Latest update from Patient Safety Learning's hub ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­    ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏  ͏ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­  
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Hi wendy micklewright
Welcome to the hub newsletter.

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Martha's Rule

Martha’s Rule gives patients and families a vital way to escalate concerns when they believe a patient’s condition is deteriorating and they are not being heard. In a new 'Florence in the Machine' blog, a critical care outreach nurse in an acute NHS Trust explains why, as the scheme expands, the NHS must preserve its patient-safety focus by setting clear expectations, providing suitable routes for other concerns and supporting staff who handle difficult calls.

 

Florence in the Machine is an area on the hub for anonymous health and care staff to blog about the state of the health service as they experience it on a daily basis. If you would like to share your experiences, contact content@pslhub.org.

 

Last chance to join our practical thematic analysis training

Following the success of our London training, we still have a few places left on our bespoke course: Practical Thematic Analysis for Patient Safety on 2 November in Leeds. Our facilitators, Dr Helen Vosper and Claire Cox, will combine deep subject matter expertise with systems thinking and human factors principles to help you turn patient safety data into actionable learning and improvement. The highly practical and evidence informed course will continue once you return to the workplace with support to give you the confidence to put what you've learned into practice.

 

"Practical tasks that relate to everyday practice."

"Excellent course, really enjoyed it."

 

Interested? Email clarew@patientsafetylearning.org. Deadline Wednesday 28 October.

 

New Patient Safety & AI Network 

AI is arriving in health and care faster than the guidance and assurance around it, and too often the same problems are being solved separately, in isolation. Our new Patient Safety & AI Network intends to help change that.This month we ran sessions with two groups to shape what the Network should be.

 

The Network runs as two Communities:

  • Patient Safety and AI Community 1 is for the people buying and using AI across health and care. If you are procuring, deploying or working alongside these tools in a provider, commissioner or care setting, this is your space.

  • Patient Safety and AI Community 2 is where vendors, academics and innovators are gathering. If you are building, researching or assuring AI products, join this one. 

To join, register on the hub. Once you're logged in, click 'Networks' in the top navigation and choose your Community.

We look forward to you joining and being part of our community! 

 

Evaluating the impact of Patient Safety Partners

Lea Tiernan, Patient safety engagement & involvement lead at Imperial College Healthcare NHS Trust, shares their approach to evaluating the impact of Patient Safety Partners, alongside a suite of related resources for others to adapt and use.

 

If you are a Patient Safety Partner and would like to join the Patient Safety Partner Network, see our 'Join a private community' page or email support@pslhub.org. 

A systems thinking approach in maternity safety 

 In a new blog, hub topic lead Aditi Desai considers whether retrospective inquiries alone are enough to improve maternity safety, arguing that individual errors rarely explain the full picture. Aditi explores how systems thinking and human factors expertise can reveal the pressures, interactions and everyday working practices that create hidden risks across maternity services. She calls for the considerable energy currently devoted to investigating harm to go towards designing safer maternity systems before the next incident occurs. 

A governance improvement journey

At a recent Patient Safety Management Network meeting, Doug Woodcock and Marieke Emonts gave a presentation on Newcastle upon Tyne Hospitals' Family Health Board governance improvement journey. They have also shared their improvement journey in a blog on the hub.

 

If you would like to join the Patient Safety Management Network, see our 'Join a private community' page or email support@pslhub.org.

Patient topic leaders wanted! (2)
hub top picks

This month saw World Menopause Awareness Day dedicated to raising global awareness about menopause and the health-related issues women face during this phase of life. In a new hub top picks, we’ve collated (1) resources and blogs shared on the hub for people who are going through menopause, and (2) resources and guidance for healthcare staff to support their patients and improve services. 

 

the hub gems

A reminder of recent content you may

have missed...

