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Everyone deserves to learn and work in a safe, respectful environment. The new Breaking the Silence: Sexual Safety for Healthcare Students and Trainees e-learning offers practical steps to speak up safely, set clear boundaries and get the right support. Feel more confident about what’s acceptable, what isn’t, and what to do if you see or experience behaviour that crosses the line. Understand where to raise concerns and how to support a colleague who shares an experience. Whether a student, trainee, educator, or staff member complete the e-learning to strengthen your own wellbeing and professionalism and help build a culture where harassment is not tolerated.  The e-learning is accessed via the NHS learning hub or via the e-Learning for Health platform. Find out more from the attachment below.

A recent white paper, Clinical Competency in the Age of AI,  presents findings from a systematic narrative synthesis of 445 studies examining clinical competency requirements in AI-augmented healthcare. It addresses a structural gap in how current competency frameworks prepare clinicians for AI-assisted practice. In addition to examining the breadth of research into clinical risks associated with use of AI in clinical care, the research analysed 23 existing AI competency and capability frameworks, including the NHS Health Education England AI and Digital Healthcare Technologies Capability Framework and the DECODE international consensus framework. It found that across all reviewed frameworks, the competencies most critical for frontline patient safety—critical appraisal of AI recommendations, detection of biased outputs, governance escalation, and protection of professional moral accountability—are largely limited to awareness statements for frontline users. Clinicians are expected to understand what AI is. They are not equipped to practise safely with it. The white paper proposes a five-domain competency framework, specified across three career stages, that translates intersecting AI risks into assessable clinical capabilities for practising clinicians. Key findings AI erodes clinical reasoning without competency safeguards. The Budzyń et al. (2025) multicentre colonoscopy study provides the first real-world evidence: adenoma detection rates fell from 28% to 22% among endoscopists after three months of AI assistance. The skill had not been assessed. It had not been exercised. It had atrophied. Cognitive overload drives uncritical AI acceptance. Alert override rates of 90–96% have been documented in deployed clinical AI environments—a workforce adapting to unsustainable demand by reducing evaluative effort. AI tools assessed as safe under controlled conditions carry significantly higher risk in busy, overstretched environments where they are most needed. Governance infrastructure is inadequate. Over 70% of NHS trusts lack documented clinical safety assurance for deployed AI tools (Oskrochi et al., 2025). Clinicians in these settings carry full personal professional accountability for AI-assisted decisions without the institutional infrastructure that should underpin them. Risks compound, but are treated as parallel separate risks. Time pressure increases automation bias severity. Automation bias accelerates deskilling. Deskilling undermines safety governance capacity. Equity failures concentrate where burnout is highest and training resources most limited. Current frameworks miss these feedback loops. Healthcare-specific competency frameworks are insufficient. Over 75% of medical students receive no formal AI education. Where training exists, assessment tools lack specificity for healthcare contexts. This research defines what AI clinical competency requires: technical understanding, critical appraisal, equity awareness, safety governance knowledge, and professional identity maintenance, integrated rather than treated as separate modules. Implementation guidance remains fragmented. Governance frameworks address safety. Education frameworks address training. Workforce research addresses burnout. Each treats its domain rigorously while missing the system dynamics. This research consolidates evidence into practical principles for curriculum development, organisational deployment and regulatory strengthening. Harm concentrates in those least able to detect it. The populations most at risk from biased AI outputs are served by clinicians least equipped to recognise that bias, in settings least able to monitor it. This convergence is structural and will not be resolved by improving AI performance alone.

This short film shows a fictional scenario of a handover between two healthcare workers. It has been created by Patient Safety Learning to help facilitate a group discussion around bias. Please read the guidance below (and attached) when using this within your teams. How to use this resource: exploring bias in handover This short video is designed to help you recognise how biases can influence clinical handovers and, ultimately, patient safety. It works best as a group learning activity. Step 1: Watch the video Watch the handover between Celia and Doreen all the way through once without interruption. As you watch, think about: What information is emphasised or dismissed. How decisions are explained. Whether anything feels “off” or incomplete. Or: Play “Bias Bingo”. Before watching again, either individually or in small groups, use a simple “bias bingo” card (you can create one using common biases such as confirmation bias, anchoring bias, etc.). Your task: Spot where different biases occur in the handover. Tick them off as you notice them. Note down the exact words or behaviours that suggest the bias. You may spot more than one bias in a single patient discussion. Step 2: Group discussion In small groups, discuss: Which biases did you identify? Did everyone spot the same ones? Where did opinions differ? How might these biases affect patient care or outcomes? Encourage open discussion—there are no “trick answers”. Step 3: Feed Back The group feeds back: One example of a bias they identified. Why they think it is that bias. What the potential risk to the patient could be. Have you seen similar situations in real handovers? What strategies could reduce bias? (e.g. structured handovers, questioning assumptions, using checklists). What would you do differently in Doreen’s position? Share your feedback If you use this resource, we'd love to hear from you. Was it useful? Did anything in the discussion surprise you or spark wider action? Please comment below or get in touch with us at [email protected].

