Resources

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. 

As a hospital CEO, Bernadette McDonald did a lot of listening. But when her organisation decided to create a ‘patient expectations’ document, she realised she didn’t always ‘hear’. This lightbulb revelation led to significant change.

In this episode of ‘Listen to THIS’,  podcast from the THIS Institute at Cambridge University, the hosts discuss learning from failure as essential for improvement,  to better understand what doesn’t work and why. 

Safer Care Victoria has developed a framework and toolkit to guide Morbidity and Mortality (M&M) meetings to provide health services with a systems-based and Just Culture approach to M&M case reviews and discussions.  

Evidence supporting the association between high organisational performance and the presence of clinicians in senior leadership and management roles is steadily growing. Clinical involvement in organisational leadership has been positively linked to operational efficiency and care quality improvements. This in-depth research report from The Health Foundation looks at what the NHS can gain from strengthening clinical leadership and management, the challenges involved in doing so and how they might be overcome. 

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.
 

Is clinical governance lagging behind corporate  governance, despite years of focus? This article argues that healthcare governance and management are still skewed towards corporate and administrative functions. 

In Australian health services, roles that support consumer safety are a mix of trained specialists, people who evolve on the job and those who struggle through the basics with little opportunity for development. In the UK,  the NHS has created a new role of ‘patient safety specialist’, introduced to bring a more structured, professional approach to patient safety. This evaluation article seeks to understand the professionalisation of patient safety, with implications for the further development of patient safety specialists in the UK and other countries. 

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.

Variation in healthcare quality is an ongoing issue. This study seeks to understand how differences in hospital practices and policies can lead to disparities in consumer outcomes and overall care quality. The authors compared process and outcome measures to detect variation and characteristics of hospitals with lower variation.