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The World Health Organization (WHO) are pleased to invite you to the fourth webinar in a five-part global webinar series on the implementation of the World Patient Safety Day Goals for safe care for every newborn and every child. This webinar will bring together global experts and practitioners to discuss practical solutions and evidence to reduce risks for small and sick newborns The webinar will focus on: Why reducing risks is essential for the safety of small and sick newborns. How Goal 5 can be implemented in practice at the point of care. What health care workers, leaders, managers, and policymakers can do to reduce risks for small and sick newborns. This webinar series is co-hosted by the World Health Organization, the International Pediatric Association, and the Child Health Task Force. Register

This webinar will bring together global experts and practitioners to explore how Infection Prevention and Control (IPC) interventions can be implemented to improve safety in newborn and child care and help reduce avoidable harm. The webinar will focus on: Why infection prevention and control is essential for safe newborn and childcare. How Goal 4 can be implemented in practice at the point of care. What health care workers, leaders, managers, and policymakers can do to prevent health care–associated infections. This webinar series is co-hosted by the World Health Organization, the International Pediatric Association, and the Child Health Task Force. Register

This webinar will bring together global experts and patient champions to explore how meaningful engagement of children, parents, and families can improve safety in newborn and child care and help reduce avoidable harm. The webinar will focus on: Why engaging children, parents, and families is essential for safe newborn and child care How Goal 1 can be implemented in practice at the point of care What health care workers, leaders, managers, and policymakers can do to enable meaningful engagement This webinar series is co-hosted by the World Health Organization, the International Pediatric Association, and the Child Health Task Force. One webinar will be organized each month, with each session focusing on a specific World Patient Safety Day Goal. Register

