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This webinar is jointly sponsored by the International Society for Quality in Healthcare (ISQua) and American Academy of Pediatrics' Council on Quality Improvement and Patient Safety (AAP COQIPS) Join us for our first ISQua - AAP COQIPS webinar! In this interactive webinar you will learn about implementation tools and resources to decrease medication errors in the ambulatory paediatrics setting. These tools can also be applied to children with medical complexity, who are frequently at higher risk for medication errors due to challenges with care fragmentation, miscommunication, and polypharmacy. Register for the webinar

Pharmacy Forum NI and the DoH Strategic Planning & Performance Group (SPPG) have created a three-part webinar series entitled, ‘A systematic Approach to Insulin Safety in Community Pharmacy’. The first webinar in the series will take place on Wednesday 21 September 2022 at 7-9pm via Zoom and will focus on an introduction to human factors, concepts & tools, and their relevance to patient/medication safety and the wellbeing of the pharmacy team. Event programme and registration Who should attend? These events are targeted at all members of the community pharmacy team who play a part in the safe supply of medicines to patients, namely: pharmacists and foundation trainee pharmacists pharmacy technicians and assistants owners and superintendents medicines safety leads Guest speakers We are delighted to partner with Professor Paul Bowie and Dr Helen Vosper for the three-part event series. Professor Paul Bowie is a Safety Scientist, Medical Educator and Chartered Ergonomist and Human Factors specialist. He has over 25 years’ experience in a range of quality and safety leadership and advisory roles in healthcare, medical defence, military medicine and academia. He gained his doctorate in significant event analysis from the University of Glasgow in 2004 and has published over 150 papers on healthcare quality and safety in international peer-reviewed journals and co-edited a book on safety and improvement. Paul is also Honorary Professor and a PhD supervisor/examiner in the Institute of Health and Wellbeing at the University of Glasgow and a Visiting Professor at Queen’s University, Kingston, Canada. He is Honorary Fellow of the Royal College of Physicians of Edinburgh and the Royal College of General Practitioners, and a Chartered Member of the UK Institute of Ergonomics and Human Factors where he is the patient safety lead of the healthcare specialist interest group Dr Helen Vosper is a chartered ergonomist and graduate of the Loughborough Human Factors Masters Programme and an academic with 15 years’ experience of teaching Human Factors to healthcare students and professionals, including pharmacy students and pharmacists. She is currently the lead for Patient Safety in the School of Medicine, Medical Sciences and Nutrition at the University of Aberdeen. Helen also has a part-time role as a Senior Investigation Science Educator at the Healthcare Safety Investigation Branch and is a scientific adviser in Human Factors and Patient Safety to NHS Education for Scotland.

The Patient Academy for Innovation and Research (PAIR), Organisation of Pharmaceutical Producers of India (OPPI) and DakshamA Health are celebrating World Patient Safety Day, with a webinar on the theme of "Role of stakeholders in GPSAP in the country's context to ensure medication safety". This event will bring all the stakeholders together to discuss their roles in ensuring medication safety and reducing medication-related harm through strengthening systems and practices of medication use, making the process of medication safer and free from harm and galvanizing action on the challenge by calling on all stakeholders to prioritize medication safety and address unsafe practices and system weaknesses. The objectives of World Patient Safety Day 2022 by WHO are - RAISE global awareness of the high burden of medication-related harm due to medication errors and unsafe practices, and ADVOCATE urgent action to improve medication safety. ENGAGE key stakeholders and partners in the efforts to prevent medication errors and reduce medication-related harm. EMPOWER patients and families to be actively involved in the safe use of medication. SCALE UP implementation of the WHO Global Patient Safety Challenge: Medication Without Harm. Register for the webinar The webinar will take place at 3.00-4.30 IST (10.30am-12pm BST)

Medication-related harm accounts for up to half of the overall preventable harm in medical care. Patients in low- and middle-income countries are twice more likely to experience preventable medication harm than patients in high-income countries. Considering this huge burden of harm, “Medication Safety” has been selected as the theme for World Patient Safety Day 2022. To commemorate the day, WHO is organizing a Global Virtual Event, calling on all stakeholders to join efforts globally for “Medication Without Harm”. During the event, stakeholders will discuss medication safety issues within the strategic framework of the WHO Global Patient Safety Challenge: Medication Without Harm, including 1) Patients and the public, 2) Health and care workers, 3) Medicines, and 4) Systems and practices of medication. Interpretations will be available in Arabic, Chinese, English, French, Hindi, Portuguese, Russian and Spanish. Register for the webinar Save the date-flyer_Global Virtual Event WPSD 2022_15 September 2022.pdf

