In conversation with Dr Adam Sutherland & Jonathan Bamber

Posted on by christopherhatton

To celebrate World Patient Safety Day’s 2025 theme “Safe care for every child and for every newborn” we have invited a group of exceptional clinicians and researchers in the field to talk about their research and broader topics relevant to this year’s theme.

In this blog we are talking to Dr Adam Sutherland, Associate Professor in Quality & Safety in Healthcare at University of Bradford School of Pharmacy, Optometry and Medical Sciences and a Research Associate with the NIHR Yorkshire and Humber Patient Safety Research Collaboration (PSRC), and Jonathan Bamber, Head of Quality Improvement at the Royal College of Paediatrics and Child Health and Visiting Researcher at University College London (UCL).

Can you tell us a bit about your backgrounds and your respective roles in the NIHR Patient Safety Research Collaboration (PSRC) Network (SafetyNet) and Royal College of Paediatrics and Child Health (RCPCH)?

Adam: I’ve been a registered pharmacist for nearly 25 (!) years and spent most of my career (2005-2023) working in paediatric critical care. Naturally I was interested in medication safety and was fortunate enough to get NIHR funding for a Masters and then a PhD to study medication safety systems for hospitalised children and young people. Throughout those studies I became more interested in human factors and patient safety more generally. I now lead the Human Factors Working Group for SafetyNet, which is comprised of the six NIHR funded PSRC’s across England. My aim is to build paediatric research capacity and capability within the Network.

Jonathan: I’ve worked in quality improvement and patient safety for nearly 20 years now, initially commissioning safety research for the Health Foundation, then working as a QI specialist for the Royal College of Surgeons of England alongside work as a qualitative researcher for UCL. My focus is on improving outcomes for those in need by ensuring evidence and improvement efforts are effective, relevant and practical. This has led me to join RCPCH to lead their QI and safety work. I see patient safety as an essential and foundational aspect of improvement, so have been working on ensuring our members and children, young people and their parents are supported to improve safety. This includes two core things: having access to up-to-date evidence and information on paediatric patient safety; and having agency and voice to shape our improvement efforts. I see this partnership with SafetyNet as an exciting opportunity to support this.

Can you tell us a bit more about the work the SafetyNet and RCPCH are doing to develop priority research questions related to the delivery of safe care for newborns and children?

Adam & Jonathan: We came together to discuss our ambitions for progressing the paediatric patient safety agenda and discovered that our plans aligned well. At RCPCH we are keen to understand the priorities for improving safety that children and young people and our members have.

In the NIHR SafetyNet we are tackling strategic patient safety challenges. Across our six centres we’re exploring and working to improve patient safety in maternal healthcare, mental healthcare, transitions between hospital and home, and medication safety (to name a few). While we study paediatric safety in of some of our projects (e.g. we’re running the formative evaluation of Martha’s Rule implementation and studying the safety implications of single checking of medications) it isn’t the primary focus. We want to get more involved but we know much less about the specific safety issues that affect newborns, children and young people and what the solutions might be.

There is an obvious synergy between RCPCH and their expertise in paediatric service development and improvement, and SafetyNet in its infrastructure and network of world-renowned patient safety researchers.

When we think about patient safety research, we need to know what the priority questions are to ensure that we make the best possible use of research funding and produce the outcomes that our service users need.

In your opinion, what are the biggest challenges that prevent the delivery of safe care in newborns and children?

Adam & Jonathan: The simple answer is complexity.

Paediatric services have unique challenges of delivery and care and there are aspects of patient safety that are specific to paediatrics. Children aren’t just small adults, and  paediatric services are disadvantaged in a wider healthcare system that is designed around adults; there are enormous physiological and emotional maturity challenges; medication is not designed for them; and, systems do not typically take account of advocates like their parents.1-3

Addressing paediatric patient safety issues can lead to enormous long term benefits but there are difficulties in establishing and delivering paediatric research.4 When considering paediatric patient safety there is an enormous data gap compared with adult patient safety research.  In a meta-analysis of paediatric adverse events including 32 studies over 30 years, with 33,873 admissions and 8,577 adverse events, it was concluded that it was impossible to provide a prevalence estimate of avoidable harm or it’s causes.5  In the most highly cited global estimate of preventable healthcare adverse events derived from 70 studies over 20 years involving 337,025 patients and 28,150 harmful events, only 3% of the included patients (10,314) were children or neonates.6 Consequently, we don’t know what the specific issues are that face our patients, nor the scale of the problems that we face or how we can measure future improvement.

