https://www.gosh.nhs.uk/about-us/our-strategy/quality-and-safety/raising-concerns/patient-safety-at-gosh/
Patient Safety at GOSH
At Great Ormond Street Hospital (GOSH), patient safety is at the heart of everything we do. We care for hundreds of children and young people every day and we work hard to ensure that care is safe, effective, responsive and well led.
While most patients receive care safely and recover well, healthcare can sometimes involve risks. On occasions, things may not go as planned. When this happens, we take it seriously. We act quickly to understand what went wrong, support patients and families, and learn how we can improve care in the future.
A patient safety event is when something happens that wasn’t planned or expected happens (including something not being done) during healthcare that could, or did, result in harm to a patient.
Patient safety events can vary in type and impact. They may include:
- medication errors
- delays in diagnosis or treatment
- communication problems
- issues related to clinical care or procedures
Not all patient safety events result in harm. Some are near misses, where harm was avoided. Reporting and reviewing all events help us understand risk and improve safety. We use the term 'patient safety events' to describe a wide group of things we learn from, including when patients are harmed near misses (where harm did not occur), and patterns of events identified over time.
All reported patient safety events are reviewed by our Patient Safety Team to:
- understand what happened and why
- assess the actual or potential impact
- identify any immediate actions needed
- decide on the most appropriate learning response
In some cases, this may include a Patient Safety Incident Investigation (PSII), which focuses on understanding systems and contributing factors rather than individual blame.
Should a patient safety event impact your child and result in moderate or greater harm, we will promptly notify you, adhering to our legal Duty of Candour requirements.
We will:
- explain what is known about what happened
- offer a sincere apology
- discuss any immediate actions being taken
- explain how we will learn from the safety event
- involve you appropriately in the learning process if that is something you would like
Under the Patient Safety Incident Response Framework (PSIRF), our focus is on learning and improvement rather than blame and supports:
- compassionate involvement of patients, families and staff
- system‑based approaches to learning
- proportionate responses to patient safety events
- oversight focused on improvement and safer care
We use information from multiple patient safety events to understand patterns, risks and themes, helping us prioritise improvement across the organisation.
NHS England PSIRF guidance places strong emphasis on engaging and involving patients, families and carers following a patient safety event.
We recognise that your experience and insight help us:
- understand what matters most
- identify safety concerns that may not be visible to staff
- improve communication and trust
- strengthen learning and improvement
Our Patient Safety Partners contribute to shaping how we respond to and learn from patient safety events.