From recording to learning: Six ways general practice can improve its response to significant events

In this blog, Liam Stratton, a former Care Quality Commission (CQC) inspector, outlines six ways general practices can improve their approach to signifcant events reporting. These include making reporting accessible to every member of staff, examining reporting systems, involving patients where appropriate, turning findings into measurable actions and sharing learning across the organisation. 

Scan4Safety: turning stronger evidence into safer care

In this blog, Georgina Lawton, head of healthcare at GS1 UK, reflects on what she has learned from working with healthcare organisations on Scan4Safety. She explains why successful implementation starts with a patient safety problem, rather than the technology, and why clinical involvement, senior leadership, reliable data and dedicated capacity all matter. 

 

 

My submission to the national review of clinical risk management standards DCB0129 and DCB0160

Earlier this year, NHS England ran a national review of the clinical risk management standards DCB0129 and DCB0160: the two standards that govern how health IT systems are assessed for safety before and during use.

In this blog, Clive Flashman, Patient Safety Learning's Chief Digital Officer, summarises his response to that review.

 

The PPE scandal has been exposed. Now we need accountability

Naomi Fulop, board member of Covid-19 Bereaved Families for Justice and Professor of Health Care Organisation and Management UCL, argues that although the UK Covid-19 Inquiry has exposed serious systemic failures around the procurement of personal protective equipment (PPE), meaningful accountability remains largely absent. 

 

What does climate change have to do with patient safety?

In this 2-minute video, Angela Hayes, a Nurse Fellow and Project lead at the Centre for Sustainable Healthcare, explains what climate change has to do with patient safety and how it is putting pressure on healthcare systems around the world. 

Is integrated patient experience intelligence finally possible in the NHS? 

Is integrated patient experience intelligence finally possible in the NHS? Or will infrastructure without design leave us with expensive technology and limited value? Ben Kenyon explores this in a three-part series. 

The side effects from dopamine agonists the doctors don't tell you about

In this opinion piece, Julie Gould draws attention to the side effects of the dopamine agonists she was prescribed for restless legs syndrome. She says that GPs are failing to warn and monitor patients about the serious and often under-recognised behavioural and psychological side effects of dopamine agonists, including augmentation and impulsive control disorder. 

Non-adherence to treatment: more than a patient problem

In this blog, hub Topic lead Risa Mallory says that when patients are listened to, respected and engaged as partners, treatment adherence becomes about collaboration rather than compliance.

 

 
Martha’s Rule—Learning from others

Victoria Wilkins, NHS Resolution, shares insights from a recent Northern Safety and Learning network meeting where four pilot trusts discussed their progress in implementing Martha’s Rule and shared their learning with other members. 

Discover more content

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Upcoming patient safety events

 ASPiH Conference 2026

25-27 November 

The ASPiH conference 2026 explores the theme Simulation: The Next Era - examining how simulation is evolving as a driver of education, system learning and healthcare transformation. 

 Is anyone really learning from deaths?

16 December

Dr Zoe Brummell will summarise her research into the Learning from Deaths programme and explore the obstacles to organisational learning as well as the ways it should happen.

More events

Join in the discussions in the Private networks

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Updates from the Patient Safety Networks

The Patient Safety Management Network logo

Recent Patient Safety Management Network meetings have included presentations on hierarchical task analysis, using AI to help with reviewing PSIRF learning response reports and a thematic review exploring differential diagnosis in the emergency department.

View the presentations and notes

The Patient Safety Partners Network logo

At the October meeting, Parkinson's UK gave a presentation.

View the notes from the meetings

Presentations and slides are only available to Network members.

To find out more about the Networks and how to join, see our 'Join a private community' page. 

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Latest news

Proposals to transfer the Health Services Safety Investigations Body functions to the Care Quality Commission dropped

 

Burnham says he will work to 'get justice' for Primodos victims

Virtual ward patient died due to failure to transfer him to hospital

The NHS is not ready for winter, top A&E doctors warn: ‘We can’t tell where one crisis ends and the next begins’

UK government failures led to Covid spreading ‘like wildfire’ in care homes, inquiry finds

 

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