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In healthcare, we often talk about 'never events'—serious incidents that should not occur if appropriate systems are in place. But what happens when they do occur? I recently had the great pleasure of working with a group of anaesthetic resident doctor colleagues on a patient safety project that began with exactly that question. Within a short period in 2025, our large UK teaching hospital experienced two wrong-sided peripheral nerve blocks after six years without a single reported incident. We wanted to understand why. Looking beyond individual error Both incidents occurred during a major transition: we were moving anaesthetic records, consent forms and safety checklists from paper to digital. At first glance, the timing felt more than coincidental. After initial governance processes were completed, our team used the Patient Safety Incident Response Framework (PSIRF)[1] to explore what had happened. Introduced in the NHS in 2022, PSIRF promotes a systems-based approach rather than searching for a single 'root cause'. It examines how elements such as people, tasks, tools and technology, environment and organisational factors interact to increase risk. For us, this shift in perspective proved crucial. Instead of asking “who made this mistake?”, we were able to consider “what conditions made this error more likely?”. What we found: small gaps in a complex system We brought together a multidisciplinary 'learning MDT', combining insights from staff interviews and systems analysis. A clear pattern emerged: no single failure caused these incidents. Instead, multiple small vulnerabilities aligned. One issue stood out. In our previous paper-based system, clinicians used a 'Stop Before You Block' (SBYB) sticker—a simple but effective visual cue prompting a final safety pause before performing a nerve block. During the digital transition, this physical prompt disappeared. Other contributing factors reinforced the problem: Staff worked under cognitive overload, juggling interruptions, changing plans and high-acuity patients. Digital consent processes made SBYB checks feel more cumbersome, drawing attention away from the patient and towards the computer. Poor visibility of surgical site markings increased the barriers to performing SBYB. Ergonomic challenges in anaesthetic rooms made equipment setup frustrating. Time pressure on theatre lists encouraged task compression. In both cases, clinicians skipped the SBYB pause entirely—not out of negligence, but because the system no longer reliably supported it. These events didn’t reflect individual failure. They reflected a system under strain during organisational change. From insight to action: designing safer systems We knew we couldn’t eliminate complexity from clinical environments, but we could design systems that make the safe action the easy action. We developed a multi-faceted improvement plan. 1. Strengthening standards and education We updated our local guidance, aligning it with national recommendations from the Safe Anaesthesia Liaison Group and Regional Anaesthesia UK.[2] We rebranded it as the 'Prep Stop Block LocSSIP' (Local Safety Standard for Invasive Procedures). We promoted this through clinical governance meetings and delivered targeted teaching to consultants, trainees and anaesthetic practitioners. To support sustainability, we embedded a training video into the anaesthetic resident doctor induction programme and uploaded it to our intranet. 2. Fixing friction in the system We addressed practical barriers: Improved access to longer ultrasound cables. Standardised surgical site markings to improve visibility. Explored integrating anaesthetic complexity into theatre scheduling. Trialled LED signs to indicate when the anaesthetic room is in use; thus creating a 'sterile cockpit' by discouraging interruptions during anaesthetic procedures. Introduced electronic tablets so consent forms could be viewed alongside the patient and checklist. Each of these changes aimed to reduce cognitive load and create space for safer practice. 3. Introducing a physical safety barrier Our most impactful intervention was the 'Prep Stop Block Lid'. We designed a lidded box displaying a safety infographic. Clinicians place prepared local anaesthetic inside and cannot access it until they complete the SBYB pause. This shifts safety from memory to physical design, creating a clear pause point in the workflow. We refined the intervention through Plan–Do–Study–Act (PDSA) cycles with frontline feedback before wider rollout. What we’ve learned so far Early data show improvements in process measures, including increased visibility of the SBYB step. Audits of Prep-Stop-Block compliance suggest an improvement from 34% during digital transition to 100% at most recent review. However, we remain cautious. We are still in a 'zone of vulnerability', where changes are ongoing and their full impact is unclear. Because never events are (fortunately) rare, it will take time to determine whether these interventions reduce harm. That said, several key lessons have already emerged: Never events are rarely about individuals. They arise from system conditions that make errors more likely. Digital transformation can unintentionally remove safety cues. We must actively design these back into new systems. Education and policy are necessary but insufficient. The most reliable safety interventions are embedded into workflow, especially physical or procedural 'forcing functions'. A call to action If your department is undergoing digital transformation, take a moment to ask: “What safety cues might we be losing—and how will we replace them?” We need to move beyond simply digitalising existing processes. Instead, we should use these transitions as opportunities to design safer, more resilient systems from the ground up. Because when it comes to patient safety, 'never' is not a guarantee, it’s a goal we must actively work towards. References https://www.england.nhs.uk/long-read/patient-safety-incident-response-framework/ https://www.salg.ac.uk/salg-publications/stop-before-you-block/