To mark the annual World Patient Safety Day, three organisations - COHSASA of South Africa, AfiHQSA of Ghana and C-CARE (IHK) of Uganda - are collaborating to bring you the latest thinking across Africa regarding 'Medication without harm', the theme for WHO's Third Global Patient Safety Challenge. The Challenge aims to reduce the global burden of iatrogenic medication-related harm by 50% within five years. Join us to hear new ideas, visions and solutions to address medication-related adverse events which cause untold death and suffering around the world. Register for the meeting FINAL INVITE FOR WPSD WEBINAR.pdf

As this year's theme of World Patient Safety Day 2022 is "Medication safety" and increasing awareness about safe medication usage in clinical practice, the Peerless Hospital, Kolkata, India, are organising a one day conference " MediSafeCon" dedicated to increasing awareness about patient safety and medication safety in clinical practice among pharmacists, nurses and doctors. The following sessions by leading doctors, pharmacists, nurses and medicolegal experts of West Bengal and India: 1. Medication safety issues in Critical Care practice 2. Medication safety issues in Pediatric practice 3. Medication safety issues in Oncology practice 4. Medication safety issues in Gastroenterology practice 5. Medication safety issues in Surgical practice 6. Medication safety issues in Domiciliary care 7. Medication safety issues in Telemedicine services 8. Medication errors and Medicolegal implications. Information brochure Medisafecon_brochure.pdf

The International Alliance of Patients’ Organizations (IAPO) and Patient Academy for Innovation and Research (PAIR Academy) in partnership with Dakshama Health are launching a series of webinars to introduce the Strategic Framework of the Global Patient Safety Challenge - Medication Without Harm. The 4th webinar of the medication without harm webinar series is scheduled on June 18th, 2022, from 11:30 to 12:30 GMT. The theme is "Importance of Systems and Safe Medication Practices for patient safety”. This webinar will emphasize on the "Importance of Systems and Safe Medication Practices for patient safety ", within WHO’s Global Patient Safety Challenge: Medication Without Harm, to improve medication safety. The patient safety series of webinars will focus on the strategic framework of the Global Patient Safety Challenge, which depicts the four domains of the challenge: patients and the public, health care professionals, medicine, and systems and practices of medication, and the three key action areas—namely polypharmacy, high-risk situations, and transitions of care, The series of webinars will share challenges, technical strategies, tools, and patient experiences in implementing the Strategic Framework of the Global Patient Safety Challenge to reduce medication-related harm. Register for the webinar

Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. WHO Patient Safety Flagship has initiated a series of monthly webinars on the topic of “WHO Global Patient Safety Challenge: Medication Without Harm”,. The main objective of the webinar series is support implementation of this WHO Global Patient Safety Challenge: Medication Without Harm at the country level. Considering the huge burden of medication-related harm, Medication Safety has also been selected as the theme for World Patient Safety Day 2022. With each transition of care (as patients move between health providers and settings), patients are vulnerable to changes, including changes in their healthcare team, health status, and medications. Discrepancies and miscommunication are common and lead to serious medication errors, especially during hospital admission and discharge. Countries and organizations need to optimise patient safety as patients navigate the healthcare system by setting long-term leadership commitment, defining goals to improve medication safety at transition points of care, developing a strategic plan with short- and long-term objectives, and establishing structures to ensure goals are achieved. At this webinar, you will be introduced to the WHO technical report on “Medication Safety in Transitions of Care,” including the key strategies for improving medication safety during transitions of care. Register

Patient Academy for Innovation and Research (PAIR Academy) and the International Alliance of Patients’ Organizations (IAPO) are launching a series of webinars to introduce the Strategic Framework of the Global Patient Safety Challenge - Medication Without Harm. The theme of the second webinar of the medication without harm webinar series is "Role of Healthcare Professionals in Ensuring Medication Safety”. Register for the webinar

