ABSTRACT Background Patient safety incidents cause substantial harm globally, with affected patients and families often experiencing additional ‘compounded harm’ from inadequate organisational responses. Despite policy imperatives emphasising engagement as essential for safety improvement, significant gaps persist in the National Health Service (NHS), where involvement in Serious Incident (SI) investigations is often overlooked or treated as a p2assive process. While previous qualitative research has primarily used thematic analysis, discourse analytic approaches can offer deeper insights into nuanced patterns of meaning. Design/Objective We conducted discourse analysis on 49 semi‐structured interviews with healthcare professionals across six NHS Trusts to examine how staff construct agency in their accounts of engaging patients and families in SI investigations and how these discourses are linked to the broader organisational context. Results Findings illustrate two prevailing but contested discourses: one depicting staff engagement with patients and families as inconsistent and limited, and the other emphasising their integral role in the investigation process. Interviewees framed themselves as either powerless or powerful, aligning with these respective discourses, while organisational factors, such as professional roles and work relationships, also influenced those constructions. Discussion A focus on the linguistic construction of agency, control and responsibility provides a powerful lens for understanding persistent gaps in patient and family engagement and highlights the value of incorporating discourse analytic approaches into health policy development and implementation. Patient or Public Contribution A Citizens' Panel ( n = 16) was involved throughout the broader research programme, ensuring public accountability; supporting wider discussions about the emergent findings of the research and their implications for fairness, equality, diversity and inclusion; and supporting the dissemination of findings in creative and accessible ways.

BACKGROUND:The COVID-19 pandemic had a profound impact on people's lives globally and affected access to, utilisation and the delivery of healthcare. Many communities were disproportionally affected by the pandemic. Community-based research approaches may help address potential healthcare inequities by identifying and understanding people's experiences and needs relating to healthcare access and utilisation. METHODS:For this qualitative study, members of community organisations were trained and supported to interview women from South Asian backgrounds and people seeking asylum and refuge about their experiences of accessing healthcare services and how they looked after their health and the health of others during the COVID-19 pandemic. Twenty-four people took part in a semi-structured interview from four community organisations in West Yorkshire, UK between July and December 2021. The approach to analysis was inductive, using reflexive thematic analysis. FINDINGS:Three themes were generated, each with its own subthemes: (1) COVID-19 magnifying existing challenges; (2) Adjusting to shifts and exclusions in healthcare, and (3) Healthcare experiences and trust. Profound psychological and social impacts were evident, with COVID-19 compounding existing life challenges. There was a commitment to following protective actions, despite perceptions of unclear and inadequate Government public health messaging. There were examples of extreme environmental challenges and using adaptation and flexibility to navigate the healthcare system. Perceived limitations of healthcare services were often 'bridged' through the support and advocacy of family and community members. CONCLUSION:Our findings highlight the significant impact of the COVID-19 pandemic on women from South Asian backgrounds and people seeking asylum and refuge, the inequality and inequity experienced whilst navigating healthcare services and looking after their health and the health of others during the pandemic, and how people adapted to rapidly evolving ways of engaging with the healthcare system. Investment in on-going community partnerships is essential to identify and work with the strengths, skills, resources and knowledge within communities to respond when needs arise. PATIENT OR PUBLIC CONTRIBUTION:Community researchers were part of the research team and involved in all phases of the research, including reviewing study documentation, participant recruitment and data collection, interpretation of the data and co-authoring this paper.