The 8th Nordic Conference on Research in Patient Safety and Quality in Healthcare 2026 brings together experts, researchers, and professionals from across the Nordic-Baltic region to discuss how health and social care systems can adapt to change while ensuring safety, quality, and equity. Keynote speakers include leading voices in health policy, research, and digital transformation: Lasse Lehtonen (Kela), Liina-Kaisa Tynkkynen (Finnish institute for health and welfare), Anne Moen (University of Oslo), Josephine Ocloo (King’s College London), and Henrique Martins (Universidade da Beira Interior / ISCTE-IUL). The program features national and regional perspectives on client and patient safety, discussions on the use of artificial intelligence in healthcare, and presentations on medication safety, rehospitalization, home treatment, and client safety in social services. The conference also explores key issues such as digital health literacy, citizen engagement, educational innovations, and the impact of inequity in client and patient safety. Together, these sessions aim to strengthen collaboration, share evidence-based practices, and inspire progress toward safer and more effective health and social care across the Nordic-Baltic region. The conference also aims to foster dialogue between health and social care quality and safety and warmly welcomes social care experts, researchers, and practitioners to join the conference. Register

The Safety 360° Summit is a curated, high-level event that for the first time brings together senior European leaders from diverse risk domains in a cross-industry dialogue on the central safety challenges of our time. Cyberattacks, AI-driven disinformation, rising geopolitical tensions, and societal polarisation simultaneously shape today’s landscape of safety and risk – yet they are still largely addressed in isolation within industry-specific silos. The Safety 360° Summit transforms this fragmentation into a shared strategic dialogue, laying the foundation for more effective responses to the central safety challenges of our time. Register

The RiskReimagined 2026 Conference is a premier event for sharing best practice and innovation, designed to help NHS professionals move from awareness to applied implementation. Delegates will gain hands-on frameworks, tested delivery models, and peer-derived insights on embedding safe, equitable, and sustainable transformation within their organisations. Dedicated Skill Clinics provide practical tools, checklists, and implementation templates for enhancing governance, risk oversight, and incident response. Lessons Learned Sessions offer candid reflections from NHS leaders on real-world challenges, course corrections, and successes. This is not a showcase of what to achieve, but a skills exchange on how to achieve it, translating national ambition into measurable improvement. This year’s event is structured around clear outcomes. Delegates will leave understanding: Evolving governance for safer care: clarifying responsibilities for safety oversight at system level and strengthening board leadership, accountability, and assurance around quality and risk. Applying AI and early warning systems: improving early identification of emerging risks and embedding proactive approaches to risk management into everyday clinical practice. Building a learning culture from incidents: encouraging open reporting, meaningful follow-up, and consistent learning from incidents, including effective use of PSIRF, HSSIB insights, and safer medicines management. Strengthening the Estate infrastructure: addressing weaknesses in estates, equipment, and organisational preparedness, while strengthening plans to maintain care during disruption. Improving continuity and trust in patient information: supporting joined-up care through better stewardship, sharing, and governance of patient records, enabling a single, trusted view of the patient journey. Building workforce risk capability: through targeted training, multidisciplinary governance structures, and safety leadership aligned with People and Quality frameworks. Why attend: Earn 8 CPD Points by attending. Build professional confidence through applied, hands-on learning. Access ready-to-use frameworks for governance, interoperability, and workforce transformation. Hear real experiences from peers and leaders driving NHS improvement. Leave with practical artefacts, toolkits, and action plans for local rollout. Join a community of NHS professionals committed to capability-building and sustainable delivery. Who would benefit: This conference is ideal for Board Members, Chief Executives, Governance and Quality Leads, Patient Safety Managers, Risk and Assurance Directors, and ICS Executives driving NHS transformation. It will also benefit clinical and operational leaders, CCIOs, CIOs, service managers, and workforce planners seeking practical guidance on embedding safety, accountability, and resilience. Suppliers, digital partners, and academic collaborators will gain insight into implementation priorities, workforce skill gaps, and the real-world enablers shaping the next decade of NHS transformation. Register