1 Blog - Inappropriate prescribing during a pandemic: dementia and antipsychotics A growing number of people with dementia who live in care homes are being prescribed antipsychotic medication, but there are serious questions about whether these drugs are being prescribed appropriately. In this blog, a family describes how their father with Alzheimer’s disease came to be prescribed antipsychotic medication at his care home. They raise concerns about the decision to prescribe antipsychotics when there were obvious non-drug based alternatives to pursue, the lack of involvement the family had in the decision-making process and the negative ways in which the medication has affected their father’s personality. 2 Belfast Healthy Cities: Pharmacy Schools Programme (2021) The Pharmacy Schools Programme is an innovative teaching resource developed by Belfast Healthy Cities. Using a health literacy approach, it is designed to be used in primary schools in Northern Ireland to help educate children about self-care, medication safety and community pharmacy services. 3 WHO - Medication safety webinar series: engaging patients and families for medication safety (8 March 2022) As part of its Third Global Patient Safety Challenge: Medication Without Harm, WHO launched a series of webinars to introduce the strategic framework, technical strategies, tools for reducing medication-related harm. You can access the presentations from this webinar focused on engaging patients and their families to improve medication safety: Patient engagement tool: “5 Moments for Medication Safety”, Nagwa Metwally and Helen Haskell Patients, families and health workers partnering for medication safety, Dr Irina Papieva Developing programmes for patient and family engagement - Canadian experience, Ioana Popescu and Maryann Murray 4 Patient Safety Spotlight interview with Marie Lyon, chair of the Association for Children Damaged by Hormone Pregnancy Tests In this interview, Marie Lyon talks about her campaign for justice for families affected by hormone pregnancy tests, why she is passionate about reforming medicines regulation and the important role patient campaigners play in improving patient safety. 5 Blog - Please don’t undermine my pain relief! A call for learning and respect for patients with long term needs This blog calls for action on the careful review of established pain medication when a patient is admitted to hospital. The author, Richard von Abendorff, describes the experience of two elderly patients who suffered pain due to their long term medication being stopped when they were admitted to hospital. He highlights the importance of ensuring that pain management needs are not ignored or undermined and argues that there needs to be carer and patient involvement and their consent when making a decision to stop established pain medication. 6 HSE Ireland - My Medicines List leaflet (January 2020) This leaflet produced by the Irish Health Services Executive (HSE) provides a central place for patients to record information about their medications. It acts as a reference point for patients to use when discussing their medications with a healthcare professional and includes a reminder of the Know, Check, Ask campaign, aimed at reducing medication errors in the community. 7 Blog - Digitising pharmacy: Bilingual medication information on pharmacy dispensing labels (July 2022) This blog by NHS England looks at how a service which provides bilingual medication information is helping to reduce healthcare inequalities and medication errors in London. Written Medicine’s software allows pharmacies and hospitals to translate and print medication information, instructions and warnings. Drawn from a dataset of 3,500 phrases, printed labels are available in fifteen different languages. The bilingual labels help patients take ownership of their treatment, giving them a better understanding of how to take their prescribed medication. The solution is helping to reduce errors, improve medication adherence and enhance patient safety and experience. Take a look at our Top picks for World Patient Safety Day 2022: Medication safety in hospitals

