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Continuing with the JCI Patient Safety Grand Rounds, the next session of the Grand Round is “Diagnostic Safety: From Error to Excellence in Patient Care. This strengthens the global efforts to improve diagnostic safety, building on the World Patient Safety Day theme of 2024. The upcoming session will feature a compelling conversation between internationally recognised leaders in the field. Dr. Hardeep Singh, Professor of Medicine at Baylor College of Medicine, will be joined by Dr. Laura Zwaan, Associate Professor at the Institute of Medical Education Research Rotterdam, Dr. Elizabeth Liz Mort, Vice President and Chief Medical Officer at The Joint Commission, and Dr. Neelam Dhingra, Vice President and Global Chief Patient Safety Officer at Joint Commission International JCI invites you to register now to be part of this important initiative and share this information with your networks and social media channels. The registration is complimentary. Register

In this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on the charity’s work and key patient safety developments in the past 12 months. She also looks ahead to the new year, considering the UK Government’s forthcoming 10-Year Health Plan and new Patient Safety Learning projects in 2025.  At Patient Safety Learning we seek to harness the knowledge, enthusiasm and commitment of healthcare organisations, professionals and patients for system-wide change and the reduction of avoidable harm. Avoidable harm and patient deaths because of unsafe care remains a global problem. The World Health Organization (WHO) estimates that 1 in every 10 patients is harmed while receiving hospital care, and 50% of that harm is preventable. In 2019, NHS England stated in its NHS Patient Safety Strategy that there were around 11,000 avoidable deaths annually in the UK due to safety concerns. However, in practice, this figure is now likely to be a significant underestimate, given the ongoing enormous strain faced by the healthcare system. Now more than ever we need to continue to make the case that persistence of avoidable harm at current levels is not acceptable. We need to transform our approach in healthcare so that patient safety is not just seen as another priority but as a core purpose of health and care. the hub and its networks Five years on since we launched the hub, our platform to share learning for patient safety, we have seen it continue to grow in members, content and impact. This year, the hub has surpassed 1 million site visits since October 2019 and now has nearly 7,000 members. In the past few weeks, in two new blogs, we have been highlighting the work we have done this year and the most popular pieces of content featured on the hub: Patient safety and the power of collaboration the hub's top patient safety picks of 2024, the hub is also home to a growing number of networks for people involved in patient safety. These communities of interest are informed by subject matter experts, providing forums to share knowledge and good practice. They include patient safety specialists, patient safety partners and organisational leaders with patient safety expertise. They provide a rich and valuable insight from what we term the ‘patient safety frontline’. They highlight the ‘work as done’ reality of healthcare, the challenges in delivering safe and effective care, and examples of collaboration and good practice for wider sharing and implementation. In September, together with the Patient Safety Management Network and the Patient Safety Education Network, we held our first Patient Safety Symposium. This was a practical workshop-based event for patient safety professionals, focused on the application of Patient Safety Incident Response Framework (PSRIF) tools and methods. This was very positively received and we are exploring how we can deliver more practical PSIRF-focused events in the new year. If you are interested in joining one of the networks or would like to set up your own network on the hub, please do get in touch at [email protected]. Global perspective There have been a number of new international patient safety developments of note in the past 12 months. In April, the Sixth Global Ministerial Summit on Patient Safety took place in Santiago, Chile. I was delighted to be able to attend this event, which focused on how countries are implementing their patient safety strategies within the framework of the WHO Global Patient Safety Action Plan. A key theme at this event concerned the 'implementation gap'—the difference between what we know and recommend to improve patient safety and what is done in practice. This mirrored issues we had been highlighting in the UK the previous month with the Health and Social Care Select Committee on progress in meeting patient safety recommendations. There have also been several new international patient safety publications this year: The Patient safety rights charter—this outlines patients’ rights in the context of safety and promotes the upholding of these rights. The Global patient safety report 2024— setting out the WHO’s assessment of the current state of patient safety across the world. The economics of diagnostic safety—a new Organisation for Economic Co-operation and Development (OECD) report assessing key drivers and barriers of diagnostic safety. Taking the pulse of quality of care and patient safety in the WHO European Region—a cross-sectional analysis of patient safety across 53 countries. On Tuesday 17 September the sixth annual World Patient Safety Day took place. In support of this year’s theme, ‘Improving diagnosis for patient safety’, we shared a series of blogs on the hub related to this. These contributions came from many different perspectives, including patients, researchers, healthcare professionals and charities. To close out the year, this month I attended the annual Institute of Healthcare Improvement (IHI) Forum in the United States. This reinforced to me that we truly are a global family for patient safety, despite the many different healthcare systems, resourcing levels, policy and government contexts. Many of the challenges and issues raised by participants at this event were similar to what we encounter in the UK: Pressures on the capacity of health systems to deliver safe, effective and timely care. Leaders not treating patient safety as a core purpose