BackgroundWhilst patients and families can and do support patient safety in several ways, empirical evidence for the specific impact of involvement in patient safety incident investigations and their outcomes, has been limited, with little information about how to undertake involvement meaningfully.AimWe aimed to (i) develop a set of common principles to guide involvement of patients and families in patient safety incident investigations; (ii) develop a working programme theory for how these might be enacted; (iii) co-design guidance to support the meaningful involvement of patients and families in patient safety incident investigations.MethodsWe synthesised three existing data sets (a literature review, a documentary analysis of incident investigation policies and 42 interviews with patients, families, lawyers, incident investigators, and healthcare staff) relating to patient and family involvement in incident investigations. Ten common principles and a working programme theory were drafted. Within a convened co-design community, we then developed guidance for patients, families, staff, and investigators in local NHS Trust and national investigations, via a series of workshops.FindingsWe developed ten ‘common principles” and a working programme theory for an approach that might support meaningful patient and family involvement in incidents investigations. Based on these principles and the programme theory, we co-designed guidance to be used within NHS Trust and national investigations of harm that follow patient safety incidents. The guidance includes information, resources and tools to enable better understanding and practice, from the perspective of patients, families, investigators and staff, on how to be meaningfully involved.ConclusionsOur ten common principles and co-designed guidance emphasise two key things. First, that organizational learning is not the only desired outcome for incident investigations, with patients, families and staff reporting the need for restoration and repair. Second, that investigations can be part of reparation, but when it fails to address the needs of stakeholders arising from investigations, it can compound the harm of the original incident. As a result, we juxtapose existing theories, and illuminate new insights, proposing a theory of “restorative learning”. We see design as an ongoing phenomenon—the guidance is our current iteration, and we learnt several valuable lessons about doing co-design.

OBJECTIVE:To understand how National Health Service organizations routinely responded to, investigated, and learned from patient safety incidents in England before the implementation of the Patient Safety Incident Response Framework, and to identify associated success criteria and barriers. METHODS:We followed rapid review methodology and searched 2 electronic databases. We aimed to identify and synthesize literature regarding patient safety incident response, investigation, and learning within the English National Health Service, before the implementation of the Patient Safety Incident Response Framework. RESULTS:Nineteen articles were included. A narrative synthesis generated 4 concepts: (1) a multifaceted reporting culture, (2) investigation processes, (3) the landscape of support and involvement, and (4) opportunities to learn. Barriers to incident reporting included time, task characteristics, a culture of blame, and lack of feedback. Root cause analysis was cited as the most common investigation method. Studies outlined points of support and involvement for patients and families, the importance of supporting and involving patients and families, and acknowledged contributions from patients and families may be overlooked currently. For health care staff, the need for timely and personalized support soon after an incident was emphasized. Studies underlined the limitations of current approaches to learning and improvement. CONCLUSIONS:These findings lend support to the challenges associated with health care systems' infrastructures and strategies for responding to and learning from patient safety incidents. These challenges centre on 2 interrelated issues: the investigative challenges of rigorously conducting systems analysis and learning-oriented improvement; and the relational challenges of supporting genuine relationships of care, open and honest communication, and supportive engagement after patient safety incidents.

Background:There are multiple reasons for involving patients and families in incident investigations. Fiscally, costs due to clinical negligence claims approximate £4 billion annually. Logically, patients and families provide important information about patient safety incidents. Morally, involving harmed patients and families helps address their concerns. However, little United Kingdom-based evidence was available to support systematic involvement. Objective:To co-design processes and resources to guide the involvement of patients and families in incident investigations at a national and local level, and to test these processes to understand their impact upon experience, learning and likelihood of litigation. Design and methods:A mixed-methods programme of research was undertaken. Stage 1 comprised a scoping review of evidence for the experience of patients/families in incident investigations, and a documentary analysis of 43 National Health Service Trust incident investigation policies. Stage 2A extended this with 41 qualitative interviews with patients/families, healthcare staff and investigators. Stage 2B synthesised previous data to develop common principles and programme theory. Stage 3 involved a 6-month co-design phase with a 'co-design community' of > 50 stakeholders. In stages 4 and 5, co-designed guidance was evaluated in a 15-month ethnography, within four National Health Service Trusts and the national independent investigatory body. Twenty-nine investigations were followed in real time, including 127 interviews and 45 hours of observation. Four final co-design workshops supported iterations to the final guidance and website. A substudy explored meaningful involvement in, and learning from, investigations following suicide via interviews and a qualitative survey involving 32 people (healthcare staff, policy-makers and managers; people bereaved by suicide). Findings:Stage 1 found stakeholders valued involvement, but it was not well supported by local policy, even though it likely reduces litigation. Stage 2A found a need for navigational support, and support for other needs. In stage 2B, 10 common principles and a programme theory were developed, emphasising the aim of reducing compounded harm, alongside promoting organisational learning. In stage 3, four draft guidance booklets and a training session were developed. Stage 4 found these to be feasible, with stakeholders positive about involvement, and generally agreed that it aided organisational learning. The guidance supported systematisation of involvement and encouraged relational working, but wider organisational challenges were highlighted. The substudy found that suicide was regarded as somewhat different to other safety events. Meaningful involvement was complicated by a range of factors and should be decoupled from postvention support. Limitations:Undertaking research during the pandemic may have impacted sample representativeness in stage 2A. Ethnically minoritised and lower socioeconomic groups were under-represented across the programme. Future research:Research should explore how people from minoritised groups experience investigations and any required adaptations to the approach. Research should also explore the possibilities for 'harm-centred' rather than 'incident-centred' responses to safety. Conclusions:Investigations are complex, relational processes. Our guidance was found to be feasible, with stakeholders being positive about involvement and the impact on organisational learning. It may help to reduce the significant and long-lasting experience of compounded harm for patients and families. However, involvement may always be challenging due to the divergent needs of patients/families and organisations. Study registration:This study is registered as Current Controlled Trials ISRCTN14463242. Funding:This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 18/10/02) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 18. See the NIHR Funding and Awards website for further award information.