This practical and engaging two-day course will explore how the SEIPS (Systems Engineering Initiative for Patient Safety) framework can be applied within health and care investigation and design to support safer, more effective systems and services. Whether you are involved in patient safety, investigation, quality improvement, service design or systems thinking, this course will provide valuable insight and practical tools to apply in your organisation. SEIPS in Health and Care Investigation and Design is an interactive two-day face-to-face course designed to introduce participants to practical systems-based investigation and design using the Systems Engineering Initiative for Patient Safety framework (SEIPS). Through collaborative workshops and realistic scenarios, learners will work alongside others to explore and analyse real-world incidents and system challenges commonly encountered across health and care settings. Participants will develop practical skills in identifying how people, environments, technologies, organisational factors, and workflows interact to influence safety, quality, and care outcomes. Delivered in a supportive learning environment, the course is facilitated by experienced faculty leading work across systems thinking, human factors, and safety investigation. Learners will have opportunities to discuss ideas, test approaches, and build confidence applying SEIPS methods through guided simulation and group-based activities. By the end of the course, participants will have developed a structured approach to investigating complex system issues and designing practical, system-focused improvements for health and care services. To find out more or book your place, please email: [email protected]

Promoting Learning, Safety, and Improvement in Surgical Teams Team Based Quality Reviews (TBQR) provide a structured, evidence-based approach to team learning in clinical practice. Building on existing processes such as morbidity and mortality (M&M) meetings and significant event analyses, TBQR supports whole-team reflection from the point of an event through to shared learning, meaningful actions, addressing unintended consequences and follow-up for improvement. This one-day course, developed in partnership with NHS Education Scotland, RCSEd and the GMC, equips healthcare professionals with the tools, frameworks, and strategies needed to embed TBQR into clinical practice. Participants will gain practical skills in implementation strategies, analysing events, identifying meaningful actions, and overcoming barriers—such as time, resources, and system alignment. Designed for colleagues leading or interested in safety reviews, or seeking to improve daily work practices, this course provides an opportunity to enhance the understanding, and application of Human Factors and Systems Thinking into practice. It explores how TBQR can be used not only to learn from harm, but also from success, innovation, and complexity in care delivery. This course provides delegates with an opportunity to join a wider network of professionals and learn from areas of good practice across the globe. By supporting collective learning and psychological safety, TBQR strengthens team performance, staff wellbeing, and organisational resilience, ultimately advancing safe, effective, and sustainable healthcare. Target audience: Surgeons and health care professionals leading safety reviews or team based review meetings, including mortality and morbidity meetings. Currently aimed at ST3 onwards but applications are encouraged from interested individuals. Register

Promoting Learning, Safety, and Improvement in Surgical Teams Team Based Quality Reviews (TBQR) provide a structured, evidence-based approach to team learning in clinical practice. Building on existing processes such as morbidity and mortality (M&M) meetings and significant event analyses, TBQR supports whole-team reflection from the point of an event through to shared learning, meaningful actions, addressing unintended consequences and follow-up for improvement. This one-day course, developed in partnership with NHS Education Scotland, RCSEd and the GMC, equips healthcare professionals with the tools, frameworks, and strategies needed to embed TBQR into clinical practice. Participants will gain practical skills in implementation strategies, analysing events, identifying meaningful actions, and overcoming barriers—such as time, resources, and system alignment. Designed for colleagues leading or interested in safety reviews, or seeking to improve daily work practices, this course provides an opportunity to enhance the understanding, and application of Human Factors and Systems Thinking into practice. It explores how TBQR can be used not only to learn from harm, but also from success, innovation, and complexity in care delivery. This course provides delegates with an opportunity to join a wider network of professionals and learn from areas of good practice across the globe. By supporting collective learning and psychological safety, TBQR strengthens team performance, staff wellbeing, and organisational resilience, ultimately advancing safe, effective, and sustainable healthcare. Target audience: Surgeons and health care professionals leading safety reviews or team based review meetings, including mortality and morbidity meetings. Currently aimed at ST3 onwards but applications are encouraged from interested individuals. Register

