Resources

As AI systems increasingly permeate clinical environments, the importance of establishing a structured approach to identifying, predicting and mitigating patient care safety risks grows. Recognising and addressing these risks is fundamental if AI is to fulfil its potential as a care guidance tool, without sacrificing patient safety in the process. 

The London Protocol is a well-known framework designed to guide deep analysis of clinical incidents to improve safety. The 2025 revision of the Protocol introduces significant updates to strengthen the analysis of clinical incidents. A key enhancement is the increased emphasis on engaging patients and their families as active partners in the incident analysis process. 

The importance of a safety culture, incorporating psychological safety and encouraging people to speak up, has been identified as critical to safe care for some time. However, achieving and maintaining such an environment can be challenging. This metasynthesis examines 15 studies to “review and synthesise qualitative research on nurses' experiences of speaking up”. 

The role of healthcare leaders is becoming increasingly complex and carries significant responsibility for consumer and employee safety. Leaders and managers often experience tension between adhering to regulatory standards and addressing the unique needs of their consumers and staff.  This dual focus can lead to a fragmented effort, where Health, Safety and Environment (HSE), with a focus on workers, and Quality and Patient Safety (QPS), with a focus on consumers, operate in silos rather than as integrated components of a cohesive safety strategy.
 

This is a little story about four people named Everybody, Somebody, Anybody, and Nobody.

The Commission has released two new resources summarising the evidence on the effectiveness of interventions that aim to improve medication management at transitions of care.

Medication errors remain a stubbornly challenging issue in the provision of safe care. Although we often associate inpatient settings with medication issues, this comprehensive review studied the triumvirate of prescribing, dispensing and administration to determine common causal factors of mistakes and inaccuracies, leading to incidents in ambulatory and outpatient settings.

Correct identification of patients has been recognised as a critical safety issue for many years. A recent report from the UK’s Health Services Safety Investigation Body (HSSIB), compiles evidence from various investigations and sources to explore the factors contributing to patient misidentification in healthcare. The report defines 'positive patient identification' as the accurate identification of a patient to ensure they receive the correct care. Whereas, 'patient misidentification' occurs when a patient is wrongly identified as someone else, leading to potential harm from incorrect or missed treatment.

This Failure Modes and Effects Analysis (FMEA) Tool, provided by the Institute for Healthcare Improvement (IHI), is a comprehensive resource designed to help human services systematically identify and mitigate potential risks in clinical processes.

We spend a lot of time on root cause analysis (RCA) – and have done it for 20 years or so. But key clinical risks remain stubbornly consistent.