This study aimed to understand the role of a national patient safety policy, the Serious Incident Framework, on local organisational practices of responding to, investigating, and learning from patient safety incidents in the National Health Service (NHS) in England. Qualitative interviews were conducted with healthcare professionals in six NHS organisations and analysed using inductive thematic analysis and taking a constant comparison approach. Systemic challenges linked to the policy's prescriptive requirements were identified, including its emphasis on metrics such as incident closure and harm levels, which often obscured meaningful learning and systemic improvement. The findings highlight the misalignment between the policy's key aims and principles and its practical implementation, revealing an 'industry of investigations' that risked turning the investigative process into a compliance-oriented 'tick box exercise'. Furthermore, the overspecification of performance requirements coupled with the underspecification of substantive guidance led to variability in investigative processes, organisational capacity and resources, and investigator training and expertise. The involvement of patients and families affected by safety incidents was found to be inconsistent and often limited, with perceptions of senior managers and frontline staff underlining some tensions in operationalising large patient safety policies. The analysis considers how the development and implementation of national safety incident policies needs to carefully and intelligently balance the need for adaptive flexibility, clarity of guidance, and specification of organisational resourcing and infrastructure to ensure future national policy can effectively support local practices of learning from safety incidents.

BackgroundThere is a growing international policy focus on involving those affected by healthcare safety incidents, in subsequent investigations. Nonetheless, there remains little UK-based evidence exploring how this relates to the experiences of those affected over time, including the factors influencing decisions to litigate.AimsWe aimed to explore the experiences of patients, families, staff and legal representatives affected by safety incidents over time, and the factors influencing decisions to litigate.MethodsParticipants were purposively recruited via (i) communication from four NHS hospital Trusts or an independent national investigator in England, (ii) relevant charitable organizations, (iii) social media, and (iv) word of mouth to take part in a qualitative semi-structured interview study. Data were analyzed using an inductive reflexive thematic approach.Findings42 people with personal or professional experience of safety incident investigations participated, comprising patients and families (n = 18), healthcare staff (n = 7), legal staff (n = 1), and investigators (n = 16). Patients and families started investigation processes with cautious hope, but over time, came to realize that they lacked power, knowledge, and support to navigate the system, made clear in awaited investigation reports. Systemic fear of litigation not only failed to meet the needs of those affected, but also inadvertently led to some pursuing litigation. Staff had parallel experiences of exclusion, lacking support and feeling left with an incomplete narrative. Importantly, investigating was often perceived as a lonely, invisible and undervalued role involving skilled “work” with limited training, resources, and infrastructure. Ultimately, elusive “organizational agendas” were prioritized above the needs of all affected.ConclusionsIncident investigations fail to acknowledge and address emotional distress experienced by all affected, resulting in compounded harm. To address this, we propose five key recommendations, to: (1) prioritize the needs of those affected by incidents, (2) overcome culturally engrained fears of litigation to re-humanize processes and reduce rates of unnecessary litigation, (3) recognize and value the emotionally laborious and skilled work of investigators (4) inform and support those affected, (5) proceed in ways that recognize and seek to reduce social inequities.