of health and care. Hostile cultures where exhausted and fearful staff are not supported to speak up. A lack of engagement with patients and families. A common theme is that we are still not transforming healthcare for patient safety at anywhere near the pace or impact that we need to. However, I also heard great examples of health systems changing cultures and driving improvement with safety huddles, empowering staff and actively supported by organisational leaders. The Patients for Patient Safety US Project Pivot is very exciting—a huge collaboration to identify what patient experiences and outcomes need to be reported to the US government for patient safety. Also, the Centers for Medicare and Medicaid Services mandatory reporting of all hospitals against patient safety domain statements, which reinfores a safety management systems approach, something that we support and are promoting through our work. At this event, we also followed up discussions from the Global Ministerial Summit earlier in the year about an exciting new initiative by several international and national patient safety agencies. We will have more details to share on this in 2025. Patient safety standards Since Patient Safety Learning was founded in 2018, we have been engaging with organisations looking to improve patient safety. A consistent theme has been the need for Trusts, Integrated Care Boards (ICBs), Independent Care Providers and individual hospitals to have access to expert advice to help them become true learning entities within a reliable Safety Management System (SMS). This year we have continued to support organisations in this area through our patient safety standards framework. Our patient safety standards are a world first—a set of unique standards with detailed evidence-based outputs, outcomes, behaviours and actions necessary for successful delivery. They have been developed from 20 years of research with inputs from NHS England’s Patient Safety Strategy, as well as learning from inquiries, policy and good practice within UK and international healthcare, including the WHO Global Patient Safety Action Plan. This year, and moving into 2025, will we continue to work with healthcare providers and use the ‘What Good Looks Like’ standards framework to help organisations assess their patient safety performance and help them develop organisation patient safety improvement strategies and action plans. If you work for an healthcare organisation and would like to know more about this, please contact us at [email protected]. Policy and influencing As well as sharing topical policy blogs and responding to public consultations on patient safety issues, we have published two new policy reports this year. In March, we looked in detail at responses to the NHS Staff Survey 2023 in We are not getting safer: Patient safety and the NHS staff survey results. The report looks specifically at survey responses on reporting, speaking up and acting on staff patient safety concerns. In this report, we make the case that the latest results indicate that blame cultures and a fear of speaking up continue to persist in a significant part of the NHS. Coupled with findings of patient safety inquiries and whistleblower testimonies, we argue that there needs to be a more transformative effort and commitment to creating a safety culture in the NHS In June, we held a virtual roundtable session with a select group of experts to discuss patient safety risks and avoidable harm associated with electronic patient record (EPR) systems. Drawing on the findings of this event, we published a new report in July, Electronic patient record systems: Putting patient safety at the heart of implementation. This outlines the key patient safety risks associated with choosing and introducing new EPR systems and identifies 10 principles to consider for safer implementation. Subsequently, we received a positive response to this report from Baroness Gillian Merron, Parliamentary Under Secretary of State for Patient Safety, Women’s Health and Mental Health. She acknowledged these concerns raised and highlighted plans by the Government to review clinical risk standards (standards DCB0129 and DCB0160) for the use of digital health technologies in 2024/25. This review was announced last week and is something that we will be contributing to in the new year. Looking ahead to 2025 The next year could prove to be a major crossroads for patient safety in the UK. Early in the year we anticipate the publication of the first part of an independent review of patient safety across the health and care landscape in England. We contributed to this review last month and eagerly await its outcome. This is expected to be followed in the Spring by the Government’s 10-Year Health Plan for health and care. We believe that patient safety must be at the core of this. With the forthcoming publication of the 10-Year Health Plan, in my view it is imperative that NHS England updates the NHS Patient Safety Strategy later next year. Much has changed since its initial publication, ranging from the impact of the Covid-19 pandemic to the introduction of Integrated Care Systems and a change of Government this year. If patient safety is to be taken seriously in the next 10 years, at a bare minimum the Strategy requires a major update and evaluation of progress to date. But it must not be a ‘silo’ strategy; patient safety must be integral to the new 10-Year Plan. We are also looking forward to a number of new projects in the new year, supported by the recent appointment of our new Director and Associate Director. This includes: A Patient Safety Forum, in partnership with Public Policy Projects, at the Royal College of Physicians in February. Speaking up for safety: A new interview series about raising concerns and whistleblowing. Welcoming the Patient Safety Commissioner for England to a meeting of the Patient Safety Partners Network in February. Working with the Association of British HealthTech Industries to develop a new patient safety white paper. Patient safety needs to be central to the healthcare sector in the new year. At Patient Safety Learning we will continue to listen, learn and promote the voice of the ‘patient safety frontline’, both healthcare professionals and patients. We welcome your engagement and collaboration. Please do contact us to find out more and shape our work to improve patient safety.