In healthcare a single report—no matter how minor—can challenge an assumption and shift an entire system toward safer care. We often assume that better tools, smarter systems and stronger procedures should naturally lead to safer care. Yet across many healthcare organisations, familiar patterns of preventable harm continue to reappear. This raises an important question: why do these incidents persist—even in environments that invest heavily in quality and safety? Recent national reviews offer a revealing insight. A 2025 U.S. Office of Inspector General report found that hospitals captured less than half of actual patient harm events—meaning a significant portion of risks never even enters the learning system.[1] A 2024 analysis of more than 280,000 safety events reached a similar conclusion, highlighting ongoing gaps driven by underreporting and inconsistencies in how incidents are documented.[2][3] In my experience, these findings reflect a deeper truth: the issue is rarely a lack of systems—it is a lack of signals. When reporting is incomplete, when near misses remain invisible, and when staff underestimate the value of submitting a report, organisations lose the very information needed to learn, adapt and prevent future harm. In healthcare, we often talk about systems, structures and processes. Yet sometimes, the most powerful lessons come from simple ideas. More than twenty years ago, my mentor, Dr Katrin Kleijnhans, shared a metaphor that continues to shape how I understand patient safety culture: the 'ant' and the 'elephant'. In her view, the ant represents a single incident report—the kind of small observation that frontline staff may overlook or dismiss. The elephant, on the other hand, symbolises the healthcare system with all its complexity, pressures and latent risks. She would often remind our teams that even the tiniest ant can move an elephant. One report—no matter how minor it may seem—can challenge assumptions, reveal hidden vulnerabilities and spark meaningful change. And when many ants come together through consistent reporting, they form a 'colony' that creates a force strong enough to shift an entire system toward safer care. Across my work in risk management, I have witnessed this principle repeatedly. A seemingly simple report—a nurse noticing an unusual pattern, a technician raising a concern, a physician describing a near miss—often became the starting point for redesigning workflows, strengthening barriers or preventing harm before it reached a patient. The impact was almost never in the size of the report itself. It was in the organisation’s willingness to listen. Although Dr Katrin Kleijnhans is no longer with us today, the mindset she instilled continues to influence how teams speak up, take ownership of safety and recognise the value of reporting. Her legacy lives on in every improvement driven by someone who chooses to report a concern. As healthcare evolves and technologies advance, one challenge remains deeply human: how do we build cultures where people feel safe—and motivated—to report? The answer begins with reinforcing a simple truth: Small reports reveal big risks. Repeated patterns expose system weaknesses. Reporting is not an administrative task—it is an act of protection. Every voice matters. To all healthcare professionals: your report might be the ant that moves the elephant. Your observation could be the insight that uncovers a hidden risk, prevents harm, or sparks the next improvement that protects patients and colleagues alike. Building a safer healthcare system does not begin with large projects. It begins with a single report—and the courage to submit it. References Office of Inspector General. Hospitals Did Not Capture Half of Patient Harm Events, Limiting Information Needed to Make Care Safer. 2025. Kepner S, Jones R. Patient safety trends in 2023: An analysis of 287,997 serious events and incidents from the nation’s largest event reporting database. Patient Safety 2024; 6(1): Hoops K, Pittman E, Stockwell DC. Disparities in Patient Safety Voluntary Event Reporting: A Scoping Review - Joint Commission. Journal on Quality and Patient Safety 2024; 50(1):46-48.

Chris Elston, a patient safety education lead, shares his journey on how he learnt and used thematic analysis in his trust, which led to him designing a lesson for his colleagues and then wider teaching outside his organisation. For many years I have thought that we could make a bigger impact on patient safety if we could examine low harm events or near misses in greater detail. Historically, they have often been left to local areas to investigate and close them. With all the time pressures and demands on them, it is hardly surprising that many get a superficial look rather than an examination. Thematic analysis allows us to do a good delve into these areas and so I sought to complete two analyses: one on falls and the other on pressure ulcers. I thought that they lent themselves to this style of analysis. I mean how hard could it be, a week or two and the analysis would be done. Simple, isn’t it? Well, I can only say how wrong I was. The first analysis took about three months to complete, the second one, a little longer. At this point, I will be honest—despite the raft of available data sources, I only used the adverse event reports (AERs). I think it may have been longer if other data sources had been used. I was pleased with the result; it showed lots of useful information that could be shared with the steering groups and individual areas to help inform their practice. Soon after this, the Patient Safety Incident Response Framework (PSIRF) was introduced and the use of thematic analysis was one of the tools that PSIRF recommended. This meant that a greater understanding of thematic analysis was required. So, after a brief hiatus, I started to research a little more about thematic analysis and its application and found there was much more to thematic analysis than I had first realised. Designing a lesson I wanted to design a thematic analysis lesson for my trust. What did people need to know before they could use it? I was no expert and I needed to learn before I attempted to teach it, so what did I need to know? My initials thought were: How do you define thematic analysis? What types are there? When could it be used? What are the advantages and disadvantages of thematic analysis? Where can we get data from? How can we code/map the data into themes? So began a journey; what should have been a short journey but has taken a few twists along the way. I developed a 2-hour lesson with what I considered to be the essentials of thematic analysis. This was then delivered in my trust, which led to some changes in our processes. This meant that thematic analysis became much more of a featured learning response. Following this, I was then asked to assist one of our wards on a project and we started with a … thematic analysis. I never dreamed I would be doing something like this. Expanding the training After a year or so, I answered a question posed on NHS Futures about thematic analysis training. I replied that I had a lesson and was willing to meet and discuss with people. I did not expect the response that I got. People from all sorts of healthcare organisations, within the NHS and outside of it, wanted to discuss thematic analysis. I was shocked and stunned at the response. I have often said, if we do not collaborate then we will never drive patient safety forwards at a great enough pace to safeguard patients and staff. So I elected to share some of my teaching. My trust offered to host some meetings, we discussed the training I could provide and what I felt comfortable sharing. There was just over 100 people interested in attending the meetings. As the time got closer, I became increasingly nervous. The imposter syndrome hit hard—I was going to be found out as a fraud and not nearly as switched on as many appeared to think. Was this such a clever idea? Conclusion We are now about 6 weeks from the last meeting and I can breathe a sigh of relief. Everything went ahead in a positive manner. Feedback has been good, although I think I could have made better use of technology and that is a lesson learnt for the future. Many in healthcare are willing to make the necessary changes but they want support in this; coaching and mentoring will be critical to delivering PSIRF. This is just one step on that path (motorway, could be a better analogy!). The experience has shown how powerful collaboration is. Further reading on the hub: Patient Safety: Emerging Applications of Safety Science "The greatest part of this adventure has been the sharing of information." Conducting a systems review of pressure ulcers in the intensive care unit