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 resources, 8000 members from 98 countries, and we have had over 1.7million visits and over 3 million page views. In this blog, the hub's Editor, Samantha Warne, reflects on our most popular pieces of original content published on the hub in 2025. These are a mix of our original blogs, interviews and resources shared by patients, frontline staff and leaders in patient safety. It shows the breadth of content we have on the hub, including collaborations we have with other organisations and people, patient stories, the challenges healthcare staff face and insights from an international perspective. Keep an eye out for more end of year content from our team at Patient Safety Learning, including a policy roundup. 1 Speaking up for patient safety: A new interview series about raising concerns and whistleblowing At the beginning of 2025, we launched our video interview series Speaking up for patient safety. The series is hosted by Peter Duffy, NHS whistleblower and Chair of the Healthcare Working Group at WhistleblowersUK, and Helen Hughes, Patient Safety Learning’s Chief Executive. In each interview we hear from someone who has raised concerns about patient safety in healthcare, often at great cost to their own career and personal life, or from those who work to help staff raise concerns through their own experience and advice. Alongside the thread of bravery and tenacity that runs through each contributor, a number of common themes come up time and again as people share their experiences. One thing that we often hear is the common tactics that some organisations use when dealing with people who speak up or blow the whistle. To highlight these tactics we created 'The whistleblower playbook' infographic, illustrating how some organisations respond to staff raising concerns about patient safety. 2 Patient Safety Learning: World Patient Safety Day 2025 The theme of this year’s World Patient Safety Day was ‘Safe care for every newborn and every child’. In a blog to mark the day, Patient Safety Learning reflected on this theme, highlighting the World Health Organization goals for this event and shared a series of guest blogs from healthcare professionals, patient campaigners, organisation leaders and safety experts on the hub, each exploring a different aspect of the theme. 3 Duty of Candour: Frequently Asked Questions Through the joint efforts of the Patient Safety Management Network in collaboration with experts from the Care Quality Commission (CQC) and NHS Resolution, these FAQs were produced to address the most pressing concerns about Duty of Candour. The collaborative approach ensured that the FAQ tool reflects the insights and expertise of those actively engaged in the regulation, implementation and oversight of candour practices. This is an example of the ‘how to’ resources that Patient Safety Learning, the networks and partners are developing to guide the implementation of good practice in patient safety. 4 Working in a toxic culture: Doing the right thing is often the least popular and hardest thing to do… In this blog, Clare Wade, Patient Safety Learning's Director, draws attention to the impact toxic cultures have on staff and how, sadly, most often nothing is done about it. Clare shares her own personal reflections from past experiences in her career. There is a clear link between toxic cultures and patient safety, and while there are no easy answers these behaviours must be acknowledged, challenged and cured if the NHS is to survive. 5 Top 10 priorities for patient safety in surgery Patient Safety Learning asked the Patient Safety Group (PSG) of the Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top tips for patient safety in surgery to share on the hub. They came up with three useful resources for surgeons and surgical trainees: Top 10 priorities for patient safety in surgery Top 10 tips for surgical safety: Think Safety, think SEIPS Top 10 patient safety tips for surgical trainees These resources are an example of the effectiveness of collaborating with partners such as the RCSEd to develop resources that will help practitioners better understand patient safety and how they can access resources to help reduce avoidable harm. 6 What do Patient Safety Incident Response Plans tell us about how the NHS is approaching safety investigations? From Autumn 2023, NHS organisations in England began to change the way they investigated cases of avoidable patient harm and near misses, introducing the Patient Safety Incident Response Framework (PSIRF). As part of PSIRF, organisations are required to create and publish a Patient Safety Incident Response Plan. Drawing from a sample of 13 Patient Safety Incident Response Plans, Patient Safety Learning considers what they can tell us about the implementation of PSIRF. This is intended to support organisations who are currently reviewing their PSIRPs to ensure that their prioritisation of investigations and reviews meets national guidance and provides an evidence based rationale to inform patients, families and staff. 7 Post-SSRI Sexual Dysfunction: After 30 years, why is the health system still failing to recognise this life-limiting adverse effect? Post-SSRI Sexual Dysfunction (PSSD) is a long-term adverse effect of Selective Serotonin Reuptake Inhibitors (SSRIs), a type of antidepressant medication. In this opinion piece, Harriet Vogt, Patient Safety Partner at NHS Sussex Integrated Care Board, outlines the need for recognition and research into PSSD to allow patients to make truly informed choices when considering SSRIs. She argues that while the health system is beginning to recognise the value of placing patients at the heart of efforts to improve safety, this focus on listening is rarely given to individual patients who express concern about the impact of their medication or treatment. 8 SEIPS in action In this blog, Patient Safety Learning’s Associate Director Claire Cox shares a video with associated training resources developed for the Patient Safety Management Network Symposium. Claire explains how they used it to facilitate an interactive workshop, bringing SEIPS (Systems Engineering Initiative for Patient Safety) to life. It's now available as a resource for you to use in your own organisation. It is simple to set up, highly engaging, and encourages teams to think beyond individuals and see the wider system in action. 9 Balancing care: The psychological impact of ensuring patient safety In this blog, Leah Bowden, a patient safety specialist working in an ambulance service, reflects on the impact her job has on her mental health and family life. She discusses why there needs to be specialised clinical supervision for staff involved in reviewing patient safety incidents and how organisations need to come together to identify ways we can support our patient safety teams. 10 Exploring the barriers that impact access to NHS care for people with ME and Long Covid For healthcare to be safe it needs to be accessible. But what does this look like for people with ME (myalgic encephalomyelitis) and Long Covid? This blog from #ThereForME explores the barriers that impact access to NHS care for people with ME and Long Covid. 11 Bridging the gap between policy and practice: A Safety-II approach to patient transfers In this anonymous blog, a patient safety lead shares how they implemented a Safety-II approach to patient transfers, highlighting the disconnect between 'work as imagined' and 'work as done', and the importance of listening to frontline voices. The author worked with subject matter experts to develop a visual, easy-to-use risk stratification tool designed to support decision making on the appropriate level of clinical escort required for safe transfer. While the tool is applicable to most adult acute settings, certain areas—such as maternity, paediatrics, and specialist theatres—require their own local adaptations. This could have wider applicability to a range of different clinical settings. 12 Evidencing the impact of culture on patient safety – a new tool from MNSI In this interview, Chris McQuitty, a clinical fellow at the Maternity and Newborn Safety Investigation (MNSI) programme, talks us through a new patient safety tool. COMPASS (Culture of Organisations and its iMpact on PAtientS’ Safety) is currently being piloted to help understand the impact organisational culture may have on patient safety in maternity settings. 13 Improving safety in healthcare—is quality improvement the answer? The healthcare landscape is evolving rapidly, with increasing complexity in patient needs, technological advancements and regulatory requirements. As this complexity grows, ensuring patient safety remains a top priority. One of the most widely adopted strategies for enhancing safety is quality improvement (QI), but is QI the right tool for navigating and improving safety in an increasingly complex health system asks Patient Safety Learning’s Associate Director Claire Cox. Claire reflects on the need for a safety management systems approach, as highlighted in Healthcare Safety Investigation Branch (HSSIB) reports, essential to embedding a proactive, system-wide perspective on patient safety. Additionally, aligning QI efforts with patient safety standards and Patient Safety Learning standards ensures a structured, evidence-based approach to mitigating risks and driving sustainable improvements. 14 Preventing patient falls in healthcare settings: The need for fall risk assessment Patient falls are a significant concern in healthcare settings, often leading to severe injuries, prolonged hospital stays and increased healthcare costs. This blog from Augustine Kumah, Deputy Quality Manager at The Bank Hospital, Accra, Ghana, explores the significance of fall risk assessment, its implementation and its role in reducing fall-related incidents in healthcare settings. 15 Patient barcode scanning in NHS hospitals: safety, snags and workarounds. A nurse’s perspective As a nurse working in the NHS for over 25 years, Claire Cox has seen first-hand how technology has transformed patient care. One of the biggest changes in recent years has been the introduction of electronic scanning. In this blog, Claire talks about the opportunities to improve patient safety and the risks associated with the use of barcode technology in healthcare. 16 Corridor care and patient safety Corridor care can broadly be defined as care being provided to patients in corridors, non-clinical areas or unsuitable clinical areas because of a lack of hospital bed capacity. It is increasingly being used in the NHS as demand for emergency care grows and hospital departments struggle with patient numbers. In a series of blogs for the hub, we shine a light on some of the key patient safety issues surrounding corridor care. Share your experiences on the hub I would like to take this opportunity to thank everyone who has contributed to the hub this year. 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. See all our 'Top picks' Our ‘Top picks’ are collections of resources, blogs and tools around a specific topic or theme. You can view them all here: Top picks.

