kar shares four steps for improving the safety of diabetic inpatients. 9 Neonatal herpes: Why healthcare staff with cold sores should not be working with new babies Chief Executive and Founder of the Kit Tarka Foundation, draws on her own devastating experience of losing her son to illustrate why healthcare staff with cold sores must stay away from new babies. Sarah highlights the need for greater awareness and a widespread review of policy in order to prevent future deaths. 10 Appreciative inquiry case study Appreciative inquiry is one of the Patient Safety Incident Response Framework (PSIRF) tools that can be used to learn from patient safety incidents. Katy Fisher, Senior Nurse Quality & Improvement at NHS Professionals, shares how she designed and introduced an appreciative inquiry tool at her hospital. 11 Measuring standards of care, not negative outcomes In this interview, Gavin Portier, Head of Nursing Quality, explains how his approach to auditing has moved beyond measuring negative outcomes, instead focusing on standards of care. Gavin shares related resources and some of their early results. 12 Safety Incident Supporting Our Staff (SISOS): A second victim support initiative at Chase Farm Hospital Chase Farm Hospital now has 24-hour support for staff affected by adverse events. The model, developed by Theatre Nurse Carole Menashy, is known as the 365 second victim support model and sets out a framework to provide support at various levels from trained peers through to professional help. In this series of blogs, Carole explains how and why she set up the support service. 13 NHS Mid and South Essex's 'We're Listening' leaflet Danielle, Critical Care Outreach Nurse, share's her 'We're Listening' leaflet as part of the trust's Call for Concern service. This service has been developed so that patients, friends and family can alert the Critical Care Outreach team if they have concerns that need listening to and gives a telephone number to call and outlines the next steps. 14 Reducing intubation errors: A simple, accessible checklist to improve safety and support staff Sam Goodhand, a registrar specialising in anaesthetics and intensive care medicine, explains why he designed and printed simple checklist cards to help reduce life-threatening complications occurring during adult and paediatric intubation procedures. He shares details of how to order the cards for your area. 15 Tackling antibiotic underdosing: Interview with Ruth Dando, Head of Nursing for Theatres, Critical Care and Anaesthetics at BHRUHT In this 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. #Share4safety Have you set up an initiative or made changes locally to improve safety? What were the challenges and successes? Are there any tools you've developed that may be useful to share with others? Why not get in touch with us at [email protected] to tell us more and share your insights. Perhaps you'll be in our next Top Picks! Patient Safety Management Network Some of our members have recently come together to set up a collaborative network for people working in patient safety roles to support one another and share ideas. They currently run weekly drop-in sessions. If you'd like to join the network, simply sign up to the hub (for free) and tick the box for the Patient Safety Management Network. Make sure you fill out the 'about me' section to highlight how your role is relevant to the group. Stephanie O'Donohue, Content and Engagement Manager

Knowing about Group B Strep when you’re pregnant or in the early weeks after birth can make a massive difference – most Group B Strep infections in newborn babies can be prevented, and early treatment can and does save lives. Group B Strep Awareness Month focuses on empowering new and expectant parents with the knowledge they need to make informed decisions about their baby and engaging with healthcare professionals to improve education and awareness.  In this blog, Patient Safety Learning has pulled together six useful resources about Group Strep B shared on the hub. 1 Leaflet on Group B Strep The charity Group B Strep Support (GBSS) has produced an information leaflet, written in partnership with the Royal College of Obstetricians and Gynaecologists (RCOG), aimed particularly at pregnant people and new parents and includes information on what Group B Strep is, what it could mean for a baby, how to reduce the risk and the key signs of Group B Strep infection. The leaflet has been translated from English into 14 other languages 2 Group B Strep: Poppy's story Group B Strep is a type of bacteria which lives in the intestines, rectum and vagina of around 2-4 in every 10 women in the UK (20-40%). Most women carrying GBS will have no symptoms and although it is not harmful to pregnant women, it can affect babies around the time of birth. Read Poppy's story. 3 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. 4 New FREE eLearning module on group B Strep (30 July 2024) The charity Group B Strep Support have launched a new FREE eLearning module on group B Strep and it comes with one hour of Continued Professional Development (CPD) credit. This vital resource is for midwives, doctors and others working in maternity and neonatal care. It has been co-produced with families, midwives, obstetricians, neonatologists and others involved in maternity and neonatal services. 5 HSIB National Learning Report: Severe brain injury, early neonatal death and intrapartum stillbirth associated with group B streptococcus infection This report published in 2020 highlighted a number of patient safety concerns and recommends that maternity care providers should consider the findings and make necessary changes to their local systems to ensure that mothers and babies receive care in line with national guidance. 6 Symptoms of group B Strep infection in babies In the UK, up to two-thirds of GBS infection in babies are of early onset (showing within the first 6 days of life). Group B Strep Support have produced an awareness poster highlighting the symptoms.