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

Last month, Public Policy Projects hosted their annual Patient Safety Forum in partnership with Patient Safety Learning. Held at the Royal College of Surgeons of England in London, it was attended by senior healthcare leaders, patient safety experts, representatives from the HealthTech industry, frontline healthcare professionals and patients.  In this article, Patient Safety Learning reflects on one of the panel discussions—AI for patient safety: Innovation, assurance and strengthening communication. From AI-enabled ambient scribing tools that reduce the burden of administration, to predictive systems capable of detecting early warning signs before harm occurs, AI has significant potential to improve patient care and outcomes. Yet, alongside these benefits come risks—algorithmic errors, data bias, and challenges in maintaining trust, governance and oversight. At the Patient Safety Forum 2026 an expert panel was convened to discuss this topic, with the following members: Clive Flashman, Chief Digital Officer, Patient Safety Learning Dr Alison Cave, Chief Safety Officer, Medicines and Healthcare products Regulatory Agency (MHRA) Anil Mistry, AI Safety Lead, Guy’s and St Thomas’ NHS Foundation Trust Dr Basil Bekdash, Clinical Safety Officer, Sheffield Children’s NHS Foundation Trust Aleksander Alski, Head of Region – USA, Canada and UK, Vasco Electronics Panellists had a lively discussion with each other and the audience about how to balance innovation with assurance, to ensure that the use of AI in healthcare enhances safety rather than undermines it. They spoke about how AI should be understood as a support tool for healthcare professionals—it provides information and removes burden but, ultimately, staff treat patients. In this blog we highlight several key topics that emerged from this debate. Importance of patient safety A key theme running throughout the panel’s discussion was the importance of patient safety being built into AI development at the outset. Clive Flashman from Patient Safety Learning reflected on this point, suggesting that too often this is seen as a compliance ‘tick box’ or treated as an afterthought. Speaking to digital innovators, his message was that “you need to think about this from the very start when you are conceptualising the product”. Panellists also recognised that putting safety at the centre of discussions around AI and healthcare means involving all stakeholders, not just the healthcare professionals using these technologies but suppliers too. Alexander Alski from Vasco Electronics emphasised the importance of this being an area of shared responsibility between suppliers and healthcare providers. Getting regulation right Alison Cave from the MHRA spoke about the ongoing work of the National Commission into the Regulation of AI. This Commission was established by the MHRA to review current regulations and provide recommendations for a new regulatory framework for AI in healthcare. It held a public call for evidence which Patient Safety Learning responded to earlier this year. Discussing how to approach future regulation, she highlighted the importance of ensuring that “the risk is associated with the decision, not the technology itself”. It was noted that in some cases there may be very complex pieces of software in use, but these may be making very low-risk decisions. Panellists underlined the importance of having a risk-proportionate regulatory framework to support safe innovation. Predicting future harm The potential to use AI to identify patient safety issues is understandably an area of significant interest. Last year the Department of Health and Social Care announced that it planned to develop a world-first artificial intelligence (AI) early warning system to automatically identify safety concerns across the NHS. Panellists were asked to consider what examples they had seen of AI moving from reacting to incidents, to predicting and preventing future harm. They spoke about the value of AI as a support tool for clinicians and more broadly how it might be used to identify emerging patient safety issues. Basil Bekdash from Sheffield Children’s NHS Foundation Trust spoke about work that had been trialled in this area, but noted that currently there have not been many examples where these have been proven on a significant scale, stating: “None of them have really quite got to the point where they're proven in widespread deployment and so I'm not going to predict that's going to happen in the next five years.” Tackling bias While an AI tool may be safe when properly implemented and used by a well-trained healthcare professional, it could be potentially dangerous if such training and support is absent. Panellists concurred that having appropriate training and tackling bias were issues of critical importance in ensuring the safety of AI in healthcare. In particularly they discussed risks presented by: Confirmation bias—healthcare professionals favouring AI outputs that align with their pre-existing view and overlooking signals that may challenge this. Automation bias—over-reliance on AI systems and accepting their recommendations without sufficient critical evaluation. Alison Cave from the MHRA said that part of the training should be ensuring that healthcare professionals understand