As the NHS shifts from reactive learning and changes to a more holistic view on patient safety and systems improvement, this creates potential new challenges in how services will evolve. There is a need to include children and young people and their parents in future research and improvement initiatives. This is an integral aspect of the work we need to do when developing paediatric specific strategies, ensuring they are not left behind in NHS modernisation.

What do you think is going to make the biggest difference in the field in the next 10 years?

Adam & Jonathan: At this point we don’t know. The World Health Organization has set a range of goals to improve patient safety in five domains including diagnosis, medication safety and newborn safety. They suggest targets for action but we’re lacking the firm direction on the work we need to do and the data we need to really measure success.7 8  In the United States, 24 priorities for patient safety research have been developed, but these were assessed from the US context and experience so their priorities may not align with the UK context.9

Our paediatric professionals and services already do a great deal to improve their services and keep their patients safe, but this is mostly through small local improvements catalysed by local leaders. It is difficult to scale those projects up without making the case for funding and having robust and reliable data on which to build those larger studies. We all need to work with parents, children and young people, clinicians and researchers to identify what the gaps and priorities are in paediatric patient safety and how we can close them. Only with a robust coordinated effort can we get to this next stage, but we are confident that paediatricians, researchers and our communities want to take this step.

In one sentence, what message would you like readers of the blog to take away?

Join RCPCH and PSRC as we collaborate to identify the priority patient safety research questions and help us respond to them. You can sign up here: https://forms.office.com/e/CExUGHXak0

References

  1. Woods DM, Holl JL, Shonkoff JP, et al. Child-Specific Risk Factors and Patient Safety. 2005 2005;1(1):17-22.
  2. Witkowska MI, Janhunen K, Sak-Dankosky N, et al. Parents’ perceptions of patient safety in paediatric hospital care-A mixed-methods systematic review. J Adv Nurs 2024 doi: 10.1111/jan.16361 [published Online First: 2024/08/09]
  3. Wyatt N, Bamber J. Empowering children, young people and their families to improve paediatric patient safety. Archives of Disease in Childhood – Education and Practice 2024 doi: 10.1136/archdischild-2024-327425 [published Online First: 18/02/2025]
  4. Speer EM, Lee LK, Bourgeois FT, et al. The state and future of pediatric research-an introductory overview : The state and future of pediatric research series. Pediatr Res 2023:1-5. doi: 10.1038/s41390-022-02439-4 [published Online First: 2023/01/25]
  5. Dillner P, Eggenschwiler LC, Rutjes AWS, et al. Incidence and characteristics of adverse events in paediatric inpatient care: a systematic review and meta-analysis. BMJ Qual Saf 2023;32(3):133-49. doi: 10.1136/bmjqs-2022-015298 [published Online First: 2022/12/27]
  6. Panagioti M, Khan K, Keers RN, et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ 2019;366:l4185-l85. doi: 10.1136/bmj.l4185
  7. Organisation WH. Global Patient Safety Action Plan 2021-2030. Geneva: WHO, 2021.
  8. WHO. World Patient Safety Day Call to Action and Key Messages 2025 [Available from: https://www.who.int/campaigns/world-patient-safety-day/2025/calls-to-action-and-key-messages accessed 09/09 2025.
  9. Hoffmann J, Keeling N, Forrest C, et al. Priorities for Pediatric Patient Safety Reseearch. Pediatrics 2019;123(2):e20180496. doi: https://doi.org/10.1542/peds.2018-0496
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