A medication error is defined as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer,” according to the National Coordinating Council for Medication Error Reporting and Prevention. An estimated 237 million medication errors occur in the NHS in England every year.[1] This number represents the sum of medication errors over all stages of the medication use process. Most errors occur during drug administration (54%), followed by prescribing (21%) and dispensing (16%). The majority of medication errors (72%) have little/no potential for harm, and only 2% have potential to cause severe harm. One of the recommendations to reduce medication errors and harm is to use the “five rights”: the right patient, the right drug, the right dose, the right route, and the right time. According to the NHS Patient Safety Strategy, “Medication errors are any Patient Safety Incidents (PSI) where there has been an error in the process of prescribing, preparing, dispensing, administering and monitoring or providing advice on medicines". The NHS Medicines Safety Improvement Programme has been established to address the most important causes of severe harm associated with medicines and aims to reduce severe avoidable medication-related harm by 50% by March 2024. Prescribing errors can be reduced by incorporating decision support software into the electronic prescribing protocol, although many of the warnings generated by this type of software are of no clinical significance and are often regarded as an intrusion or an inconvenience and are usually ignored. A pharmacist’s signing off a prescription before it is dispensed will also capture potential prescribing errors. Dispensing errors are usually identified before the prescription is issued by a second check but with the introduction of dispensing/distribution robots in most hospital pharmacies, dispensing errors have almost been eliminated. The focus today is to reduce drug administration errors. In surveys, the most common errors were late or early administration of drugs or drug omission. Distractions and interruptions are a regular part of nurses’ working lives. If these occur when nurses are preparing and administering medicines, they can lead to drug errors that compromise patient safety. Poor numeracy and the need for complex calculations have also been highlighted as contributory factors to medication errors in both hospitals and in the community. However, many of these errors can be eliminated by the provision of medicines in a ‘ready-to-administer’ format where no manipulation is required before administration to the patient. Individual doses should have machine readable codes on the label to ensure correct drug identification. Ready-to-administer injections (RTA) Injectable drugs should be made available in a ready-to-administer (RTA) format. The World Health Organization (WHO) defines RTA as “an injectable medicine that requires no further dilution or reconstitution and is presented in the final container or device, ready for administration or connection to a needle or administration set”. The preparation of IV medications at the bedside requires multiple steps and reducing these complex steps and manipulations can reduce the number of errors. Additionally, the use of prefilled RTA syringes can help reduce unnecessary wastage of medications by optimising pharmaceutical product size. Healthcare professionals responsible for administering injectable drugs should demand RTA preparations. In the first instance, hospital pharmacies should prepare high-risk injectable medicines in their aseptic compounding units or purchase them from third party contractors. Looking to the future, the pharmaceutical industry should offer licensed injectable medicines in a RTA format. Manufacturer-prepared RTA prefilled syringes can play an important role in simplifying these processes and reducing errors and potential patient harm. When contracts for injectable drugs are awarded, priority should be given to those products that are presented in a RTA format. Purchasing for safety must be implemented and not just discussed. Unit dose drug distribution (UDD) Unit dose drug distribution is a system that provides the prescribed dose of a specific drug for a certain patient at a specific time. It differs from other systems in that each dose of a prescribed drug is packaged individually, in a ready-to-administer form. Each dose is labelled so that it retains its identity right up to the time it is administered to the patient. The package, labelled with the drug name, strength, batch number, and expiry date, virtually eliminates contamination resulting from transfer and handling of the drug. Unused medications can safely be reissued. In addition, the system sharply reduces the potential for medication errors. For blister-packed tablets and capsules, separation of individual blisters and over-wrapping them in individual sachets has the advantage that the integrity and stability of the original pack is not compromised. Using a ‘closed-loop’ process where the patient, the drug and the healthcare worker are identified, a safer system for drug administration can be established using unit doses with the added advantages of reduced drug wastage, reduction in nursing time and reduced inventory on the ward. Medication errors, particularly drug administration errors can be reduced considerably by redesigning packaging, eliminating the preparation of doses in clinical areas and simplifying the medicine rounds. This can all be brought about at no overall additional cost to the healthcare provider by utilising the efficiencies generated by the new practices. Reference 1. Elliott RA, Camacho E, Jankovic D, et al. Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Qual Saf 2020:1-10. doi:10.1136/ bmjqs-2019-010206.