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

Overview This webinar will give an overview of the safety & quality scene in the US with a focus on accreditation and regulation of healthcare organisations. Aims and Learning Objectives By the end of this webinar, attendees should be able to: Understand the regulatory and accreditation world of healthcare in the US Have a glimpse at the patient safety challenges faced in the US Understand diagnostic errors and bias in healthcare. Register here Panellists Haytham Kaafarani - MD, MPH, FACS, Professor of Surgery, Harvard Medical School, Hospital Director of Patient Safety & Quality, Massachusetts General Hospital, Medical Director, Trauma Center, Massachusetts General Hospital. Vicky Sharples - Chief Nurse and Executive Director of Quality at The Christie NHS Foundation Trust. Kunal Rajput - Deputy trainee lead for SSB general surgery, ST 4 trainee, NW London. Meera Patel - Academic trainee in the NW region. Mr Chelliah Selvasekar (Moderator) - Consultant Colorectal, Laparoscopic and Robotic Surgeon at the Christie NHS Foundation Trust in Manchester. Robotic T &F group RCSEd and Chair, SSB General surgery, RCSEd Prof Sanjay Pandanaboyana (Moderator) - Consultant HPB Surgeon, Freeman Hospital, Newcastle. Ms Anna Paisley (Moderator) - Consultant General and Upper GI Surgeon at the Royal Infirmary of Edinburgh. CPD 1 Hour To be eligible to receive CPD hours for webinar attendance you must connect for the full duration of the webinar AND complete the feedback survey. Visit the FAQs for further information relating to webinar CPD. Recording A recording of the webinar will be made available in the days following the live broadcast.

On 10-12 September, to kick off the commemoration, WHO Patient Safety Flagship is organising a Global Consultation titled “Improving diagnostic safety and implementing the Global Patient Safety Action Plan 2021-2030” in Geneva, Switzerland. The objective of the consultation is two-fold: Discuss the strategies for enhancing diagnostic processes and reducing diagnostic errors Reflect on the progress and challenges in implementing the Global Patient Safety Action Plan (GPSAP) 2021-2030 based on the findings from the Global Patient Safety Report (GPSR) 2024, and agree on the approaches to effectively integrate patient safety interventions into health systems. The event will feature, patient and health worker stories, country experiences, regional perspectives, panel discussions, expert dialogues, presentations, and group work sessions. You are invited to attend this pivotal event virtually. Please note group work will not be available for virtual participants. You’ll be able to listen in on the critical conversations that will shape the future of diagnostic safety globally. Register

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Every September 17th, World Patient Safety Day is commemorated, and this year's theme is "Improving Diagnosis for Patient Safety." In line with the WHO’s Global Patient Safety Action Plan 2021–2030 and PAHO’s Strategy and Action Plan to Improve the Quality of Care in Health Services Delivery 2020-2025 for the Region of the Americas, the focus is on highlighting the importance of accurate and timely diagnosis to ensure patient safety and improve health outcomes. With the slogan "Get it right, make it safe!", the WHO calls on all stakeholders to take necessary measures to prioritize diagnostic safety and adopt a multidimensional approach that strengthens systems, ensures safe diagnostic pathways, supports healthcare workers in making correct decisions, and engages patients throughout the diagnostic process. This approach aims to reduce diagnostic errors, which often arise from a combination of cognitive and system factors affecting the recognition of key patient signs and symptoms, as well as the interpretation and communication of test and study results. This year, we will host a virtual seminar on September 25 from 10:30 a.m. to 12:00 p.m., providing patients, decision-makers, healthcare teams, and academics the opportunity to discuss and share their insights on enhancing patient safety through more timely and accurate diagnoses. Event objectives: Promote the importance of diagnostic safety at all levels of healthcare. Foster collaboration among policymakers, healthcare leaders, healthcare workers, patient organizations, and other stakeholders to advance accurate, timely, and safe diagnosis. Engage patients and families to actively collaborate with healthcare workers and leaders to improve diagnostic processes. Audience: Policymakers from Ministries of Health and other ministries, academics, healthcare leaders, healthcare professionals and workers, patient organizations, families, and communities. Register