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 11 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 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. 6 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. 7 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. 8 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. 9 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. 10 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. 11 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. 12 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.

Healthcare has become increasingly dependent on, and supported by, technology and digital solutions. We've pulled together some key pieces of hub content to help readers take a closer look at some of the patient safety considerations. Click on the headings to open the content. 1. Digital diagnosis—what the doctor ordered? The advance of artificial intelligence (AI) has seen the emergence of digital diagnostic tools, with some claiming a more accurate diagnosis than a human. But what challenges does this present to patient safety? In this blog, 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. 2. The role technology has in enhancing safety in healthcare facilities: A blog by Yasmine Mustafa Yasmine Mustafa, Co-Founder and CEO of ROAR, looks at how technology can improve healthcare for patients and staff safely, including the role of wearable technology in healthcare safety. 3. The digitalising of patient records — why patients MUST be involved In this blog, Tina* discusses the patient safety issues that can occur with electronic patient records, highlighting how easily errors can occur in a patient's record but how difficult they are to fix, and why patients must be involved in the digitalising of their own records. 4. Digital-only prescription requests: An elderly woman sent round the houses In this blog Dr Charlie tells us how their elderly mother was met with multiple digital barriers when trying to access her medications. 5. NHS England warns electronic patient record could pose ‘serious risks to patient safety’: what can we learn? NHS England recently issued a national patient safety alert to all trusts providing maternity services after faults were discovered in IT software that could pose “potential serious risks to patient safety”. In this short blog, Clive Flashman, Patient Safety Learning’s Chief Digital Officer, calls for a closer look at the reasons into this and what we can learn from it. 6. EPR systems and concerns about patient safety An investigation published by BBC News has revealed that Electronic patient record (EPR) system failures have been linked to the death of three patients and more than 100 instances of serious harm at NHS hospitals trusts in England. In this short blog, Patient Safety Learning reflects of these issues and the importance of patient safety being at the heart of the development and implementation of EPRs. 7. Digital storytelling: Learning opportunity or reputational risk? In this anonymous blog, a member of NHS staff talks about their experience promoting digital storytelling to help staff members and the wider trust learn from patients’ perspectives on incidents of harm. 8. AI in healthcare translation: balancing risk with opportunity In this blog, Melanie Cole, Translations Coordinator at EIDO Systems International, talks about the challenges, risks and opportunities for using AI in healthcare translation. 9. Putting patients at the heart of digital health Clive Flashman, Chief Digital Officer at Patient Safety Learning, looks at the benefits and barriers to engaging patients in developing digital healthcare solutions. 10. Looking at the Safety of AI from a Systems Perspective: Two Healthcare Examples In this chapter of the book Safety in the Digital Age: Sociotechnical Perspectives on Algorithms and Machine Learning, Mark Sujan argues that a systems approach is needed for the design of AI from the outset. 11. NHS England: Progress against digital clinical safety strategic commitments Read NHS England's latest updates on the implementation of the Digital Clinical Safety Strategy, These show how they've captured insights about digital clinical safety, how they are training their workforce to support safety in this area and how they use technology to drive safer care. 12. Digital Coalition: Public and patient experience of the NHS App Find out more about this research, designed to understand the public’s engagement and use of the NHS App. The report is based on findings from a survey run by The Patient Coalition for AI, Data and Digital Tech in Health (also known as the Digital Coalition). 13. Patient Safety Learning presentation slides: Embedding patient safety into digital health innovation Clive Flashman, Patient Safety Learning's Chief Digital Officer, shares his presentation slides from the Health Plus Care 2022 conference. 14. EPR systems and concerns about patient safety An investigation published by BBC News revealed that electronic patient record (EPR) system failures have been linked to the death of three patients and more than 100 instances of serious harm at NHS hospitals trusts in England. In this short blog, Patient Safety Learning reflects of these issues and the importance of patient safety being at the heart of the development and implementation of EPRs. Join the conversation Do you have insights to share around technology in healthcare and the patient safety considerations? You can comment below (sign up for free first) or contact the hub team at [email protected]