1 Error trap gallery - medication the hub’s error trap gallery provides a place to share examples of error traps you come across in your day to day work, including error traps relating to medications. An error trap is a situation that could lead to avoidable harm if not mitigated. It is a situation where the circumstances work alongside human limitations to make errors more likely—for example, packaging design that makes it hard to distinguish one medication from another. Medications with similar packaging are one of the most common error traps in busy hospitals, and being aware of them can help reduce the risk of mistaking one medicine for another. 2 Healthcare Safety Investigation Branch investigation report: Unintentional overdose of paracetamol in adults with low bodyweight (24 February 2022) The Healthcare Safety Investigation Branch (HSIB) carries out investigations into incidents of harm to gather and share learning that may help prevent similar errors happening again. In this investigation report, they look at the case of an 83-year-old woman who developed paracetamol-induced liver toxicity as a result of being overprescribed paracetamol while in hospital. The report presents key findings and safety observations around prescribing paracetamol to underweight adults. HSIB reports on a wide range of medication errors, and you can access all of their reports on the hub. 3 Blog - Unit-dose medicines distribution for hospital inpatients In this blog, independent pharmaceutical consultant Laurence Goldberg discusses the effectiveness and the potential for harm of unit-dose medicines distribution, often used in hospital settings as a way to save clinical staff time. In unit-dose dispensing, medication is dispensed in single doses in packages that are ready to administer to the patient. It can be used for medicines administered by any route, but oral, parenteral, and respiratory routes are especially common. Laurence highlights that although more research is needed, published studies have reported reductions in medication errors with unit-dose dispensing when compared with alternative dispensing systems such as ward stock systems. 4 Blog - Action needed make insulin administration in hospitals safer This blog by Patient Safety Learning considers the safety concerns highlighted by a recent report by the Healthcare Safety Investigation Branch (HSIB) into the administration of high-strength insulin from pen devices in hospitals. This blog argues that without specific and targeted recommendations to improve patient safety in this area, patients will continue to remain at risk from similar incidents. 5 PSNet - Medication safety events related to diagnostic imaging (8 July 2022) This case report by Patient Safety Network in the US looks at the benefits and risks of using sedative medication in patients undergoing diagnostic imaging such as an MRI scan. It looks at two separate cases where sedation was used so that the patient could tolerate having a scan, one of which resulted in the patient being intubated for several days due to severe acute respiratory distress syndrome as a result of aspiration while in the MRI machine. 6 Medication delays: A huge risk for inpatients with Parkinson’s Parkinson’s is the fastest growing neurological condition in the world. It affects young or old, and in the UK, around 145,000 people are living with the condition. Currently there is no cure for Parkinson’s, but medication plays a vital role in managing symptoms and preventing deterioration. In this blog, Laura Cockram, Head of Policy and Campaigning at Parkinson's UK talks about a widespread safety issue people with Parkinson’s face in hospital—delays in receiving their medication. She looks at the health implications of delayed medication, highlights potential solutions and talks about how Parkinson’s UK are campaigning for change. Take a look at our Top picks for World Patient Safety Day 2022: Patient engagement for medication safety

As part of implementing the NHS Patient Safety Strategy, there are currently a number of new initiatives being rolled out across the NHS which are intended to achieve its vision of continuously improving patient safety. This includes the development of the Learn from patient safety events (LFPSE) service, for recording and analysing patient safety incidents, a new framework for involving patients in patient safety and the Patient Safety Incident Response Framework (PSIRF). PSIRF sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents. It promotes systems-based approaches for learning from incidents, rather than methods that assume simple, linear identification of a single cause. A key aim of the Patient Safety Management Network (PSMN) is to provide those working in patient safety with a shared space to discuss new policies that impact their work, and to share knowledge and resources with their peers. In this session, the Network considered how the systems-based approaches to incidents recommended by PSIRF can be implemented in practice. They focused on an example that used two of these tools in relation to a specific patient safety incident—an After Action Review (AAR) and an observational analysis, Patient safety incident The