The Green Nursing Challenge Showcase was held on 20 October 2025 celebrating the outstanding work of six teams from hospital and social care settings—an award-winning leadership and engagement programme dedicated to transforming healthcare. The six clinical teams presented their Sustainable Quality Improvement (SusQI) projects to a judging panel, focusing on key priorities identified through carbon footprint measurements, partner collaboration and input from people with lived experience. Themes included valuing people’s time, supporting informed choices, improving access and experience for underserved groups, and addressing complex care, pelvic health and continence—all aimed at reducing environmental harm and tackling health inequalities in nursing care. Winning team Winner: Norfolk and Norwich University Hospitals NHS Foundation Trust recognised for their close collaboration between professionals across both maternity and inflammatory bowel disease (IBD) services, working together to deliver more efficient, person-centred and environmentally sustainable care. Highly commended: Oxfordshire Health NHS Foundation Trust for their joint District Nurse & Diabetic Nurse Specialist reviews, optimising care for patients in the community, reducing harms and the need for hospital admissions. Showcase outcomes and learning The Green Nursing Showcase celebrated the inspiring work of the six project teams who took part in the Green Nursing Challenge 2025. Together, these teams are helping to shape more sustainable and equitable nursing care. During the event, each clinical team presented their Sustainable Quality Improvement (SusQI) projects, focussing on priority areas identified through collaboration with challenge partners, carbon footprinting analysis, and discussions with patient and staff groups. The event’s keynote speaker was Charlotte McCardle, Global nurse consultant and former CNO for Northern Ireland and DCNO at NHS England, who spoke of nurses and midwives being the “…holders of hope, the voice of the vulnerable, and the champions of change. I believe you are very well placed to lead. Don’t undersell in any way your work… You can use what you’ve created in your projects to break down barriers for others.” The Challenge demonstrates how nurses and midwives can play a crucial role in achieving the NHS’ Net-Zero targets. By making changes in working practices, nurses can lead action to minimise the environmental harm created from healthcare services, and can help address health inequalities, improve outcomes and experiences, and contribute to a more sustainable healthcare system. To hear more about the individual projects follow the link: Green Nursing Showcase 2025 — Sustainable Healthcare