World Health Day, celebrated on 7 April, kicks off a year-long campaign on maternal and newborn health. This year's campaign, titled ‘Healthy beginnings, hopeful futures’, will urge governments and the health community to ramp up efforts to end preventable maternal and newborn deaths, and to prioritise women’s longer-term health and well-being. It is led by The World Health Organization.  The Motherhood Group focuses on creating supportive spaces where Black mothers can find community, resources, and advocacy. In this interview Sandra Igwe, Founder and CEO of the Motherhood Group, reflects on this year’s theme and the continuation of disparities in Black maternal mental health. Sandra highlights key areas for action and explains how a greater focus on lived experience leads to better outcomes for women and babies.  What does a ‘healthy beginning and hopeful future’ look like for Black maternal mental health? A healthy beginning means Black mothers receiving respectful, dignified care where their voices are heard and their concerns taken seriously. It means having access to culturally competent mental health support without stigma. Drawing from our "Interconnecting Themes" framework, a hopeful future includes: Community and Connection: Strong support networks both online and in-person Advocacy and Voice: Black mothers empowered to speak for themselves and be heard Education and Knowledge: Better information for both mothers and healthcare providers Healthcare Transformation: Systems that acknowledge cultural differences and provide equitable care Safe Spaces: Environments where Black mothers can be vulnerable without judgment This vision requires reframing Black maternal health as a human rights imperative and addressing it through an anti-racist approach, as highlighted by speakers at our conference. What are the big issues that need addressing? The most pressing issues include systemic racial disparities in maternal healthcare, lack of cultural competency among healthcare providers, insufficient mental health support for Black mothers, and the dismissal of Black women's pain and concerns. Our training workshops highlight specific challenges including: Mental health stigma within Black communities Barriers to effective engagement with healthcare services Language and cultural barriers affecting quality of care The "Strong Black Woman" myth that prevents many from seeking help Black mothers being less likely to be identified with perinatal depression due to inadequate screening tools The difficulty many Black mothers face expressing emotional distress in a system that applies western/eurocentric labels These issues disproportionately affect Black women, who in the UK are four times more likely to die during childbirth than white women and consistently report poorer experiences throughout their maternity journey. What results have you seen for women and their babies when they receive good mental health support? When Black mothers receive appropriate mental health support, we see transformative outcomes: stronger maternal-child bonding, better parenting confidence, improved family dynamics, and children who thrive emotionally and developmentally. Mothers report feeling more empowered to navigate healthcare systems and build supportive networks. Our initiatives like the NICU, Early Life and Loss panel discussions reveal how proper support can help mothers through the most challenging circumstances. The community-led initiatives showcased at our conference demonstrate that when Black mothers are supported appropriately, they often become powerful advocates and create solutions for others facing similar challenges. What more needs to happen by who? We need coordinated action across multiple fronts: Policy: Implementation of culturally sensitive care standards and mandatory training on racial bias for all healthcare workers. Funding: Greater investment in community-based maternal support services and grassroots solutions. Training: Healthcare professionals need comprehensive education on recognizing and addressing racial disparities and implicit bias. Healthcare Providers: Maternity services should collect and act on ethnicity data to identify and address disparities. GPs and Midwives: Need to create safe spaces where Black mothers feel heard and validated, with better screening for mental health concerns that considers cultural context. Community Organizations: Continued development of diverse focus groups, patient forums, and support groups (both digital and face-to-face). Our conference demonstrates the multi-stakeholder approach needed, bringing together NHS leadership, politicians like MP Florence Eshalomi and Rt Hon Diane Abbott MP, medical professionals, community groups, and most importantly, mothers with lived experiences. Final thoughts? The conversation around Black maternal health must move beyond statistics to recognize the lived experiences of Black mothers. As our conference theme "Building Better Futures: Community-Led Solutions" suggests, the most effective approaches center on the voices of those most affected. Initiatives like our project work with Genomics England and "Avoiding Brain Injury in Childbirth" (ABC) show that when Black mothers' perspectives are included in research and service design, the outcomes improve for everyone. This World Health Day theme aligns perfectly with our mission of creating healthy beginnings through community, connection, education, and advocacy. We believe that rest, as highlighted in our "Rest as Revolution" conference session, is also a critical component of maternal wellbeing that is often overlooked for Black mothers. True progress requires not just acknowledging disparities but actively dismantling the systems that create them and building new, more equitable approaches. Related hub content Addressing critical gaps in Black maternal mental healthcare: a new partnership project is launched (interview with Sandra Igwe) Working with bereaved parents for safer and more equitable care Neonatal herpes: Why healthcare staff with cold sores should not be working with new babies Women who experience high-risk pregnancies are too often forgotten when their babies are born Mums with babies in NICU: postnatal maternal mental health support Top picks: Key resources for maternity safety