example discussed in this meeting was shared by a Patient Safety Manager who had applied two PSIRF tools to a specific patient safety incident that took place on a surgical ward, where an elderly, partially-sighted patient was due to be discharged. The original intention was to consider the implications of applying these tools to two separate incidents, but due to the level of discussion around the first incident there was not time to do this. However, Network members agreed on the value of having a future session focused on another example. In this case, an Internationally Educated-Nurse (IEN) came to issue a patient with medication on discharge. On the ward they took out medication from a POD locker (‘Patients Own Drugs’ - a bedside cabinet designed to offer safe and secure medication storage) and, when distracted by another task in a busy ward, put this on a side along with medication issued for the patient by a pharmacy. Subsequently, the patient took away both sets of medication, however it transpired that the medication in the POD locker belonged to another patient. The patient took the incorrect medication following discharge and was subsequently readmitted to hospital with an irregular heartbeat. To analyse this incident, the Patient Safety Manager decided to apply the Human Factors and ergonomics tools being promoted through PSIRF rather than undertake a Root Cause Analysis recommended by the Serious Incident Framework. After Action Review In response to this incident, first an AAR was undertaken. This is a structured review based on four questions aimed at understanding what happened, why it happened and how it can be done better by those responsible and involved in the incident. This review was undertaken by the Patient Safety Manager and a colleague in the Patient Safety team, and involved all staff involved in this incident including the Ward Manager and the IEN. In this case, there were specific reasons why it did not involve the patient, although AARs often can. The review concluded that: What was expected to happen? The patient should have been delivered the correct medication by the IEN, which should have been checked by another staff member as the IEN was still waiting their PIN (registration code from the Nursing and Midwifery Council). What actually occurred? The patient was sent home with the medication belonging to another patient which when taken, resulted in a hospital re-admission. Why was there a difference between what was expected and what actually happened? The IEN was not aware they required supervision discharging patients with medication (the ward coordinator was not aware they did not have their PIN yet), the POD locker was not emptied after the last patient and the ward was short staffed. What was the learning? Staff coordinating the ward need to be aware of IEN capabilities, IENs need to be aware of restrictions prior to receiving their PIN, POD lockers require checking on discharge of patients. Observational analysis The Patient Safety Manager felt that the AAR alone hadn’t necessarily provided the team with enough insights into the issues involved in the incident and decided to apply another recommended PSIRF tool, an observational analysis. The intention of this was to understand how the ward worked in relation to patients receiving medication from POD lockers on discharge, seeing ‘work-as-done’ as opposed to ‘work-as-imagined’ by staff in this area. This observational analysis was done using a locally adapted version of the tools recommended by PSIRF. Findings of the observation included: Environment – The ward was busy, noisy, and hot, with lots of activity taking place in a small space. The POD lockers themselves were not easily visible as white boxes on white wall. Person – There was limited communication between porters and nurses and limited dialogue/handover/briefing before a patient transfer. Organisation of work – Workload was extremely high. The POD locker was not checked routinely, and it was unclear whose responsibility it was to check medications in the lockers. Tasks – The task of checking a POD locker once a patient has moved is a simple one, but needs to be performed by a trained nurse and faces the competing priorities of patient care and patient flow. Technology and tools – POD lockers are not all in the same places, not all nurses have keys to them and there are no visual cues to check the lockers when a patient is moved or when there are drugs in them. Evaluating the findings of this observational analysis, a key issue not picked up as clearly by the AAR in this case concerned the POD lockers—namely the lack of operating procedures and routine around these, limited staff having access to them and there being no clear responsibility for checking and clearing them. Following completion of the AAR and observational analysis, both documents were uploaded to the Trust’s incident reporting system and an outcome letter was shared with the patient’s family, detailing what issues had been found and what action would be taken to address these. The family were appreciative of the information and were reassured that learning was being applied that would prevent future harm to patients. The action