Recognising the critical importance of correct and timely diagnoses in ensuring patient safety, “Improving diagnosis for patient safety” has been selected as the theme for World Patient Safety Day 2024. This is especially relevant when it comes to medical imaging and radiation safety where an understanding of benefits and risks is an important aspect. Through the slogan “Get it right, make it safe!”, WHO calls for concerted efforts to significantly reduce diagnostic errors through multifaceted interventions rooted in system thinking, human factors and active engagement of patients, their families, health workers and their leaders. These interventions include but are not limited to ascertaining complete patient history, undertaking thorough clinical examination, improving access to diagnostic examinations, implementing methods to measure and learn from errors, and adopting technology-based solutions. The webinar aims to raise global awareness of errors in diagnosis contributing to patient harm and emphasize the pivotal role of correct, timely and safe diagnosis in improving patient safety. It will bring together NGOs in official relations with WHO involved in radiation safety and medical imaging. Furthermore, the WHA76.5 resolution on Strengthening Diagnostics Capacity that calls for safe use of diagnostic imaging procedures, and the IAEA’s perspective on quality in medical imaging to prevent errors and ensure patient safety will be presented. The panelists will discuss their strategies for improving diagnosis for patient safety and how their organizations can foster collaboration with policymakers, health care leaders, health workers, patients, and other stakeholders in advancing correct, timely and safe diagnosis. Agenda Welcoming remarks – Emilie van Deventer (WHO) / DG recorded message WHO’s World Patient Safety Day – Ayda Taha (WHO) Patient testimony – Steve Ebdon-Jackson WHO resolution on strengthening diagnostics capacity: Committing to safe imaging procedures – Adriana Velazquez Berumen (WHO) The IAEA’s perspective in enhancing Patient Safety in medical imaging: The power of quality to prevent diagnostic errors – Virginia Tsapaki (IAEA) Panel discussion: What is the role of NGOs in improving medical radiological diagnosis to enhance patient safety? Conclusion and closing remarks – Ferid Shannoun (WHO) Register

Diagnosis is a critical cornerstone of patient safety, impacting treatment decisions and health outcomes across the globe. With diagnostic errors contributing to nearly 16% of preventable harm in health systems, the need for accurate and timely diagnoses has never been more urgent. Inline with World Patient Safety Day 2024’s theme, “Improving Diagnosis for Patient Safety," and under the slogan “Get it right, make it safe!," we are focusing on transforming diagnostic processes to enhance patient safety and care quality. WPA is excited to announce the WPSD webinar on Diagnosis scheduled on September 18 at 9 AM ET. This event will bring together leading experts, patients and patient advocates to explore innovative strategies, share best practices, and discuss how to foster collaboration among healthcare providers, patients, and families to minimize diagnostic errors.

The Joint Commission International (JCI), along with the global patient safety community, partners and stakeholders around the world, will be commemorating World Patient Safety Day (WPSD) 2024 dedicated to the theme of “Improving diagnosis for patient safety”. WPSD is not only an advocacy campaign but a true platform for positive change. Among the wide range of activities being planned for observing the Day, JCI is organising an international webinar "Diagnostic Safety: The Multidisciplinary Approach” to highlight the importance of patient-centred and multidisciplinary approach for correct and timely diagnosis in ensuring patient safety. Register

In celebration of World Patient Safety Day 2024, the NIHR Patient Safety Research Collaboration Network (SafetyNet) invites you to an insightful online event focused on the critical theme of “Improving Diagnosis for Patient Safety.” This event brings together leading experts and patient advocates to explore the latest advancements and challenges in medical diagnostics, emphasising the role of accurate diagnosis in ensuring patient safety. Registe

Join Patients for Patient Safety US for 3 days of events centred around World Patient Safety Day (WPSD) 2024. PFPS US urges Americans impacted by missed or delayed diagnoses, bias or medical error to convene in Washington, DC for a Summit held September 15-17, 2024. The World Health Organization designates 17 September 17 as World Patient Safety Day, and WPSD 2024’s theme is Improving Diagnosis for Patient Safety. Find the full Summit event list at https://www.pfps.us/wpsd-2024, including: Sunday 15 September: Welcome reception and dinner at Johns Hopkins University Bloomberg Center to launch Project PIVOT, a national project identifying patient-prioritized outcomes and experiences and collaboration with patient organizations, US Department of Health and Human Services, Johns Hopkins University, Harvard Medical School and others. Monday 16 September: Participants visit Capitol Hill to urge Congressional leaders to ACT Now for patient safety, diagnostic safety and health equity solutions. ACT Now is PFPS US’s urgent request to leaders for Accountability, Coordination, and Transparency in health care. Later, PFPS US and AcademyHealth co-host a film premiere of The Pitch: The Next Generation of Patient Safety. From immersive tech to AI machine learning, innovations are finally making waves in medicine with the goal of safer health care. The Pitch gives a unique look at the American health care system’s ongoing challenge to embrace the next generation of patient safety. Tuesday 17 September, World Patient Safety Day: The March for Patient Safety begins at Freedom Plaza and ends with a ceremony on the US Capitol Lawn, where marchers will remember those whose lives have been lost to or impacted by preventable harm. Afterwards, PFPS US and the Bloomberg Center co-host a World Patient Safety Day Leadership Briefing with government leaders. Further information and to sign up