The National Patient Safety Improvement Programmes

The National Patient Safety Improvement Programmes collectively form the largest safety initiative in the history of the NHS. They support a culture of safety, continuous learning and sustainable improvement across the healthcare system.

How the Patient Safety Improvement Programmes work

The Patient Safety Improvement Programmes are a key part of the NHS Patient Safety Strategy, launched in July 2019 and updated in February 2021, to deliver safety and quality improvements across the NHS in England. They are managed and led by our National Patient Safety Team.

The Patient Safety Improvement Programmes aim to support and encourage a culture of safety, continuous learning and improvement across the health and care system, helping to reduce the risk of harm and make care safer for all.

The programmes are delivered by the National Patient Safety Improvement Programmes Team working with the Health Innovation Network’s 15 regionally-based Patient Safety Collaboratives (PSCs) who support integrated care systems and local health providers, to bring about practical improvements to patient safety. The programmes support leaders in patient safety across the NHS, in particular, Patient Safety Specialists, Patient Safety Partners, Medication Safety Officers, Digital Clinical Safety Officers, Medical Devices Safety Officers and Maternity Safety Champions.

The programmes support systems to test and spread effective safety interventions and strategies, learn from excellence and continuously improve, by implementing the following:

  • Culture:  promote positive safety culture, encouraging staff to gain insight and share learning from good and poor practice
  • Evidence-based improvement:  support evidence-based, quality improvement (QI) methodology, ensuring change is consistently measured and evaluated
  • Quality improvement (QI) capability:  grow QI capability in trusts and local healthcare systems so they can continue to improve
  • System-level change:  enable regional and local health systems to identify improvement priorities and share learning.

National Patient Safety Improvement Programmes

The  current National Patient Safety Improvement Programmes (are as follows:

Managing Deterioration Safety Improvement Programme

The aim of the Managing Deterioration Safety Improvement Programme is to reduce deterioration-associated harm by improving the prevention, identification, escalation and response to physical deterioration, through better system co-ordination and as part of safe and reliable pathways of care. From April 2024 the programme will include the NHS’ commitment to implement ‘Martha’s Rule’, enhancing the safety of care for deteriorating patients. Martha’s Rule will build on the evaluation of NHS England’s Worry and Concern Improvement Collaborative which involves seven regional pilots and began in 2023. They have been testing and implementing methods for patients, families and carers to escalate their concerns about deterioration and to input their views about their illness into the health record.

This work comes alongside other measures to improve the identification of deterioration, including the rollout last November of a new early warning system for staff treating children, built on similar systems already in place for adult, newborn, and maternity services.

To ensure that Martha’s Rule is effective as it can be, it will be implemented as part of an integrated programme to improve the management of deterioration using the ‘PIER’ framework, which helps systems to Prevent, Identify, Escalate and Respond to physical deterioration. This work will improve how the NHS supports staff to manage deterioration and encourage greater involvement from patients, families, and carers.

The Managing Deterioration Safety Improvement Programme has three workstreams:3

  • Phase one of ‘Martha’s Rule’ implementation, which will involve at least 100 adult and paediatric acute provider sites, where patients, families, carers and staff will have round-the-clock access to a rapid review from a separate care team if they are worried about a person’s condition. The first year will provide valuable learning around Martha’s Rule to identify any key challenges and opportunities, before rolling out the initiative across the whole of the NHS in England in the following years.
  • Continued testing and implementation of the standardised national deterioration tools addressing adults, children and young people, maternity and newborns across settings, incorporating patient, carer and family concerns.
  • Publication, implementation and spread of the PIER Framework, to improve how the NHS supports staff across systems to manage deterioration and encourage greater involvement from patients, families, and carers.

The Managing Deterioration Safety Improvement Programme has previously supported the delivery of the following workstreams:

  • Implementation of the National Early Warning Score version 2 (NEWS2) in all acute and ambulance settings for adults.
  • The national implementation of both the NHS COVID-19 Oximetry@home remote monitoring service that supports people at home who have been diagnosed with coronavirus and are most at risk of becoming seriously unwell and the COVID-19 Virtual Ward service which supports safe and earlier discharge of coronavirus patients from hospitals.
  • Pilot testing of the National Paediatric Early Warning System (PEWS) a national standardised approach of tracking the deterioration of children in hospital, which was rolled out in November 2023.
  • The spread and adoption of deterioration management tools  such as NEWS2RESTORE2, RESTORE2 mini, Stop and Watch and Personalised care and support planning (PCSP) tools in all appropriate non-acute settings across health and social care. Between January 2021 and March 2023, 11,621 care homes across England engaged with the programme and 9,164 care homes adopted a deterioration management tool. Data shows that adopting deterioration management tools improves communication between care professionals, reduces the number of hospital admissions, and for those patients that are admitted, reduces the average length of hospital stay. This means improved quality of care for residents, that is delivered at the right time and in the right place, and only those most in need attending hospital.
  • Case study: Supporting care homes to identify deterioration.