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To mark WHO’s World Patient Safety Day 2025, which focuses on safe care for every newborn and child, NIHR has joined forces with Royal College of Paediatrics and Child Health (RCPCH) to host a webinar exploring persistent and emerging safety challenges in paediatric services. Aligning with WHO’s efforts to raise awareness, mobilise, and advocate for stronger research in this area, the webinar asks the question, ‘What are the challenges in paediatric patient safety, and how do we respond to them?’ Register

Continuing with the JCI Patient Safety Pathways Grand Rounds, the next session of the Grand Round on "Pediatric Patient Safety”. This session is being organized to commemorate World Patient Safety Day 2025 aligned with the theme ‘Safe care for every newborn and every child’. This upcoming session will feature a compelling conversation between internationally recognized leaders in the fields of Pediatrics and Patient Safety - Dr. Sara L. Toomey, Senior Vice President, Chief Safety and Quality Officer & Chief Experience Officer, Boston Children’s Hospital, Associate Professor, Harvard Medical School, United States; Dr. Ashok Kumar Deorari, Pro Vice-Chancellor, Swami Rama Himalaya University, Former Professor & Head, Division of Neonatology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India; Dr. Marwa Ezz El Din, Patient Safety and Quality, Certified Patient Experience Professional, International Physician Surveyor, Joint Commission International, Dubai, United Arab Emirates; and Dr. Neelam Dhingra, Vice President and Global Chief Patient Safety Officer, Joint Commission International, Former Head, WHO Patient Safety and Blood Safety (2000-2024), Geneva, Switzerland. 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 celebration of the 2025 World Patient Safety Day (WPSD), themed “Safe Care for Every Newborn and Every Child,” the World Patients Alliance is pleased to announce a special webinar dedicated to “Patient Safety Books for Children.” This event will highlight the vital role of early education and empowerment in promoting safer pediatric care and will spotlight the creative journey behind this unique series of children’s books and their accompanying audio versions. These engaging resources are designed to introduce young minds to the principles of patient safety in a friendly, accessible way laying the foundation for a lifetime of awareness and advocacy. Join us as we explore: The development and impact of the Patient Safety Books for Children. How storytelling can promote safer care from the very start of life. Voices from authors, illustrators, patient safety champions, and young readers. Register

World Patient Safety Day (WPSD), which takes place annually on 17 September, was launched by the WHO in 2018 to raise public awareness, foster collaboration between stakeholders and mobilise global action to improve patient safety. This year's theme is Safe Care for Every Newborn and Every Child, with the slogan “Patient safety from the start!”, recognising the vulnerability of this age group to risks and harm caused by unsafe care. The WHO calls for urgent action to eliminate avoidable harm in paediatric and newborn care, driving meaningful improvements and reaffirming every child's right to safe and quality care. To help celebrate this year’s WPSD, the Royal College of Surgeons of Edinburgh (RCSEd) are hosting this webinar on the importance of system design in helping to ensure safety for neonates and children. This will feature a panel of paediatric surgery consultants, innovators and human factors experts discussing how we can best design systems and built environments to help ensure safety in paediatric surgical care. The importance of creating a simulated environment to allow people to fail safely and of ensuring appropriate psychological support when they do will be discussed. How to troubleshoot a build as a clinician to identify and ameliorate potential risks will also be covered. Also how we can adopt a multi-factorial system based approach to improving paediatric surgical care will be considered. The principles discussed will be transferable across all surgical specialties. Aims The aim of this webinar is to celebrate World Patient Safety Day and to help participants provide safe surgical care for every newborn and every child. Learning Objectives By the end of this webinar, participants will: Have a better understanding of World Patient Safety Day and the RCSEd’s commitment to patient safety. Appreciate the importance of simulation in learning and innovation, together with the value of being able to fail safely. Recognise the importance of appropriate support for staff when developing new services. Be better able to identify and ameliorate potential patient safety risks in any new infrastructure build. Be more confident in adopting a system wide, human factors approach when designing surgical services for neonates and children. Register here.