Over the past 15 years, Martin Fletcher has been part of transformational change in professional regulation through his tenure as Chief Executive of the Australian Health Practitioner Regulation Agency (Ahpra). In this blog for the hub, Martin shares Australia's regulatory journey and reflects on the UK's more gradual path to reforming their legislative frameworks. He highlights both countries' shared common goals and the challenges faced along the way. He ends the blog with three priorities for future action: integrating professional regulation into system safety, better use of data to anticipate risk and embedding equity and cultural safety. Effective regulation is a cornerstone of safe, quality healthcare, regardless of the health profession or practice context. We all know that healthcare is changing rapidly and regulation of health professionals must evolve with it.[1] This means that adaptability and the ability to pivot are essential competencies for any professional regulator.[2] Establishing the Australian Health Practitioner Regulation Agency Over the past fifteen years, I have been part of transformational change in professional regulation through my tenure as Chief Executive of the Australian Health Practitioner Regulation Agency (Ahpra). In 2010, Australia launched the National Registration and Accreditation Scheme, consolidating 85 separate registration boards and 65 pieces of legislation into a single national regulatory scheme.[3] The goals were clear: to create national consistency, support workforce mobility, raise standards for public protection and promote greater integration between professional groups delivering health and care.[4] Through this reform, Ahpra was established to administer these national regulatory arrangements in partnership with 15 National Boards, which now cover over 930,000 health practitioners across 16 professions. The UK's path to reform Transformational change in professional regulation is rare and the UK has taken a more gradual path to reform. Over a number of years, UK regulators have called for action to modernise their legislative frameworks. In response, the UK government’s consultation on Regulating Healthcare Professionals, Protecting the Public underscored the need for faster, more flexible regulation that supports innovation while safeguarding safety.[5] Yet, legislative change has been much slower, sometimes taking years to come to fruition, and, unlike Australia, the UK continues to deliver professional regulation through 10 independent regulatory bodies with differing legislative frameworks. Regulatory work is highly situational and dependent on numerous stakeholders, at times with competing views of public interest.[6] And in both Australia and the UK, there is ongoing debate about the timeliness, responsiveness and proportionality of regulatory responses to fitness to practice concerns and the issues to consider in assessing the suitability of someone to be a registered health practitioner.[7] Common goals Despite differences in the pace of change and the structure of professional regulatory arrangements, both countries share common goals: protecting patients, supporting the professionalism and ethical conduct of practitioners, responding to public expectations, and ensuring regulation keeps pace with the changing health care landscape and responds to workforce needs. The Covid-19 pandemic exposed both the strengths and limitations of our regulatory systems. In both countries, regulators responded quickly—fast-tracking registration pathways, adjusting accreditation requirements and convening stakeholders to support a surge workforce. This demonstrated that regulation can be agile when safety is at stake. The crisis reinforced the importance of collaborative regulation—where professional oversight is part of a broader safety ecosystem. Connecting professional regulation with system-wide efforts Nonetheless, one of our shared challenges is better connecting professional regulation with system-wide efforts to improve patient safety. Traditionally, professional regulation has focused on the conduct, competence and performance of individual health practitioners. As I saw from my tenure as Chief Executive of the NHS National Patient Safety Agency, patient safety is shaped by a range of factors, including clinical governance, team dynamics, design of systems and processes, technology and organisational safety culture. The rapidly growing cosmetic practices sector illustrates these challenges vividly. In both Australia and the UK, reviews have shown that regulating practitioners alone isn’t enough.[8][9] Products, procedures, facilities, social media, information asymmetry and weak professional ethics all contribute to risk of harm to patients. Without coordinated action across agencies, patients remain vulnerable. More widely, the rise of entrepreneurial models of care, telehealth, unregulated medicines for sale online, social media and AI-driven diagnostics has introduced new risk profiles to which traditional regulatory frameworks and approaches to patient safety must adapt. These shifts demand new thinking around safety, accountability, transparency and equity. A way forward Let me suggest three priorities for future action: Integrate professional regulation into system safety: We must work more closely with service, product and system regulators, and improvement bodies. Shared goals and aligned actions are critical. When regulators operate in silos, we risk missing the bigger picture. At the same time, patient safety system advocates must give due recognition to the critical role of ethical, safety-conscious, competent and accountable health professionals at the frontline of care. Better use of data to anticipate risk: Ahpra and UK regulators hold vast datasets. By investing in analytics and research, we can shift from reactive to proactive regulation. Notifications and complaints are often lag indicators—we need to get ahead of emerging risks of harm, especially in the face of the many healthcare disruptors we face. Embed equity and cultural safety: Regulation must reflect the many communities we serve. That means listening to lived experience and addressing systemic barriers. In the Australian context, this has meant facing the ugly reality of racism in the healthcare system for Aboriginal and Torres Strait Islander Peoples. The naming of racism in the National Law, which underpins the regulatory arrangements in Australia, has been a powerful catalyst for action.[10] Undoubtedly, the UK faces similar challenges in addressing racism in a multicultural society.[11] Regulation is more than rules—it’s about trust, transparency and care. As Australia marks 15 years of national regulation and the UK continues its reform journey, it is essential to place patient safety at the heart of everything we do and close the gap between professional oversight and system-wide efforts to improve safety. References Professional Standards Authority for Health and Social Care. Reviewing right-touch regulation: discussion paper. London: PSA; March 2025. Institute of Regulation. Rapporteur report: annual conference of the Institute of Regulation 2025. London: Institute of Regulation; 2025. Australian Health Practitioner Regulation Agency. Annual Report 2009-10. Melbourne: Ahpra; 2010. Fletcher M. Reflections on 15 years of National Health Practitioner Regulation in Australia. Australian Health Review 2025; 49, AH25131. https://doi.org/10.1071/AH25131 Regulating healthcare professionals, protecting the public: consultation response - executive summary - GOV.UK Austin Z. Regulation of wicked problems: opportunities, responsibilities, and threats. J Med Regul. 2023;109(3):6–11. doi:10.30770/2572-1852-109.3.6 National Health Practitioner Ombudsman and Privacy Commissioner. Investigation into delay and procedural safeguards for practitioners who are subject to immediate action. Melbourne: NHPPC; June 2024. Brown A, Duggan A, Kirkland A, McCausland R. Independent review of the regulation of medical practitioners who perform cosmetic surgery: Final report. Melbourne: Australian Health Practitioner Regulation Agency; August 2022. The regulation of non-surgical cosmetic procedures in England - House of Commons Library Australian Health Practitioner Regulation Agency. Joint statement: Aboriginal and Torres Strait Islander health and cultural safety at heart of National Law changes Melbourne: AHPRA; October. Accessed 15 June 2025. Royal College of Nursing. RCN reports 55% rise in members facing racist abuse. 27 October 2025.