the devices they are using and where there are trade-offs between sensitivity and a specificity. Basil Bekdash from Sheffield Children’s NHS Foundation Trust noted the importance of having in mind the different levels of digital competence of staff, stating that when designing AI systems: “It is best to test by using your least capable people who are the least digitally enabled and that's not a criticism that's just the reality of the normal spread of what people do, and their primary function is to look after patients.” Transparency and patient communication As use of AI grows in healthcare, it is vital that patients understand how this is being applied if they are to have confidence in its safety. Panellists discussed issues around how to inform patients when AI influences their care, particularly when it affects clinical judgments. Anil Mistry from Guy’s and St Thomas’ NHS Foundation Trust suggested that: “If the AI result is going to affect their patient’s care, and it's going to limit their access to finite resources like a waiting list or appointments or ICU beds, then absolutely have that sort of communication.” However, he also spoke about some of the challenges this raises; for example, if a patient asked about whether AI has been used in their care. In practice this could cover a very broad range of areas, from the use of ambient scribes to take notes to tools that analyse images from scans. Panellists indicated that transparency needed to be balanced and proportionate to both the risk and impact on individual care. Governance requirements AI healthcare technologies have significant scope to evolve and change over time. When they iterate rapidly (with new versions being released at regular intervals) it can be difficult for existing governance frameworks, designed for other types of medical devices, to keep up. Panellists discussed the importance of having flexibility to governance arrangements. There was the suggestion that lower risks tools (such as those in Class 1 for Medical Devices under the MHRA framework in the UK) should have greater flexibility, with higher levels of scrutiny reserved for decision-influencing tools. It was also made clear that any new regulation will need to carefully consider the level of ongoing evaluation that will be required to account for these systems evolving and changing over time. This may be much longer than for other medical devices and change at significant pace. One audience member commented that with these tools becoming increasingly complex, in the future “realistically there is going to be a need for an AI tool that assesses AI tools”. Panellists also considered how procurement processes could act as potential leverage mechanisms for AI technologies in healthcare. It was noted they offer the potential opportunity to embed the open standards we want to see being used by AI technologies in the earliest stages of their design, putting safety concerns at the centre of the product before it ever reaches patients. Improving the quality of data Data accuracy, completeness and representativeness is key to ensuring AI technologies work safely in health and care environments. Panellists noted that poor foundational data standards undermine AI model training and lead to unreliable outputs. Their discussion reflected that a significant proportion of time is often spent on data cleaning before even applying AI. Improving this would have wider benefits for research, operational efficiency and public healthcare. As we increase the use of AI health technologies, it is vital that we do not embed existing health inequalities. Following on from comments in an earlier session from Professor Bola Owolabi from the Care Quality Commission, Alison Cave from the MHRA noted a “perennial challenge in all of our areas is to ensure that the training data is representative”. Training data for AI systems must be representative of diverse populations and care settings. Sharing insights from the frontline If healthcare organisations, professionals and suppliers are to share responsibility for the safe implementation of AI technologies in healthcare, this must go hand in hand with shared learning. Panellists discussed the need for sustained and transparent feedback loops between suppliers, regulators and healthcare organisations. On this point an audience member asked: “How do we ensure our learning keeps pace so that existing insight from frontline teams that really know the business can optimally inform the evolution of products, but without stifling the pace?” Panellists highlighted the absence of standardised mechanisms for frontline staff to provide real-time, structured feedback to AI suppliers on safety issues. One proposed suggestion to this was the potential to mandate native feedback functionality within AI health technologies. This would mean that feedback mechanisms are built directly into the AI tool’s user interface and workflow, allowing those using them to provide input about the AI’s output without leaving the system. Find out more about the Patient Safety Forum 2026 You can read more about different discussions and panel sessions at this year’s event in the below: Patient voice, safety and the NHS 10 Year Plan: Reflections from the Patient Safety Forum 2026 Safe systems, safe cultures: reflections from the Patient Safety Forum 2026