to address the issues identified in the observation included referral to the Trust-wide Medicines Management Committee for review of the need for improvements in the management of medication and POD lockers. Network discussion In the subsequent discussion of these approaches to analysing and learning from this patient safety incident, there were a range of reflections from Network members: In relation to the specific patient safety incident: It was noted that in this case, involving the IEN in the AAR was positive as it provided immediate reassurance to the staff member that the aim of this review to learn rather than blame, as the IEN had concerns about the professional consequences of this error and the potential impact on their employment status. There was a discussion of whether it would make sense to do a short-term fix with regards to the POD lockers, such as painting them a distinct colour, and whether this would have a significant positive impact, or potentially unintended consequences if done in isolation of other quality improvement activities. An interesting outcome in this case is that the AAR review seemed much more centred on the individual involved in the incident, while the observational analysis drew our wider environment factors. In relation to the application of PSIRF tools more broadly: There were questions about how information from AARs, observations and other new PSIRF tools would subsequently feed into organisational plans. It was posited that these could be reviewed at regular intervals (for example, every three months) by the patient safety team, and their insights used to feed into an organisation-wide quality improvement project, or a thematic review. PSIRF highlights the new approaches and tools to be adopted, but organisations need to consider how they respond to the outcome of new tools and how information is reported and acted on with quality improvement projects and organisational oversight. There was a question about whether the staff conducting the AAR and observational analysis got the right support. A question was posed as to whether there could be an opportunity for a constructive friend challenge by a Human Factors expert or discussion about how this was approached afterwards? There was an acknowledgement that sometimes it can be difficult to define what observations fit into which SEIPs categories—for example, something in the ‘Environment’ that may also fit under the ‘Technology and tools’ heading. Also, a question was asked as to whether this matters as long as the learning is recorded. It was noted that training for PSIRF tools is covered in Healthcare Safety Investigation Branch training, but that it would be helpful if there were also simple practical guides to help staff when undertaking these reviews. In relation to the observational analysis: There was also discussion about how to approach observations of this type. Many highlighted the issue that when staff know they are being observed, they potentially act differently. The question was raised as to how close you get to seeing an accurate reflection of ‘work-as-done’—is the presence of someone observing having a significant impact on how activities are being approached? Other points raised included: An observational analysis of this type can be easily done in a hospital, but how effective or simple would it be to perform it in a community setting, for instance if the issue occurred involving a nurse in a patient’s home? Would it potentially be better to do observations while also doing a shift on a ward, as opposed to joining simply to do an observation? Or would this add in unexpected bias into the process? Is there more to be done for staff to understand how to ‘observe well’? With training or guidance from Human Factors/ergonomics experts? If the aim is to create an open, learning culture, it is important that staff are aware they are being observed so that they do not feel they are being spied on. It is important to clearly communicate the aim of an observational analysis to staff, highlighting that it is fundamentally to understand their work and improve safety. Concluding comments At the session there were a number of positive reflections on the use of new PSIRF tools and their potential to improve learning from patient safety incidents. The discussions also underlined the importance of ensuring that staff have the appropriate support and training to help embed the use of the tools and develop how the outcomes of each tool inform improvement and organisational oversight. How to get involved in the PSMN Are you a patient safety manager interested in joining the Patient Safety Management Network? You can join by signing up to the hub today When putting in your details, please tick ‘Patient Safety Management Network’ in the ‘Join a private group’ section. If you are already a member of the hub, please email claire@patientsafetylearning.org Related Reading Applying the After Action Review for the PSIRF – some real life examples (10 March 2022) Observational tools, Human Factors and patient safety: a recent discussion at the Patient Safety Management Network (9 March 2022) Patient Safety Management Network – the time is now (25 October 2021)