Join Aqua for their national event, ‘Transforming Tomorrow Through Leadership and Improvement Today’ to connect, learn, and shape the future of health and care through co-production and partnership working. It will be bringing together healthcare leaders, innovators, and change-makers for an afternoon of insightful discussion and meaningful connections as we mark 15 years of the Advancing Quality Alliance being the leading improvement partners. With an exciting line-up of speakers and time for discussion and networking, this event is an opportunity for you to gain fresh perspectives and reconnect with peers. Register

The first of four webinars co-hosted by the WHO Department of Integrated Health Services (IHS) and the Global Health Partnerships (GHP) (formerly THET) to explore the transformative potential of relationality in community engagement and how it can be leveraged for people-led change. It’s part of a series being run by WHO and the Global Health Partnerships (GHP) (formerly THET), building on last year’s policy report on this issue launched at the World Innovation Summit for Health (WISH) https://wish.org.qa/wp-content/uploads/2024/09/Relationality-in-Community-Engagement.pdf Register

Integrated care systems (ICSs) have the potential to radically transform health and care through collaboration, long-term thinking, and by pushing the boundaries of what is possible. In this summit, we give voice to innovative thinking and practices by hearing from senior leaders and partners from both within and outside of the health and care service, who have found ways to create meaningful impact by doing things differently. Be inspired by leaders who despite challenging circumstances and a backdrop of a 30% reduction in running costs have carved out opportunities for collaboration to create transformational change. Join us at this event to be at the forefront of discussions and debate on how ICSs can work differently to meet the needs of their local populations and fulfil their original purpose. Through keynote speeches, panel debates, case studies and interactive workshops, this summit will explore: how we meet the potential of ICSs to transform health and care the importance of focusing on prevention as a way of sustainably meeting the needs of local populations, and the role data has in it how provider collaboratives and Integrated Care Boards (ICBs) can work together differently and effectively to deliver integrated care services how reconvening community services so that care is moved closer to home can potentially transform the health and care system the value of working with patients and communities to provide better services how system-wide solutions can be utilised to tackle the workforce crisis what leading in uncertainty feels like and what can be learnt from it. Register

Patient Safety Movement Foundation invites you to the 11th World Patient Safety, Science & Technology Summit. Patient safety thought leaders and advocates from around the globe will come together to share their expertise and develop transformative solutions to enhance safety and outcomes of care for patients worldwide. Register