Overview Technical skills alone are insufficient to ensure optimal outcomes following surgery. The Non-Technical Skills for Surgeons (NOTSS) Masterclass provides participants with a broad knowledge and practical experience of the non-technical skills that have been demonstrated to be essential for safe patient care. These include the cognitive and interpersonal aspects of operative surgery that are critical for optimising individual and team performance in surgery. Target audience Consultants and Senior Trainees in all surgical specialties. Learning style Participants are sent reading material prior to attending the course. The course gives participants practical experience of observing and rating non-technical behaviours. The format is centred on small group work and the use of simulated scenarios from the operating theatre and other industries. Learning outcomes By the end of this masterclass, participants should be able to: Discuss the underlying principles of non-technical skills which contribute to safe surgical care. Differentiate between four major categories of non-technical skills: Situation Awareness, Decision Making, Team Communication, and Leadership. Identify and assess surgical non-technical skills in a series of operative video simulations using the NOTSS taxonomy. Register

Overview Technical skills alone are insufficient to ensure optimal outcomes following surgery. The Non-Technical Skills for Surgeons (NOTSS) Masterclass provides participants with a broad knowledge and practical experience of the non-technical skills that have been demonstrated to be essential for safe patient care. These include the cognitive and interpersonal aspects of operative surgery that are critical for optimising individual and team performance in surgery. Target audience Consultants and Senior Trainees in all surgical specialties. Learning style Participants are sent reading material prior to attending the course. The course gives participants practical experience of observing and rating non-technical behaviours. The format is centered on small group work and the use of simulated scenarios from the operating theatre and other industries. Learning outcomes By the end of this masterclass, participants should be able to: Discuss the underlying principles of non-technical skills which contribute to safe surgical care. Differentiate between four major categories of non-technical skills: Situation Awareness, Decision Making, Team Communication, and Leadership. Identify and assess surgical non-technical skills in a series of operative video simulations using the NOTSS taxonomy. Register

This innovative educational initiative was developed as a direct and constructive response to the communication inadequacies exposed by the Montgomery case, and subsequent legislation. While it is not difficult to give "more information" it is harder for surgeons and patients to achieve a decision partnership. The ICONS workshop content has been informed by internationally recognised experts in Shared Decision Making, by consensus among senior practising surgeons, by patients and by professional experts in risk management and risk communication. Delegates on the ICONS workshops will acquire skills and knowledge to implement best practice in sharing the complex decisions surrounding informed consent. By participating in a workshop, they will also contribute to the development of resources for future training in the important area of informed consent. Target audience All grades of trainees; SAS / LED / Trust Doctors; Consultants. Non FRCS surgeons – Ophthalmologists; Obstetricians and Gynaecologists. Learning style Focussed topic introductory talks. Small group facilitated discussion tutorials based on review of exemplar videos of consent and other patient doctor communication scenarios. Aims & objectives The objectives of the course include: Learn the potential catastrophic and costly consequences of failure adequately to share important surgical decisions. Recognise the importance of discussion treatment options rather than risks. Understand key features of the case Montgomery v LHB 2015. Appreciate the legal view of Shared Decision Making. Identify key elements of a Shared Decision Making consultation. Understand how to deliver treatment recommendations. Gain new consultation skills. Identify and apply effective ways of risk communication. Appreciate the role of decision support tools before, during and after the clinical encounter. Understand the added value of writing letters directly to patients. Learning outcomes Having attended the ICONS workshop you will be able to: Understand the practical importance of the Montgomery decision. Identify the key elements of a Shared Decision Making consultation. Discuss options including surgery – elective and emergency. Employ efficient methods of eliciting patient needs, preferences and values in a busy clinic. Understand the added value of patient activation before options are discussed, and decision distribution thereafter. Develop skills for well-balanced, meaningful surgeon patient interactions. Communicate risk to patients in a more realistic way. Appreciate the role of recommendation. Review the limitations of and variation in current consent forms. Register

Team Based Quality Reviews (TBQR) provide a structured, evidence-based approach to team learning in clinical practice. Building on existing processes such as morbidity and mortality (M&M) meetings and significant event analyses, TBQR supports whole-team reflection from the point of an event through to shared learning, meaningful actions, addressing unintended consequences and follow-up for improvement. This one-day course, developed in partnership with NHS Education Scotland, RCSEd and the GMC, equips healthcare professionals with the tools, frameworks, and strategies needed to embed TBQR into clinical practice. Participants will gain practical skills in implementation strategies, analysing events, identifying meaningful actions, and overcoming barriers—such as time, resources, and system alignment. Designed for colleagues leading or interested in safety reviews, or seeking to improve daily work practices, this course provides an opportunity to enhance the understanding, and application of Human Factors and Systems Thinking into practice. It explores how TBQR can be used not only to learn from harm, but also from success, innovation, and complexity in care delivery. This course provides delegates with an opportunity to join a wider network of professionals and learn from areas of good practice across the globe. By supporting collective learning and psychological safety, TBQR strengthens team performance, staff wellbeing, and organisational resilience, ultimately advancing safe, effective, and sustainable healthcare. Learning style There are two components to this course, as follows: Online / e-Learning training module. This pre-workshop module supports the learner in their understanding of the TBQR process, its underlying principles and provides an overview of designing quality and safety review pathways. Face-to-face workshops which will involve interactive lectures on core topics relevant to safety reviews and practical work. Aims & Objectives To equip surgeons and the healthcare workforce with the knowledge, skills, and implementation strategies to design, lead, and participate in Team Based Quality Reviews (TBQR), grounded in contemporary safety science and Human Factors principles. The course complements existing national safety review policies and frameworks, fostering a culture of learning, improvement, and understanding of resilience in systems. Learning outcomes By the end of the course, participants will be able to: Explain the purpose, principles, and practical relevance of Team Based Quality Reviews (TBQR) within health and care settings. Describe and map a TBQR process tailored to their own team or organisation, applying Human Factors principles to enhance learning and safety. Apply Systems Thinking and appropriate analytical frameworks to review cases in TBQR, M&M meetings, or similar review and reflective practices. Demonstrate the use of the TBQR process in a simulated scenario to identify system strengths, vulnerabilities, and strategies to build resilience within the system. Evaluate, plan, and apply implementation strategies to embed TBQR in their workplace in order to: Enhance learning and innovation Advance training Focus resources where required Improve staff wellbeing Promote psychological safety Engage patients and families. Register

