Patient Safety
government and the voluntary sector to ensure these reforms protect the patient voice that many patients desperately need.” RCN General Secretary and Chief Executive,
Professor Nicola Ranger, said: “Taking a match to independent organisations designed to protect the public is a high-risk move when things are still so unsafe for patients and tens of thousands of nursing posts lie vacant. “Reducing duplication is always sensible and it is right that the new national quality board will focus on quality and outcomes, but patients must be prioritised over drives for efficiency and financial savings. “The biggest threat to patient safety is having
too few nurses and there is a clear link between better nurse to patient ratios and improved patient outcomes, mortality and length of stay. The best safety measure would be ensuring there are the right number of nursing staff to meet patient need, including in the community where numbers have collapsed. Without urgent investment in the workforce, and the publication of staffing levels to aid public scrutiny, efforts to improve patient safety will fall short.
“This review promises greater transparency for patients, but the government is yet to publish any data on corridor care, despite repeated promises. The Ten Year Health Plan rightly commits to eradicating this horrific practice, but patients are continuing to suffer the indignity of being crammed into hospital corridors and cupboards while they wait for this vital first step. “The government’s plans to turn around the
NHS must not fail and nursing staff stand ready to support them. But to truly protect patients, ministers must take ownership of the real safety issue, the staffing crisis on our wards and in our communities.”
CSJ
View the full report at:
https://www.gov.uk/ government/publications/review-of-patient- safety-across-the-health-and-care-landscape
Clear information needed for safe medication post discharge
HSSIB has published a report highlighting the importance of sharing patient information between services effectively and ensuring patients are confident in medication-self administration before hospital discharge. The report is the third and final report in a series of investigations exploring patient safety events in NHS organisations to understand why patients may not have received medications as planned. The particular investigation explores the systems and processes in place to support when patients are discharged into the community with medications. The investigation also explores the role played by ePMA systems and electronic patient record systems (EPR) in supporting care in this area. In the case they examined, a 53-year-old
patient was admitted to hospital after a fall. While in hospital a change was made to his diabetes medication. He was given support/ education on self-administration, but six days after he left hospital, he had a follow up with the diabetes team and told them he was unable to remember all the information about his medication. He was already receiving wound and catheter care from a district nurse, so the team made a referral via his GP for district nursing to support his self-administration. However, the district nursing team were not made aware of the referral and 17 days after being discharged
from hospital, he told the district nurse he had not been taking his insulin. A glucose reading was taken and was high enough to prompt him to be taken via ambulance back to the hospital for treatment and observation overnight. The investigation highlighted specific concerns
around gaps in patient records and the loss of critical information between hospitals and primary/community care. It also reinforced the importance of ensuring patients are properly educated and feel comfortable and confident when discharged from hospital, especially if they have to manage their own medication needs. While the investigation focused on a single case involving a diabetic patient, the findings offer valuable insights that can inform wider discussions and drive safety improvements across the NHS.
Multiple healthcare providers were involved
with the patient’s care. They used different electronic patient record (EPR) systems that did not interact to share information about the patient’s care and referral status. The report concludes with comprehensive
local-level learning prompts to help organisations and staff identify and think about how to respond to specific patient safety concerns at the local level. The prompts cover care in hospital, discharge planning and care in the community. Rebecca Doyle, Safety Investigator, commented:
32
www.clinicalservicesjournal.com I September 2025
“While individual cases can be complex, this incident clearly highlighted persistent challenges with information sharing — an issue we continue to see in investigations that explore communication and the interaction of digital systems. This information sharing is critical to keep people safe at home, managing their medical conditions and avoiding readmission to hospital. “It also underlined the importance of education and tailored support in hospital, to ensure patients don’t miss or delay critical medication, particularly when they need to self- administer. In this case, the patient’s emergency readmission after not taking his insulin shows the real potential for harm when these systems don’t work as intended. The insights and analysis presented in the report, along with the learning prompts, offer valuable guidance — not just for Trusts and providers, but also for those working at a national level on discharge planning and improving the interoperability of electronic patient record systems. “Ultimately, improving information flow and
patient support at discharge is not just an administrative task — it’s a matter of patient safety.” The investigation report is available at:
https://www.hssib.org.uk/patient-safety- investigations/medication-related-harm/
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