Trigger warning: This blog contains themes that may be triggering for some people.  Hope Virgo is an author, a multi award winning mental health campaigner, and secretariat for the All-Party Parliamentary Group (APPG) for eating disorders. In this blog, she explores the patient safety issues affecting children with eating disorders and their families. Hope highlights how lack of investment and understanding is leading to avoidable harm and shares five key actions for change.  This blog is part of our World Patient Safety Day 2025 (WPSD 25) series - Safe care for every newborn and every child. My campaigning work was born out of wanting to fight the injustices that so many people affected by eating disorders go through. Having lived with anorexia from the age of 12-17 before being admitted to a mental health hospital where I began my journey to recovery, I know first-hand just how awful eating disorders are. I have spent huge amounts of life feeling frustrated by how many people get turned away from services for not having that “particular stereotypical look” and with how much neglect is taking place in treatment across the UK. Patient safety concerns Often people still think someone with an eating disorder will be underweight or have been labelled with anorexia. Eating disorders are so much more than that. During my campaign work and the APPG evidence sessions, I’ve met hundreds of people who have been denied treatment for not looking that way. We have spoken to parents who have children with avoidant restrictive food intake disorder (ARFID), who have not been able to access treatment and support. The reality is, there is a postcode lottery and a lot of children and their families aren’t being given the best chance of life. Many carers also tell me how often their concerns are dismissed as silly worries. This cultural dismissiveness across eating disorder services and the lack of training and funding, is leading to huge issues for patient safety. It is causing people to die. It can feel so hard to speak up when support is so limited, but as a parent or carer, learning to push for support is crucial. I’d also recommend looking at the amazing resources for carers produced by the organisation FEAST. Stigma, misunderstanding and dangerous narratives Eating disorders are an illness that is massively stigmatised and misunderstood. Contrary to many assumptions, people with an eating disorder: are not making a lifestyle choice are not being difficult are not all white females. Eating disorders can impact people of any age, size, gender or race. Stigma and misunderstanding leads to so many people being denied treatment for an eating disorder. Marked as ‘untreatable’ One narrative that we have seen in the last two years is an increasing amount of people with eating disorders being marked as untreatable, too complex and in some cases as terminal and moved to palliative care. This dangerous narrative is causing many people to be discharged from services too soon and given inadequate care. If they are discharged prematurely and still have a malnourished brain they are not being given the chance for it to fully rewire - leading them at high risk of relapse. Time for change For too long eating disorders have been stigmatised and underfunded, with very little specific staff training. For children’s services, whilst there has been some investment, it has been very limited. Five key changes to support patient safety The APPG published a report in January 2025 calling on the government for five key things: Develop a national strategy for eating disorders. Provide additional funding for eating disorder services. This funding should address the demand for both adult and children’s services. Launch a confidential inquiry into all eating disorder deaths. Increase research funding for eating disorders: The aim is to enhance treatment outcomes and ultimately discover a cure for eating disorders. Ensure non-executive director oversight for adult and children's eating disorder services. This oversight and accountability should be implemented in all NHS Trusts and Health Boards in the UK. Recovery When you have an eating disorder, it completely consumes you. It takes over every area of your life. And it consumes your family life too. The research shows that people can and do recover at any age, severity of illness or length of illness. So why are we allowing so many to remain stuck living with an eating disorder and denying them the care they need? Over the last few years. we have seen pockets of good practice in services from the development of integrated enhanced cognitive behavioural (I-CBTE) therapy, to areas where GPs have quickly referred patients or supported families to recover. With the right support and treatment in place for people with eating disorders we will not only save lives but also money. Through early intervention we can prevent hospital admissions and prevent begin becoming more malnourished thus leading to quicker recovery times. Final thoughts Eating disorders are a serious mental health issue. They have the highest mortality rate of any other psychiatric illness yet are often hidden in plain sight. It doesn’t have to be this way. People with eating disorders can and do make full recoveries, we just need to do better to enable this to happen. This growing epidemic can only be reversed by investing into prevention, early intervention, and timely, high-quality treatment. Access to services needs to be free from discriminating criteria and bias. The current inpatient treatment approach results in poor outcomes and 40-50 percent relapse rates. Without a cultural shift and a complete reformation of services nothing is going to change. Campaigners, clinicians and others need to work together to make this change happen. March with us On 21 June, 2025, we’ll be taking to the streets of London for the third consecutive year to march for those we love, for those we have lost, and for the future generations affected by eating disorders. This march is not just a walk — it’s a statement to demand better services and put an end to the neglect faced by those struggling with eating disorders across the UK. Find out how you can join.