The considered shift from individual blame and sanctions towards a commitment to system-wide learning from incidents in healthcare has led to increased understanding of both the moral and epistemic importance of involving those affected. It is important to understand whether and how local policy describes and prompts involvement with a view to understanding the policy landscape for serious incident investigations in healthcare. This study aimed to explore the way in which involvement of those affected by serious incidents is represented in incident investigation policy documents across acute and mental health services in the English NHS, and to identify guidance for more effective construction of policy for meaningful involvement. We conducted a documentary analysis of 43 local serious incident investigation policies to explore the way in which involvement in serious incident investigations is represented in policy documents across acute and mental health services in the NHS in England. Three headline findings were generated. First, we identified involvement as a concept was conspicuous by its absence in policy documents. Direct reference to support or involvement of those affected by serious incidents was lacking. Even where involvement and support were recognised as important, this was described as a passive process rather than there being moral or epistemic justification for more active contribution to learning. Second, learning from serious incidents was typically described as a high priority but the language used was unclear and ‘learning’ was more often positioned as construction of an arbitrary set of recommendations rather than a participatory process of deconstruction and reconstruction of specific systems and processes. Third, there was an emphasis placed on a just and open culture but paradoxically this was reinforced by expected compliance, positioning investigations as a tool through which action is governed rather than an opportunity to learn from and with the experiences and expertise of those affected. More effective representation in policy of the moral and epistemic reasons for stakeholder involvement in serious incident investigations may lead to better understanding of its importance, thus increasing potential for organisational learning and reducing the potential for compounded harm. Moreover, understanding how structural elements of policy documents were central to the way in which the document is framed and received is significant for both local and national policy makers to enable more effective construction of healthcare policy documents to prompt meaningful action.

Accessible Summary What is known on the subject Mental health wards can feel unsafe. We know that patients and staff have different ideas about what makes a hospital ward safe or unsafe. Patients are often the first to know when the atmosphere on a ward becomes tense, but often, no one asks them for their views. Patients and staff are experts and should be included in discussions about how to make wards safer. What this paper adds to existing knowledge We got together with some service users and staff, and made an app that helps patients to tell staff when they are not feeling safe on a mental health ward. We tried it out on six wards and we asked patients and staff what they thought. The app was easy to use and most people liked the look of it. Patients said staff did not talk with them enough and so they liked using the app. However, some staff said they could tell how patients were feeling without an app and so they did not need it. Ward managers told us that staff were often very busy and did not always have time to use the app. What are the implications for practice This app could help staff know straightaway when patients do not feel safe on the ward, so that they can act quickly to calm things down. To make the most of the app, staff need to get used to it and bring it into ward routines. Abstract Introduction Safety improvement on mental health wards is of international concern. It should incorporate patient perspectives. Aim Implementation and evaluation of ‘WardSonar’, a digital safety‐monitoring tool for adult acute mental health wards, developed with stakeholders to communicate patients' real‐time safety perceptions to staff. Method Six acute adult mental health wards in England implemented the tool in 2022. Evaluation over 10 weeks involved qualitative interviews (34 patients, 33 staff), 39 focused ethnographic observations, and analysis of pen portraits. Results Implementation and evaluation of the WardSonar tool was feasible despite challenging conditions. Most patients valued the opportunity to communicate their immediate safety concerns, stating that staff had a poor understanding of them. Some staff said the WardSonar tool could help enhanced ward safety but recognised a need to incorporate its use into daily routines. Others said they did not need the tool to understand patients' safety concerns. Discussion Foreseeable challenges, including staff ambivalence and practical issues, appeared intensified by the post‐COVID‐19 context. Implications for Practice The WardSonar tool could improve ward safety, especially from patients' perspectives. Future implementation could support staff to use the real‐time data to inform proactive safety interventions.