Maternity and Neonatal Safety Improvement Programme

The Maternity and Neonatal Safety Improvement Programme works alongside the Patient Safety Collaboratives, with all 134 maternity and neonatal providers in England to reduce unwarranted variation and provide a high-quality healthcare experience for all women, babies and families. The programme supports a range of key improvement projects aligned to the national ambition and the Three year delivery plan for maternity and neonatal services, published in March 2023.

The Maternity and Neonatal Safety Improvement Programme aims to:

  • Reduce the rates of maternal and neonatal deaths, stillbirths and brain injuries that occur during or soon after birth by 50% by 2025 (as set out in Better Births) by ensuring:
  • Reduce the national rate of preterm births from 8% to 6% by 2025 (as set out in Safer Maternity Care) by ensuring:
    • All babies are born in appropriate care setting for gestation (place of birth).
    • Magnesium sulphate is offered to women where preterm birth is imminent.
    • Intrapartum antibiotics prophylaxis is offered to women in established preterm labour.
    • Antenatal corticosteroids are offered to women in threatened preterm labour.
    • Optimal cord management is received by all preterm babies.
    • Optimal normothermic range (36.5-37.5 Degrees Celsius) for all preterm babies.
    • Maternal breast milk is received within 24 hours of birth by all preterm babies.
    • Caffeine is started within 24 hours of birth for preterm babies.
    • Volume-targeted ventilation in combination with synchronised ventilation as the primary mode of respiratory support is given to preterm babies.
  • Support all maternity and neonatal providers to undertake culture surveys and debriefing to influence local improvement plans.

Impact of the Maternity and Neonatal Safety Improvement Programme to date:

  • The ONS Child And Infant Mortality Statistics published on 17 February 2022, shows that:
    • The stillbirth rate has reduced by 25.2% from 5.1 per 1,000 births in 2010 to 3.8 per 1,000 births (equivalent to 752 fewer stillbirths) in 2020.
    • The neonatal mortality rate has reduced by 36.0% from 2.0 per 1,000 live births in 2010 to 1.3 per 1,000 live births (equivalent to 412 fewer neonatal deaths) in 2020.
  • Since 2021, there has been a 100% adoption of offering magnesium sulphate to women where preterm birth is imminent or planned for babies born at less than 30 weeks gestation. It is estimated that magnesium sulphate treatment has resulted in an estimated 431 fewer babies born with cerebral palsy and a cost saving to welfare and society of up to £441m.
  • Since 2021, the percentage of women receiving intrapartum antibiotics prophylaxis in established preterm labour for preterm babies increased from 17% to 75%. The improvements in intrapartum antibiotics administration have resulted in an estimated 16 lives saved.
  • Since April 2020, 13,956 preterm babies have received Optimal cord management. Optimal cord management reduces death in premature babies by a third, saving an estimated 627 babies.
  • Since 2021, the percentage of preterm babies receiving breast milk within 24 hours of birth increased from 12% to 74%

Medicines Safety Improvement Programme

The Medicines Safety Improvement Programme addresses the most important causes of severe harm associated with medicines, most of which have been known about for years, but continue to challenge the health and care systems in England.

The key ambition for the Medicines Safety Improvement Programme are as follows:

  • Improving care for people with persistent pain by reducing opioid analgesic use.
  • Improving care for people with epilepsy, bipolar and conditions for which Valproate is prescribed.
  • Improving care for people taking anticoagulants.
  • Developing the Medication Safety Officer workforce.

In addition to these ambitions, from April 2024 to March 2027 the programme will also explore how to:

  • Improve care for people with a learning disability by reducing the burden of medications that act on the brain. This will complement the STOMP/STAMP campaigns.
  • Improve care for people with frailty by optimising their medicines to reduce death and fractures caused by falling. This will support the work of the National Falls Prevention Coordination Group.
  • Improve care for people by ensuring that they receive the critical medication they need on time. This will include working with Parkinson’s UK in support of their Get It On Time campaign.
  • Reduce the incidence of acute kidney injury that is caused by, or worsened by medication.

The programme has contributions from across NHS England. Key delivery partners are the and the networks of Medication Safety Officers supported by the Specialist Pharmacy Service.

Impact of the Medicines Safety Improvement Programme:

  • Patient benefit from medicine safety improvements has resulted in an estimated 518 lives being saved, the prevention of 4,676 severe harms, 24,128 hospital readmissions avoided, and £9.6M avoided costs of admissions due to harm from medicines. Including:
    • 68 lives saved by improving the dosing of oral anticoagulants
    • 36 lives saved by reducing use of NSAID without gastro-protection
    • 24 fewer major bleeds have occurred by reducing use of NSAID with anticoagulant
    • 2255 fewer people are at risk of overdose from Methotrexate
    • 1,979 fewer acute kidney injuries have been caused by a ‘triple whammy’ drug combination (NSAID, diuretic, renin-angiotensin-aldosterone system inhibitors)
    • 1,979 fewer acute kidney injuries have been caused by a ‘triple whammy’ drug combination (NSAID, diuretic, renin-angiotensin-aldosterone system inhibitors)
    • 414 lives saved by reducing use of opioids. Data for the period September 2022 to July 2023 shows 7,217 fewer people per month being prescribed high-dose opioids compared to the 2021 baseline, with patients reporting a better quality of life, less pain and less disability as a result of improved care.
    • Case study – Faye’s story: good practice when prescribing opioids for chronic pain, highlights the difficulties in prescribing opioids to manage chronic pain and offers advice and guidance to all healthcare professionals who are responsible for administering them.
  • The Valproate Integrated Quality Improvement national programme launched in November 2023, to support Integrated Care Boards to make the use of Valproate as safe as possible. The programme strives to eliminate the harm Valproate causes to babies in the womb, while providing the best possible personalised care for patients and preventing deaths from epilepsy and/or bipolar disorders. The programme has so far seen a 35% reduction in number of women of childbearing age prescribed Valproate.