MedLed, in partnership with Midlands Air Ambulance Charity, is hosting a Human Factors & Patient Safety for Clinical Leaders course this June and spaces are now open to the wider healthcare sector. Human Factors & Patient Safety for Clinical Leaders is a 2-day face-to-face course built with pre-hospital care as its foundation: the high-stakes, time-pressured, operationally complex environment where Human Factors challenges are most visible. But the principles apply across all of healthcare, and we now have spaces available for clinical and non-clinical professionals beyond the pre-hospital community. What's covered? How human capabilities and limitations influence leadership, management, and the quality of care. Systems thinking and models of safety, moving beyond individual blame and the flawed concept of human error. Why practice doesn't always make perfect and how to recognise error-provoking conditions. The relationship between stress, physiological needs, and performance. Strategies for leading high-performing teams, including ad hoc teams under pressure. How to create an environment of psychological safety for your team. Register

Making mistakes is an inescapable part of being a surgeon, yet research shows that many surgeons feel ill-prepared for this reality and struggle with the deep personal impact that errors can have. Feelings of isolation and lack of support are common, and even conversations with colleagues can sometimes intensify rather than relieve distress. Despite the centrality of this issue to our profession, it is rarely discussed openly. Many surgeons suffer in silence—leading to burnout, dropout, or reliance on unhelpful coping strategies. The True Cut workshop offers a safe and supportive space for honest reflection and practical learning. It explores how we can build better coping strategies in ourselves and our colleagues, how we can respond compassionately to patients and families, and how we can support one another in the aftermath of an error. The workshop is designed to be equally relevant for experienced surgeons and those in training. Target audience: Surgeons at all levels and Trainees Learning style: The day centres on selected excerpts from True Cut, a verbatim play created from interviews with surgeons, their colleagues, and patients. Each scene serves as a starting point for facilitated small-group discussions, held in a safe, supportive, and confidential setting. Scientific evidence is woven together with stimulating perspectives from the arts, encouraging thoughtful engagement and deeper reflection. Aims & objectives: To examine the ever-present possibility of mistakes in surgery, enabling participants to better understand and navigate their impact. Learning outcomes Participants will: better understand the universal nature of mistakes in human activity appreciate the deep and lasting impact of mistakes in surgical practice share and normalise the immediate and late effects on theatre staff - empathise with different perspectives - prepare themselves and others for the aftermath of mistakes support each other to grow and thrive in practice despite and even because of mistakes explore how we should respond to patients and families encourage a more open culture within their own practice, fostering dialogue and candour in their own unit - make links to online and in person resources The course covers the following areas of the Surgical Curriculum: GPC 1 : Values and behaviours GPC 2 : Communication and interpersonal skills. Dealing with complexity and uncertainty GPC 5 : Teamworking GPC 6 : Patient safety Register