Background:Acute inpatient mental health services report high levels of safety incidents. The application of patient safety theory has been sparse, particularly concerning interventions that proactively seek patient perspectives.Objective(s):Develop and evaluate a theoretically based, digital monitoring tool to collect real-time information from patients on acute adult mental health wards about their perceptions of ward safety.Design:Theory-informed mixed-methods study. A prototype digital monitoring tool was developed from a co-design approach, implemented in hospital settings, and subjected to qualitative and quantitative evaluation.Setting and methods:Phase 1: scoping review of the literature on patient involvement in safety interventions in acute mental health care; evidence scan of digital technology in mental health contexts; qualitative interviews with mental health patients and staff about perspectives on ward safety. This, alongside stakeholder engagement with advisory groups, service users and health professionals, informed the development processes. Most data collection was virtual. Phase 1 resulted in the technical development of a theoretically based digital monitoring tool that collected patient feedback for proactive safety monitoring. Phase 2: implementation of the tool in six adult acute mental health wards across two UK NHS trusts; evaluation via focused ethnography and qualitative interviews. Statistical analysis of WardSonar data and routine ward data involving construction of an hour-by-hour data set per ward, permitting detailed analysis of the use of the WardSonar tool.Participants:A total of 8 patients and 13 mental health professionals participated in Phase 1 interviews; 33 staff and 34 patients participated in Phase 2 interviews.Interventions:Patients could use a web application (the WardSonar tool) to record real-time perceptions of ward safety. Staff could access aggregated, anonymous data to inform timely interventions.Results:Coronavirus disease 2019 restrictions greatly impacted the study. Stakeholder engagement permeated the project. Phase 1 delivered a theory-based, collaboratively designed digital tool for proactive patient safety monitoring. Phase 2 showed that the tool was user friendly and broadly acceptable to patients and staff. The aggregated safety data were infrequently used by staff. Feasibility depended on engaged staff and embedding use of the tool in ward routines. There is strong evidence that an incident leads to increased probability of further incidents within the next 4 hours. This puts a measure on the extent to which social/behavioural contagion persists. There is weak evidence to suggest that an incident leads to a greater use of the WardSonar tool in the following hour, but none to suggest that ward atmosphere predicts future incidents. Therefore, how often patients use the tool seems to send a stronger signal about potential incidents than patients' real-time reports about ward atmosphere.Limitations:Implementation was limited to two NHS trusts. Coronavirus disease 2019 impacted design processes including stakeholder engagement; implementation; and evaluation of the monitoring tool in routine clinical practice. Higher uptake could enhance validity of the results.Conclusions:WardSonar has the potential to provide a valuable route for patients to communicate safety concerns. The WardSonar monitoring tool has a strong patient perspective and uses proactive real-time safety monitoring rather than traditional retrospective data review.Future work:The WardSonar tool can be refined and tested further in a post Coronavirus disease 2019 context.Study registration:This study is registered as ISRCTN14470430.Funding:This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128070) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 14. See the NIHR Funding and Awards website for further award information.

Abstract Background Safety incidents are common in adult acute inpatient mental health services, and detrimental to all. Incidents spread via social contagion within the ward, but social contagion is difficult to quantify. Better measures of social contagion could support a milieu in which safety incidents are less likely to be prolonged, spread, or repeated, with widespread benefits. The WardSonar project, based in the United Kingdom (UK), developed and evaluated a prototype digital safety monitoring tool to collect real-time information from patients on acute adult mental health wards, about their perceptions of ward safety. A prototype Wardsonar tool was developed from a collaborative, co-design approach, and implemented in real-world hospital settings. The current study aimed to understand whether the tool can help to predict incidents, by examining (i) the feasibility of capturing real-time feedback from patients about safety and (ii) how the resulting data related to quality and safety metrics. This study was registered as ISRCTN14470430 on 10/January/2022. Method Patients can record real-time perceptions of ward safety using the tool, and staff can access these as anonymous, aggregated data. The tool was implemented in the UK in six National Health Service adult acute mental health wards. A novel approach to analysis involved construction of an hour-by-hour dataset over each ward. This revealed relationships between quantity and content of patient reports, staffing, time of day, and ward incidents, per ward. Results There is strong evidence that an incident leads to increased probability of further incidents within the next four hours. This supports the idea of social/behavioural contagion and puts a measure on the extent to which the contagion persists. COVID-19 impacted the research processes. Conclusions There is potential to use the WardSonar digital tool for proactive real-time safety monitoring, to identify developing incidents and help staff to facilitate timely preventative or de-escalating interventions. Further refinement and testing in a post COVID-19 context are needed. Trial registration ISRCTN14470430 https://doi.org/10.1186/ISRCTN14470430 . Registered 10/January/2022.