Angela Hayes, is a Nurse Fellow and Project Lead at The Centre for Sustainable Healthcare. In this blog, she tells us more about the Green Maternity Challenge and draws on three case studies to highlight it’s success in delivering low carbon, equitable and safe maternity care: local screening for newborn developmental hip dysplasia supporting breast-feeding reducing health-inequalities for Albanian-speaking women. This blog is part of our World Patient Safety Day 2025 (WPSD 25) series - Safe care for every newborn and every child. Background With births totalling over 673,000 in 2022, maternity services contribute significantly to the overall carbon footprint of the NHS, and therefore, to the environmental crisis. Pregnant women and infants are particularly vulnerable to climate change, which exacerbate existing health complications. Women from ethnic minorities or disadvantaged backgrounds are disproportionately affected so significant health inequalities persist. The Green Maternity Challenge was delivered in partnership with the Centre for Sustainable Healthcare, The Royal College of Obstetricians and Gynaecologists, The Royal College of Midwives and The Sustainable Healthcare. It aimed to: address the environmental impact of maternity care improve health outcomes create a more sustainable, equitable healthcare system. Nine clinical teams in the UK were chosen and supported by CSH to develop a Sustainable Quality Improvement project (SusQi) and measure its impact. Examples of impact Local screening for newborn developmental hip dysplasia - Orkney Due to geographical limitations, access to advanced equipment and specialist care and skills can be limited. Presently, families need to travel to Aberdeen with their newborns for the Ultrasound Newborn Screening for Hip Dysplasia. This has the potential to negatively affect clinical outcomes for patients, particularly those from peripheral areas such as Orkney Island, due to increased travel time and delay in travel owing to unpredictable weather, longer waiting periods and inconvenience to families. Local screening programmes can reduce waiting times and increase access to healthcare. It can also allow for early management and intervention in newborns. A team in Orkney introduced local screening facilities for newborn developmental hip dysplasia and eliminated the need for travel to the mainland. The programme has created increased job satisfaction for staff and reduced stress, travel and delays for patients. The environmental savings projected are around 22,500 miles and costs savings rising to £17000/year. Supporting breast-feeding - Great Western Hospitals NHS Foundation Trust Breastfeeding is important because it improves the long-term health of both mothers and babies. Between 74-86% of birthing people start breastfeeding in the first 48 hours. Around 8% stop breastfeeding by the time they go home from hospital and a further 20% stop during the first two weeks at home. There are several reasons for this, but a lack of infant feeding support is a major contributor. Lack of support also contributes to 5-20 mothers and babies a month requiring readmission for jaundice, weight loss and tongue tie. Staff on the post-natal ward at the Great Western Hospitals NHS Foundation Trust hoped to improve breast-feeding rates through the implementation of daily feeding support groups. They demonstrated improvements in effective person-centred care, staff satisfaction and patient confidence. With breast-feeding rates up by 5%, they projected yearly savings over £4600, reductions in re-admissions and outpatient appointments, and environmental savings equivalent to driving almost 5000 miles. Reducing health-inequalities for Albanian-speaking women - Kingston Vulnerable groups such as migrants and ethnic minorities, face various barriers in accessing healthcare, and as a result, face poorer clinical outcomes. One such example is that of Albanian speaking women in Kingston. Comprising of 1% of all maternity care bookings at Kingston (as compared to the 0.2% national population), Albanian women face various challenges such as language barriers, asylum seeking status, poor socio-economic status, lack of support, histories of human trafficking and sexual abuse, and pre-existing mental health conditions. They are also subject to discrimination and culturally insensitive care. All these factors contribute to underutilisation of healthcare services, limited access to high quality care, concerns about confidentiality as well as lack of faith in healthcare system. Delay in getting timely and appropriate care can lead to poorer health outcomes, often necessitating more intensive and resource heavy treatments. The Olive Clinic in Kingston & Richmond midwifery team arranged for an interpreter to support their ante-natal clinic for Albanian-speaking women to support them during and after pregnancy. Impact studies are yet to be measured but qualitative data shows encouraging results from women and midwives. Summary There are many more examples and case studies but these three particularly highlight how green initiatives can be aligned to patient safety improvements to make sure every newborn and every child receives safe care. With projected annual savings of £860,669, and carbon savings equivalent to 778,978 disposable nappies, they made a huge impact on sustainable and equitable maternity. Share your insights Do you have insights to share around balancing patient safety with sustainability? What are the challenges and opportunities? Contact the editorial team at [email protected] to share your ideas.

