The NHS Patient Safety Strategy is now realising the impact we anticipated when we launched it in 2019: saving 1,000 additional lives and £100 million annually.

This update highlights the significant achievements across the strategy’s national patient safety programmes.

Martha’s Rule

• Martha’s Rule gives patients, families and staff a way to request a rapid review if they are worried that deterioration is not being addressed
• Piloted across 143 acute hospital sites and launched in May 2024
• Between September 2024 and February 2025:
  • 2,389 calls made to escalate concerns; 73% from families seeking help and 47% relating to acute deterioration
  • 129 potentially life-saving interventions triggered, including:
    • 57 urgent admissions to high dependency or intensive care units
    • 60 transfers to specialist services (coronary care, respiratory care, return to theatre)
  • Changes in care for a further 336 cases, for example the introduction of a new medication such as an antibiotic
  • Calls unrelated to acute deterioration are also improving patient care, including:
    • 340 calls led to clinical concerns such as medication delays being addressed
    • 448 calls resolved communication issues

Maternity and neonatal care

• 1,499 neonatal lives saved through safer care bundle interventions, including improvements in optimal cord management and the administration of antenatal steroids
• 518 fewer premature babies with cerebral palsy from the administration of magnesium sulphate during pre-term labour; the estimated saving in lifetime care costs is £518 million

Medicines safety

• 1,900 deaths prevented through medicines safety initiatives
• £9 million saved in admission costs
• Better management of long-term opioid use has significantly contributed to this. Against the 2021 baseline, data to November 2024 shows:
  • 596 lives saved over 2 years
  • a projected 1,802 lives saved from reversing the rising trend in opioid use
  • 3% reduction in high-dose opioid prescribing
  • 12,657 fewer patients a month on high-dose opioids, halving their risk of death from opioids
  • 5% sustained reduction in rate of opioid prescribing for chronic use
• Safer use of valproate and oral anticoagulants, fewer incidents of gastric bleeding, methotrexate overdose and drug-induced acute kidney injury

Early identification of deterioration (in addition to Martha’s Rule)

• New early warning system for staff treating children launched November 2023
• Supporting 1,621 care homes to identify deterioration, reducing 999 calls, emergency admissions and length of hospital stays
• Testing of PIER resources that help systems prevent, identify, escalate and respond to physical deterioration

Transforming how we learn and respond to patient safety events

Patient Safety Incident Response Framework (PSIRF)

• Patient Safety Incident Response Framework (PSIRF), a revolutionary new approach to incident response that centres on maximising learning and patient safety improvement now implemented in every NHS secondary care provider and being piloted in 50+ GP practices
• Embeds systems thinking and improved engagement with patients, families and staff, promoting a patient safety culture
• Providers report they are better able to identify safety priorities and act quickly

Learn from Patient Safety Events (LFPSE) service

• Learn from Patient Safety Events (LFPSE) service: full implementation by November 2024 across all NHS trusts of new national system for recording and learning from patient safety events
• Real-time incident reporting across the NHS, with over 3 million patient safety events recorded each year

National medical examiner system

• National medical examiner system developed: local medical examiner offices cover the whole of England and Wales
• Requirement for medical examiners to provide independent review of all deaths became statutory in September 2024
• This system also provides enhanced support for bereaved families to ask questions and raise concerns about care, helping to identify hundreds of patient safety incidents that can then be responded to

Identifying and responding to patient safety risks

• The National Patient Safety Team’s statutory function to identify and act on emerging safety risks, including by issuing National Patient Safety Alerts. Annually this:
  • saves 160 lives
  • prevents 480 severe harm incidents
  • saves £13.5 million in treatment costs
• New approach to National Patient Safety Alerts developed, including accreditation of alert issuing organisations

Building capability and capacity to address safety challenges

Patient safety leadership

• Network of over 800 patient safety specialists created; they provide expert patient safety leadership, guidance and support at NHS organisations across England
• All patient safety specialists offered in-depth training in patient safety (see below)

Patient safety training and education

• The first National patient safety syllabus launched in 2022
• Over 1.47 million staff completions of the essentials for patient safety’ training
• Over 850,000 completions of the level 2 access to practice training. This is for staff who want to understand more about patient safety or go on to access higher levels of training
• Over 70,000 completions of the level 1 training for boards and senior leaders
• All patient safety specialists offered training in the advanced levels 3 and 4 of the syllabus – almost 500 completions to date
• 3,000+ digital clinical safety training completions

Involving patients and the public in patient safety

• Framework for involving patients in patient safety published in 2021
• Patient safety partner role introduced to enhance the involvement of patients in patient safety work at a national and local level
• From 2025/26 it will be an NHS Standard Contract requirement for all NHS trusts to have appointed and work with patient safety partners
• Simple steps to keep you safe during your hospital stay video and leaflet for patients developed

Strengthening national patient safety systems

• Digital clinical safety strategy published September 2021
• Primary care patient safety strategy published September 2024
• Improving patient safety culture – a practical guide published July 2023 – setting out approaches for NHS organisations to improve their patient safety culture
• National work on assessing patient safety inequalities started to understand how harm is experienced unequally by different groups.

Research and evaluation

The national patient safety strategic research needs highlights eight themes of patient safety challenges in relation to our work and priorities in the NHS Patient Safety Strategy. The six National Institute for Health and Care Research (NIHR) patient safety research collaborations (PSRCs) are undertaking numerous research projects.

Completed and ongoing studies include:

• Understanding the nature and frequency of avoidable harm in primary care–  study completed, protocol and findings
• Understanding the scale and nature of avoidable harm in prison healthcare– study completed, methods, analysis of incidents and scale of harm
• Evaluation of medical examiner’s review to identify potential avoidable deaths due to problems in care– study completed, journal article
• Formative evaluation of the patient specialist role
• Adverse medical incidents and outcomes in the NHS– study completed, findings
• Inequalities in healthcare safety- merged with the above research, awaiting publication
• Missed diagnostic opportunities in primary care. Review protocol
• Developing an effective Safety Management System (SMS) for the NHS in England