BACKGROUND Acute mental health services report high levels of safety incidents that involve both patients and staff. The potential for patients to be involved in interventions to improve safety within a mental health setting is acknowledged, and there is a need for interventions that proactively seek the patient perspective of safety. Digital technologies may offer opportunities to address this need. OBJECTIVE This research sought to design and develop a digital real-time monitoring tool (WardSonar) to collect and collate daily information from patients in acute mental health wards about their perceptions of safety. We present the design and development process and underpinning logic model and programme theory. METHODS The first stage involved a synthesis of the findings from a systematic review and evidence scan, interviews with patients (n=8) and health professionals (n=17), and stakeholder engagement. Cycles of design activities and discussion followed with patients, staff, and stakeholder groups, to design and develop the prototype tool. RESULTS We drew on patient safety theory and the concepts of contagion and milieu. The data synthesis, design, and development process resulted in three prototype components of the digital monitoring tool (WardSonar): (1) a patient recording interface that asks patients to input their perceptions into a tablet computer, to assess how the ward feels and whether the direction is changing, that is, “getting worse” or “getting better”; (2) a staff dashboard and functionality to interrogate the data at different levels; and (3) a public-facing ward interface. The technology is available as open-source code. CONCLUSIONS Recent patient safety policy and research priorities encourage innovative approaches to measuring and monitoring safety. We developed a digital real-time monitoring tool to collect information from patients in acute mental health wards about perceived safety, to support staff to respond and intervene to changes in the clinical environment more proactively.

Background Patients have expressed a growing interest in having easy access to their personal health information, and internationally there has been increasing policy focus on patient and care records being more accessible. Limited research from the UK has qualitatively explored this topic from the primary care staff perspective. This study aimed to understand what primary care staff think about patients accessing electronic health records, highlighting errors in electronic health records, and providing feedback via online patient portals. Methods A focus group study involving 19 clinical and non-clinical primary care staff. Primary care practices were purposively sampled based on practice size and the percentage of patients using online services. Data were analysed inductively using reflexive thematic analysis. Results Three themes were generated: (1) Information - what, why and when? (2) Changing behaviours and protecting relationships, and (3) Secure access and safeguarding. The emotional considerations and consequences for staff and patients featured prominently in the data as an overarching theme. Conclusions Primary care staff described being invested and supportive of patients accessing their electronic health records, and acknowledged the numerous potential benefits for safety. Uncertainty around the parameters of access, the information available and what this might look like in the future, processes for patients highlighting errors in records, relational issues, security and safeguarding and equitable access, were key areas warranting examination in future research.

Background Safety netting in primary care may help diagnose cancer earlier, but it is unclear what the format and content of an acceptable safety-netting intervention would be. This project aimed to co-design a safety-netting intervention with and for primary care patients and staff. Aim This work sought to address how a safety-netting intervention would be implemented in practice; and, if and how a safety-netting intervention would be acceptable to all stakeholders. Design and setting Patient representatives, GPs, and nurse practitioners were invited to a series of co-design workshops. Patients who had and had not received a diagnosis of cancer and primary care practices took part in separate focus groups. Method Three workshops using creative co-design processes developed the format and content of the intervention prototype. The COM-B Framework underpinned five focus groups to establish views on capability, opportunity, and motivation to use the intervention to assist with prototype refinement. Results Workshops and focus groups suggested the intervention format and content should incorporate visual and written communication specifying clear timelines for monitoring symptoms and when to present back; be available in paper and electronic forms linked to existing computer systems; and be able to be delivered within a 10-minute consultation. Intervention use themes included ‘building confidence through partnership’, ‘using familiar and current procedures and systems’, and ‘seeing value’. Conclusion The Shared Safety Net Action Plan (SSNAP) — a safety-netting intervention to assist the timely diagnosis of cancer in primary care, was successfully co-designed with and for patients and primary care staff.