In this interview, Chris McQuitty, a clinical fellow at the Maternity and Newborn Safety Investigation (MNSI) programme, talks us through a new patient safety tool. COMPASS (Culture of Organisations and its iMpact on PAtientS’ Safety) is currently being piloted to help understand the impact organisational culture may have on patient safety in maternity settings. The tool was designed by Chris and Nicki Pusey, Maternity Investigation Team Leader at MNSI. This blog is part of our World Patient Safety Day 2025 (WPSD 25) series - Safe care for every newborn and every child. Why was COMPASS developed? COMPASS was created based on work carried out by the Patient Experience Library who conducted a literature review of over 10 years’ worth of avoidable harm enquiries, which included the reports on the maternity services at East Kent and Morecambe Bay. The work has been collated into a report called ‘Responding to Challenge’¹. The review demonstrated that poor organisational culture is a recurrent theme in avoidable harm, with significant impact on patient safety. Their work highlights how organisational culture remains challenging to quantify and articulate which hampers external bodies’ ability to provide insight to providers. Through our safety investigations it became evident that MNSI did not have a way to record and analyse cultural observations in a structured and evidence-based format. This inhibited us from feeding back our observations to organisations to help them see how their organisational culture might be impacting on patient safety. What are the aims of COMPASS? We developed COMPASS for two key reasons: To provide MNSI staff with a standardised process to record observations around organisational culture, empowering MNSI staff to articulate their observations to trusts in a structured and evidence-based manner rather than based on personal experience or individual interpretation of certain situations. To highlight to trusts areas where their organisational culture is contributing positively to patient safety, and areas where enhancing their focus will support and improve safer care to be delivered. There is already significant work being done to help trusts to improve culture and leadership within maternity services, and COMPASS is a tool designed to complement this by focussing on how organisations respond to and learn from patient safety events. How is COMPASS being used? COMPASS is currently being piloted in partnership with 12 NHS trusts in England and is due to finish at the end of May. MNSI staff are using COMPASS to gather observations about organisational culture that may have impact on patient safety, in a structured manner that reflects the findings from the ‘Responding to Challenge’ report. The findings are then collated and reviewed to determine how frequently these types of observations are occurring so we can assess the overall level of impact to patient safety that may be occurring within each of the specific areas. These findings are then shared with trust leadership teams to flag areas that may require attention or focus to improve safety and organisational culture and also highlight observations of culture that have had a positive impact on patient safety. What is next for COMPASS? After the pilot, and with the help of feedback from both MNSI staff and trusts who piloted the report, we hope to: Adapt the COMPASS tool to match the needs of both MNSI and organisations we work with to maximise the impact of the tool. Showcase the positive impact COMPASS has had on patient safety within maternity and newborn services. Share our learning through the development of COMPASS and explore how this can be utilised in other sectors to improve patient safety across healthcare. If feedback suggests that the tool is of value to both MNSI and trusts, we may seek to use COMPASS on a regular basis to help share our insights into organisational culture with trusts to help improve patient safety. How can people find out more? Introducing COMPASS: A new safety tool to help understand the impact of culture on patient safety MNSI has launched a new patient safety tool COMPASS Red Flag Tracker – a tool to help recognise the red flags for harmful healthcare cultures by the Patient Experience Library References 1. The Patient Experience Library's Responding to Challenge report April 2025 Do you have a safety tool or project to share? Are you implementing a change that has had a positive impact on patient safety? Could you share your insights, tools and knowledge to help others? Or perhaps you are at the start of the journey, seeking ways to address a patient safety issue that you've identified. Comment below (sign up for free first) or contact our editorial team at [email protected] to tell us more.

The Healthcare Improvement Scotland webinar aligns with World Patient Safety Day on Wednesday 17 September. The theme for World Patient Safety Day is “Safe care for every newborn and every child” This event is for staff working in maternity and neonatal services, and those looking to learn more about Quality Management Systems in action. The webinar will look at Scotland’s evolving approach to perinatal safety through a quality management lens. This session offers an opportunity to: hear about our first year of maternity inspections and the development of national standards explore learning from emerging perinatal safety intelligence and improvement design hear from leads shaping the quality management approach contribute to a shared vision for safer, more equitable maternity care across Scotland The aims of our webinar are: Aligning the HIS Perinatal Quality Management System (QMS) with World Patient Safety Day 2025 – Patient Safety from the Start! Promoting an understanding of the HIS Perinatal QMS. Building an environment of collaboration between perinatal stakeholders. Register here.

hub topic lead, Peter Sidgwick, consultant in the Paediatric Intensive Care Unit (PICU) and Associate Medical Director at Great Ormond Street Hospital, reflects on working in PICU and highlights some of the risks. He discusses the safety measures in place that mitigate these risks and keep children as safe as possible while they are in PICU. This blog is part of our World Patient Safety Day 2025 series - Safe care for every newborn and every child. A resident doctor at the end of their rotation through the PICU where I worked asked me how I can keep coming back to such a high-stakes, high-risk job, day in, day out. At the time, I didn’t have a ready answer—I think I told them that I loved what I did, and that was enough. That answer still holds true, but I now know that this passion is only sustainable because I understand and have confidence in the systems that surround me and my team, which keep our patients as safe as possible while they are in our care. Risks in PICU There are lots of reasons that risks are high in PICU—the list makes a sobering read. Our patients’ clinical condition can change within minutes, they can’t always communicate their needs and their care often involves complex, high-risk interventions. Their unique anatomy and physiology—smaller airways, faster metabolic rates and narrower margins for error—mean that clinical deterioration can be swift and severe. Seemingly minor missteps in airway management, fluid balance or medication calculation can have significant negative consequences. Protocols and technology Protocolised practice and technology go a long way to mitigating these risks. As an example, the risk of medication errors is high in PICU, largely due to the need for weight-based calculations, the absence of standard dosing for many drugs and the fact that many of our patients are dependent on several medications to sustain life. Solutions to the risk that surrounds this include double-checks for high-alert medications, standardised concentrations, smart infusion technology with built-in dose limits and electronic prescribing with clinical decision support. Structured safety tools—such as pre-procedure briefings, closed-loop communication, and checklists—are proven to reduce errors. Similarly, care bundles for prevention of ventilator associated pneumonia and central line associated blood stream infections, and early rehabilitation and mobilisation bundles to ensure quick recovery from critical illness, all ensure that the harm accrued by our patients due to the therapies we use is as low as it can possibly be. A positive safety culture However, protocols and technology can only take a team so far, and the risks we see in PICU are not fully mitigated by these. The most sophisticated equipment is only as safe as the team operating it. Communication failures, unclear role allocation and cognitive overload remain significant contributors to patient safety incidents. As is so often true in life, the quality and maturity of the relationships within and across all members of the team affects how well the team functions. At it’s best, that team function and culture allows an environment in which every team member, regardless of seniority, feels empowered to speak up and participate in reflection upon and learning from a potential risk or actual patient safety incident. With a positive safety culture, regular incident reporting becomes the norm, debriefing after critical events feels safe not threatening, and mortality and morbidity discussions become focused on deep learning and achieving real improvement for the next patient. Family and carer involvement There are two other teams that contribute in untold ways to safety in PICU—our patients' families and carers, and the systems and organisations with whom we benchmark our clinical outcomes. The overwhelming majority of patients in PICU have loved ones looking out for them—focused on their monitors, their subtle signs and signals of recovery or deterioration and willing them better. Family and carer engagement is a super-power in PICU—a voice of advocacy, an interpreter and a crucial reminder of the human at the centre of the tubes, wires, pumps and machines. Properly curated activity, risk and performance data and the benchmarking of clinical outcomes that it allows may be less ‘human’ than family and carers, but it is critical in helping the team know where their practice falls in relation to their peers. Signals, acted upon early, allow improvement or evolution of clinical practice when patients are experiencing harm that may not be visible in an individual patient's story but becomes clear when a sufficiently well-organised data set is analysed. In PICU safety is not just a checklist—it’s an ongoing, team-wide commitment to vigilance, precision and adaptability. Our patients’ resilience is remarkable, but it is our responsibility to ensure the environment around them is as safe as possible. And when they are safe, I can feel safe in my practice and keep coming back to do the job I love.