System Safety Improvement Programme

The System Safety Improvement Programme aims to create optimal conditions for patient safety and quality improvement by supporting the implementation of the Patient Safety Incident Response Framework (PSIRF) in all health and care settings in England. PSIRF is a key deliverable in the NHS Patient Safety Strategy following the publication of the PSIRF guidance for implementation in August 2022.

The PSIRF supports the development and maintenance of an effective patient safety incident response system that integrates four key aims:

  • Compassionate engagement and involvement of those affected by patient safety incidents.
  • Application of a range of system-based approaches to learning from patient safety incidents.
  • Considered and proportionate responses to patient safety incidents.
  • Supportive oversight focused on strengthening response system functioning and improvement.

The Patient Safety Collaboratives are supporting the integrated care systems and the providers within each system in England to embed PSIRF in secondary care settings. The national ambition is to assess PSIRF implementation in general practice settings in 2024/25,  before a wider roll out across primary care in the future.

Patient Safety Collaboratives

The National Patient Safety Improvement Programmes fund 15 regionally based Patient Safety Collaboratives (PSCs) , hosted by the Health Innovation Network, which bring together the NHS, industry, academic, third sector and local organisations to foster innovation and improve health.

The National Patient Safety Improvement Team commissions the Health Innovation Network to deliver improvement support through the PSCs and leads on the commissioning and assurance process.

For more information on Patient Safety Collaboratives or to get involved in patient safety improvement where you live or work, please contact your local Heath Innovation Network.

Completed programmes

Adoption and Spread Safety Improvement Programme

The Adoption and Spread Safety Improvement Programme identified and supported the adoption and spread of effective and safe evidence-based interventions and practice across England.

The programme achieved the following:

  • Between 2021-22 supported a three-fold increase in the proportion of patients (from 8% to 24%) in acute hospitals receiving every element for which they are eligible of the BTS COPD discharge care bundle, which helps to reduce the number of patients who are readmitted following discharge after an acute exacerbation of chronic obstructive pulmonary disease.
  • Supported all the NHS hospitals in England to increase the uptake of all elements of the BTS asthma discharge care bundle so that 56% patients (1 in 2) admitted due to asthma received all elements of the bundle to which they were eligible for aimed at reducing readmissions and improving outcomes.
  • Supported the adoption of three evidence-based tracheostomy safety interventions (bedhead signs, availability of emergency equipment, daily care bundle) in 92% of NHS hospital sites in England between 2020-21. This improved care for an estimated 15,000 NHS patients needing tracheostomy, reducing the average length of stay during their hospital admission and saving an estimated £1.92m per hospital in England. Detailed results are provided through the evaluation of the safer tracheostomy care programme published in partnership with University of Manchester, ARC Manchester: Improving tracheostomy care during the COVID-19 pandemic.
  • Between 2021-22, supported an increase in the proportion of patients receiving all elements for which they are eligible of the emergency laparotomy care bundle in 97% of eligible NHS hospitals.

The Mental Health Safety Improvement Programme

The Mental Health Safety Improvement Programme concluded at the end of September 2023.

The programme worked with the National Collaborating Centre for Mental Health (NCCMH) and the Mental Health Patient Safety Networks (which are supported by Patient Safety Collaboratives), to improve patient safety for those who use inpatient mental health and learning disability services, including staff in health care settings.

The work of the programme has seen a 15% reduction in restrictive practice, such as traumatising restraint, seclusion and rapid tranquilisation, recorded in 38 pilot inpatient wards in England.

The learning from the restrictive practice improvement workstream has been incorporated into the co-production of the Culture of Care Standards for Mental Health Inpatient Services and the associated national implementation support offer, which will see a new Culture Change Programme delivered across all NHS-commissioned providers of inpatient services.

Get involved

Email for more information on our Patient Safety Improvement Programmes, or visit each programmes’ page on FutureNHS, a collaboration platform for people working in health and social care.

Background to our work

The 2013 Francis Report that examined failings in care at Mid Staffordshire NHS Foundation Trust, triggered a need to understand how the whole NHS system could improve further. Professor Don Berwick, a leading expert in global healthcare improvement, was asked to look at whether we could ‘make zero harm a reality’ and what could be done to achieve a continual reduction in harm over time.

The report published by the national advisory group led by Don Berwick, A promise to learn – a commitment to act (2013) made a series of recommendations to improve patient safety. The National Patient Safety Improvement Programme was created to support the call for ‘the NHS to become a system devoted to continual learning and improvement’ in order to make care safer for all.