Background Values are of high importance to the nursing profession. Value congruence is the extent to which an individual’s values align with the values of their organisation. Value congruence has important implications for job satisfaction. Aim This study explored nurse values, value congruence and potential implications for individual nurses and organisations in terms of wellbeing and patient care and safety. Method Fifteen nurses who worked in acute hospital settings within the UK participated in semi-structured telephone interviews. Thematic analysis was utilised to analyse the data. Results Four themes were identified: organisational values incongruent with the work environment; personal and professional value alignment; nurse and supervisor values in conflict; nurses’ values at odds with the work environment. Perceived value incongruence was related to poorer wellbeing, increased burnout and poorer perceived patient care and safety. The barriers identified for nurses being able to work in line with their values are described. Conclusions Value congruence is important for nurse wellbeing and patient care and safety. Improving the alignment between the values that organisations state they hold, and the values implied by the work environment may help improve patient care and safety and support nurses in practice.

Objectives To produce a narrative synthesis of published academic and grey literature focusing on patient safety outcomes for people with learning disabilities in an acute hospital setting. Design Scoping review with narrative synthesis. Methods The review followed the six stages of the Arksey and O’Malley framework. We searched four research databases from January 2000 to March 2021, in addition to handsearching and backwards searching using terms relating to our eligibility criteria—patient safety and adverse events, learning disability and hospital setting. Following stakeholder input, we searched grey literature databases and specific websites of known organisations until March 2020. Potentially relevant articles and grey literature materials were screened against the eligibility criteria. Findings were extracted and collated in data charting forms. Results 45 academic articles and 33 grey literature materials were included, and we organised the findings around six concepts: (1) adverse events, patient safety and quality of care; (2) maternal and infant outcomes; (3) postoperative outcomes; (4) role of family and carers; (5) understanding needs in hospital and (6) supporting initiatives, recommendations and good practice examples. The findings suggest inequalities and inequities for a range of specific patient safety outcomes including adverse events, quality of care, maternal and infant outcomes and postoperative outcomes, in addition to potential protective factors, such as the roles of family and carers and the extent to which health professionals are able to understand the needs of people with learning disabilities. Conclusion People with learning disabilities appear to experience poorer patient safety outcomes in hospital. The involvement of family and carers, and understanding and effectively meeting the needs of people with learning disabilities may play a protective role. Promising interventions and examples of good practice exist, however many of these have not been implemented consistently and warrant further robust evaluation.

The study aimed to explore mental health professionals' perceptions of patient safety issues across community and inpatient mental health services. Fourteen mental health professionals across community and inpatient settings participated in qualitative interviews. Framework analysis, guided by the Yorkshire Contributory Factors Framework - Mental Health, was used to analyse the data. Safety issues identified by mental health professionals mapped on to 19 of the 21 factors in the Yorkshire Contributory Factors Framework - Mental Health. The factors most frequently mentioned by participants were 'safety culture' which focused on raising concerns, learning from incidents and the influence of targets; 'communication systems' to support effective communication between staff; 'service user factors' including a perceived increase in illness acuity; 'service process' including how patients access and interact with services; and 'staff workload' perceived being as unmanageable. Mental health professionals consider there to be a broad range of safety issues associated with mental health services. Future research should aim to develop interventions to improve safety focused across the factors raised by professionals.

Abstract Background Service user and carer perspectives on safety issues in mental health services are not well known and may be important in preventing and reducing harm. The development of the Yorkshire Contributory Factors Framework—Mental Health (YCFF‐MH) provides a broad structure within which to explore these perspectives. Objective To explore what service users of mental health services and their carers consider to be safety issues. Design, setting and participants Qualitative interviews with 13 service users and 7 carers in the UK. Participants were asked about their experiences and perceptions of safety within mental health services. Perceived safety issues were identified using framework analysis, guided by the YCFF‐MH. Results Service users and carers identified a broad range of safety issues. These were categorized under ‘safety culture’ and included psychological concepts of safety and raising concerns; ‘social environment’ involved threatened violence and sexual abuse; ‘individual service user and staff factors’ dominated by not being listened to; ‘management of staff and staffing levels’ resulting in poor continuity of care; and ‘service process’ typified by difficulty accessing services during a crisis. Several examples of ‘active failures’ were also described. Discussion and conclusions Safety issues appear broader than those recorded and reported by health services and inspectorates. Many safety issues have also been identified in other care settings supporting the notion that there are overlaps between service users and carers’ perspectives of safety in mental health services and those of users in other settings. Areas for further research are suggested.

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