The World Health Organization (WHO) and the Partnership for Maternal Newborn and Child Health (PMNCH) are holding this webinar to mark World Patient Safety Day 2025 under the slogan “Patient safety from the start!”. The event will bring together patient representatives, health leaders, frontline health workers and international partners to shed light on the preventable harm children face in health care, share experiences and innovations from around the world, launch the campaign materials and World Patient Safety Day 2025 Goals, and mobilize collective action to make care safer for every newborn and child. Programme highlights include: Opening addresses from WHO and PMNCH leadership Keynote by WHO Envoy for Patient Safety, Sir Liam Donaldson Voices of patients and frontline health workers Launch of the WPSD 2025 campaign materials and Goals Commentaries from experts and partners Closing reflections Register here.

Ensuring safe care for patients is a fundamental priority, yet newborns and children remain especially vulnerable to patient safety risks. To bring attention to this critical issue, “Safe care for every newborn and every child” has been selected as the theme for World Patient Safety Day 2025. This is especially relevant when it comes to medical imaging and radiation safety where an understanding of benefits and risks is important. The webinar aims to raise global awareness of safety risks in paediatric and newborn care in all health care settings, emphasizing the specific needs of children, families and caregivers when using radiation for diagnosis and treatment. It will bring together a number of Non-State Actors in official relations with World Health Organization (WHO) involved in radiation safety and medical imaging to discuss strategies for improving patient safety and radiation protection in paediatric and newborn care. Agenda Welcoming remarks – Dr Rüdiger Krech, Director a.i., Environment, Climate Change One Health and Migration (WHO) World Patient Safety Day 2025 – Dr Ayda Taha, Technical Officer (WHO) DG recorded message WHO activities on radiation protection of children and newborns – Dr Ferid Shannoun, Scientist (WHO) Paediatric Imaging in newborns and children - why radiation protection matters from day one – Dr Elaine Kan and Dr Kevin Fung (WFPI) Panel discussion with Non-State Actors in official relations with WHO on: Their role in enhancing radiation protection for newborns and children; and Their collaboration through a multidisciplinary approach to strengthen radiation protection for paediatric and newborn care across different regions. Conclusion and closing remarks – Dr Emilie van Deventer, Unit Head (WHO) Register here.

To mark World Patient Safety Day, this interactive session, hosted by the Association of British Paediatric Nurses, will explore the role of childhood immunisations as a cornerstone of safe care for newborns and children. The diverse panel brings together expertise from emergency care, public health nursing, and hospital-based practice to share practical insights, challenges, and strategies for promoting vaccine uptake. It is designed for children’s nurses and student nurses and will include short presentations followed by discussion and Q&A. Chair & Presenters: Kath Evans Director of Children’s Nursing, Barts Health; Babies, Children & Young People’s Clinical Lead, North East London Integrated Care Board; CYP Participation champion at NHS England (London). Becky Platt, Children’s Nurse and Advanced Clinical Practitioner, Emergency Department, Royal London Hospital Helen Donovan, Independent nurse consultant and immunisation specialist nurse. Josephine Bakar, Ward Manager, Rainbow Ward, Newham Hospital Register here.