Source · HSSIB Patient Safety Investigation

Patient safety across regional care pathways: learning from an HSSIB investigation pilot

Published 18 June 2026 Published

Communication and decision making Access to care Continuity of care

We've identified patient safety risks across regional care pathways, linked to unclear roles, limited oversight and inconsistent information sharing which can limit how risks are identified and managed across NHS organisations.

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Summary

20 learning prompts

Learning Prompts

20 total

Prompt 1 Learning prompt How do you identify and resource dedicated support to implement new care pathways?

Prompt 2 Learning prompt How do you ensure appropriate tools and resources are used to support the design and implementation of the care pathway?

Prompt 3 Learning prompt How do you identify and mitigate unexpected challenges to patient safety arising from the care pathway’s implementation?

Prompt 4 Learning prompt How do you identify and mitigate any mismatch between the expectations of patients, families, carers or staff and what the pathway can deliver in practice?

Prompt 5 Learning prompt How do you ensure that implementation of a care pathway is effectively evaluated to improve safety and learning?

Prompt 6 Learning prompt How do you identify and mitigate potential harm caused when implementing a new care pathway?

Prompt 7 Learning prompt How do you identify and manage incivility between staff across different organisations?

Prompt 8 Learning prompt How do you facilitate shared learning opportunities for staff across different organisations?

Prompt 9 Learning prompt How do you ensure information and documentation used to support the care pathway are aligned across different organisations?

Prompt 10 Learning prompt How do you enable staff to understand the context in which the care pathway may work in different organisations?

Prompt 11 Learning prompt How do you engage staff to understand the different requirements for electronic systems that may exist across the care pathway?

Prompt 12 Learning prompt How do you support interoperability of electronic systems to enable effective information sharing across different organisations?

Prompt 13 Learning prompt How do you enable new technology to be adopted and used across different organisations?

Prompt 14 Learning prompt How do you consider relevant tools and guidance when developing work processes across different organisations?

Prompt 15 Learning prompt How do you ensure shared governance forums are appropriately established and resourced, and are effective?

Prompt 16 Learning prompt How do you ensure concerns about the care pathway are escalated and acted on by senior and executive leadership teams across different organisations and the integrated care board?

Prompt 17 Learning prompt How do you ensure consistency in how data is collected and shared across different organisations, including with integrated care boards?

Prompt 18 Learning prompt How do you ensure that risks to the care pathway are identified and mitigated to as low as reasonably practicable across different organisations?

Prompt 19 Learning prompt How do you ensure messages about the care pathway are effectively shared and understood by staff across different organisations?

Prompt 20 Learning prompt How do you identify and facilitate proactive communication with a point of contact at the integrated care board with oversight of the care pathway?