Working across frontline emergency care, patient safety and digital patient safety over the course of my 22-year career in the NHS has given me a unique perspective on how digital systems shape real clinical practice. As a paramedic now working as a Clinical Safety Officer within NHS Wales, I’ve seen first‑hand how digital tools can support safer care—but also how they can contribute to patient harm when things don’t work as intended. In this blog, I reflect on the challenges of identifying issues and, more importantly, assessing patient harm in a digital context. These thoughts aren’t theoretical, they come from day‑to‑day reality: the calls, the investigations, the conversations and the moments where something in the digital healthcare system doesn’t work the way it should—and a patient feels the impact. I’m sharing these thoughts to stimulate conversation, hopefully build shared understanding and help strengthen our collective approach to digital patient safety across the UK. The growing complexity of digital healthcare Digital healthcare has evolved rapidly, and with that evolution comes complexity. Electronic health records, diagnostic platforms, telehealth solutions, national and local systems—all interacting with each other in ways that aren’t always obvious. When something goes wrong, pinpointing where the issue originated can be incredibly challenging. Was it a configuration setting? A workflow design flaw? A user misunderstanding? A vendor update? A mismatch between national and local versions of the same system? Add to that, the fact that some third‑party suppliers are unable or unwilling to share detailed technical information (I assume due to concerns that competitors may gain access to it) makes it even harder to determine how the incident occurred or how to prevent it from happening again. Interconnected systems, shared responsibilities Because digital care rarely sits within a single organisation, the responsibilities for harm often cross boundaries too. Different organisations use systems differently. Local configurations vary. Some teams rely on national services; others are still using legacy versions. All of this makes investigation slower, more complicated and highly dependent on strong cross‑organisational collaboration. No single organisation can fully assess digital‑related harm in isolation, but still we try! The challenge for non-patient‑facing Health Bodies For organisations like mine, there is an added complexity: we don’t have direct clinical access to patients. This means our ability to assess harm depends on the engagement of colleagues across health boards and trusts—many of whom are experiencing significant operational pressures. Data security and privacy Sharing information about harm while protecting patient data is essential, but not always simple. We must balance transparency with strict confidentiality requirements. Digital errors, diagnostic risks and human interpretation Not all harm is caused directly by digital systems. Sometimes the system works correctly, but the presentation of the data creates an issue, or the clinician/user interaction or interpretation of the data is the issue. Other times, issues stem from algorithmic limitations, technical malfunctions or messaging fabric (infrastructure that connects the system components and allows them to communicate) problems. Determining whether harm originated with the tool, the user or the interaction between them is rarely straightforward, and tools like Systems Engineering Initiative for Patient Safety (SEIPS) are vital in breaking this complexity down. Training, local workarounds and the gaps no one talks about Training remains a significant challenge. National bodies like mine are not responsible for delivering frontline training, and local approaches vary widely. This leads to several risks: Depth and quality of training varies. Important system features may be misunderstood or overlooked. Safety considerations are not always emphasised during training. Local 'shortcuts'—never designed, tested or approved—become normal practice. Once these shortcuts become embedded in everyday workflows, they can be incredibly difficult to unwind. Yet they often play a significant role in digital‑related incidents. The existing DCB0129 and DCB0160 standards provide a useful foundation, but they offer limited guidance on how to investigate and learn from digital incidents. They were designed at a time when digital healthcare was far less complex than it is today. Suppliers don’t like to highlight their products weaknesses or errors made; therefore, there is vast variation in the quality of investigation reports shared post incident. Rather than worrying about reputational damage, I wish the focus was on candour and opportunities for learning and development. The timeliness problem: when harm takes time to surface Digital harm isn’t always immediate. It may be a misfiled result, a confusing display or a workflow that gradually introduces delay. Additional challenges include: Variation in national policy timescales (in Wales six differing policies provide timescale guidance). The need for clinical review to confirm harm. Limited capacity among clinicians supporting digital investigations. This can make it difficult to meet regulatory expectations for timely disclosure—even when everyone involved is committed to doing the right thing. Freedom to Speak Up: a critical enabler of early detection Speaking up plays a vital role in identifying digital‑related safety issues early. Many concerns emerge informally at first—“this doesn’t look right” or “this field always causes confusion.” If staff feel unsure about raising these concerns, they can remain hidden until harm occurs. Strengthening a Freedom to Speak Up culture is essential. It provides all staff a protected route to escalate concerns, even when they feel uncertain or worry that a system issue might be dismissed as user error or a training gap. I firmly believe that a strong speaking up culture means digital risks are more likely to be surfaced early, before they become incidents. A rapidly changing safety landscape Wales has seen significant changes in digital governance and health policy in recent years, from the transition from NHS Wales Informatics Service (NWIS) to Digital Health & Care Wales (DHCW) to updates in national structures (NHS Executive now NHS Performance & Improvement) and regulatory expectations. As I type, the National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011 (often referred to as 'Putting Things Right') are undergoing review and update. These shifts can create uncertainty about roles, responsibilities and reporting pathways. When something goes wrong, it’s not always clear who is responsible for what—and this ambiguity can complicate harm assessment. Where digital meets traditional healthcare Digital systems are embedded into clinical workflows, communication pathways and multi‑team processes. Every interface, integration point and manual interaction/data entry represents a potential source of risk. Reviewing these interconnected pathways is rarely quick or straightforward, but it is essential for understanding how digital harm occurs and how it can be prevented. Conclusion and call to action: building a safer digital future together The reflections in this paper highlight the complexity of digital patient safety work. Digital systems bring enormous potential for improving care, but they also introduce new risks that we are still learning how to manage. To address these challenges, we need a coordinated national approach that brings together healthcare organisations, digital suppliers, clinical safety experts, policymakers and frontline staff. This means: Updating and strengthening digital safety standards. Improving consistency in both incident investigation and harm assessment. Enhancing training and digital literacy. Supporting timely, transparent reporting. Facilitating availability of clinicians to undertaken harm reviews. Encouraging openness and speaking up. Improved incident data triangulation. Thematic analysis of incidents and nationally shared learning. Building stronger cross‑organisational collaboration. Most importantly, we need a culture where digital concerns are raised early and acted upon quickly. The opportunity ahead is significant, as are some of the challenges… But I truly believe that by working together, we can shape a safer digital health landscape—one that protects patients, supports professionals and ensures that innovation enhances care rather than complicating it. Further reading on the hub: How do we harness technology responsibly to safeguard and improve patient care? NHS England warns electronic patient record could pose ‘serious risks to patient safety’: what can we learn? The foundations for a safe digital service delivery in health—A blog by Rob Ludman Applying a robust approach to digital clinical safety in diagnosis b