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We asked the Patient Safety Group (PSG) of The Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top 10 priorities for patient safety in surgery. This resource is for surgeons, anaesthetists and other healthcare professionals who work in surgery and contains links to useful tools and further reading. See also: Safety in surgery series Top 10 tips for surgical safety: ‘Think Safety, think SEIPS’ Top 10 patient safety tips for surgical trainees 1. Foster a culture of safety through design Establish a psychologically safe environment, through design, where staff feel empowered to speak up without fear of blame. Promote a Just Culture, balancing personal accountability with systems-based learning from adverse events and near misses. Actively encourage multidisciplinary teamwork and peer support, with support from senior leadership, to enhance safety and well-being. Other useful RCSEd resources: Anti bullying and undermining campaign Sexual misconduct in surgery - Lets remove it campaign Addressing conflict in surgical teams workshop 2. Implement team-based quality and safety reviews Use team-based quality reviews (TBQRs) and structured case analysis to learn from everyday work, incidents and near misses. Translate findings into sustainable improvement initiatives that enhance both patient outcomes and staff experience. Foster a culture of collective learning, ensuring safety insights lead to actionable change. Other useful RCSEd resources: Making sense of mistakes workshop 3. Apply Human Factors principles and systems thinking principles in surgical and clinical practice Design resilient systems that mitigate work and cognitive overload and enhance performance reliability. Use TBQR principles to support this. Standardise workflows, optimise usability of IT systems and medical devices, and integrate cognitive aids (e.g. WHO Safe Surgery Checklists, prompts). Ensure governance processes support safe, efficient and user-friendly surgical environments. Other useful RCSEd resources: Systems safety on surgical ward rounds Improving the working environment for safe surgical care Improving safety out of hours 4. Enhance communication & handover processes Implement structured communication tools such as SBAR (Situation, Background, Assessment, Recommendation) to improve clarity and effective decision-making. Optimise handover processes with digital tools, checklists and standardised documentation. Reinforce closed-loop communication, ensuring critical information is confirmed and acted upon. Other useful RCSEd resources: Consultation Skills that matter for Surgeon (COSMOS) 5. Strengthen leadership & accountability in patient safety Senior leaders must visibly support safety initiatives and proactively engage frontline staff in decision-making. Embed structured mechanisms for raising concerns, including TBQR, safety huddles and escalation pathways. Ensure staff have access to training, resources and protected time for safety and quality improvement work. 6. Minimise medication errors in surgery Implement electronic prescribing and technology assisted medication administration to mitigate errors. Enforce double-check procedures for high-risk medications and standardised drug labelling. Improve intra and peri-operative medication safety with clear labelling, colour-coded syringes and real-time verification. 7. Improve early recognition & response to deterioration Appropriate regular training of teams on processes and pathways supported by good design of staff rota ensuring adequate staffing levels. Implement early warning scores and establish rapid response pathways for deteriorating patients. Standardise post-operative surveillance strategies, ensuring timely escalation and intervention. Other useful RCSEd resources: Recognition and prevention of deterioration and injury (RAPID) course for training in recognising critically ill patients 8. Engage patients & families as safety partners Encourage shared decision-making to align treatment plans with patient expectations and values. Provide clear communication on risks, benefits and post-operative care, using tools like patient safety checklists and focus on informed consent processes. Actively involve patients and families in safety and quality initiatives and hospital discharge planning. Other useful RCSEd resources: Patient/carer/families resources and information Informed consent courses (ICoNS) 9. Standardise, simplify & optimise surgical processes Reduce unnecessary complexity in clinical workflows, making processes intuitive, efficient and reliable. Co-design standard operating procedures, policies and pathways with frontline teams to minimise variation. Implement automation and digital solutions where feasible to streamline repetitive tasks. Other useful RCSEd resources: NOTSS (Non Operative Technical Skills for Surgery) courses for surgeons DenTS courses for dentists 10. Promote continuous learning & simulation-based training Conduct regular simulation training for critical scenarios (e.g. sepsis, airway emergencies, human factors). Use insights from TBQR and incident reviews to target training needs and refine clinical practice. Ensure ongoing professional development by providing staff with time, resources, incentives and institutional support for learning. Other useful RCSEd resources: Education pages Edinburgh Surgery OnLine MSc in Patient Safety and Clinical Human Factors

Leadership Futures recently published a report 'Harnessing technology for human progress: Advancing into Industry 5.0', which is driven by a bold ambition: to transform organisations worldwide through technological advancements. In this blog, Caroline Beardall looks at the implications of this for healthcare and suggests five actions that organisation's should take to ensure we achieve the benefits from technology while keeping patient safety at the forefront of an evolving landscape. The recent Leadership Futures report 'Harnessing technology for human progress: Advancing into Industry 5.0' provides a valuable framework for integrating technology with human-centered leadership, which is highly applicable to advancing patient safety in health and care. Its vision of Industry 5.0 as a collaborative human-AI partnership offers a route to reduce errors, enhance clinician capacity and improve patient outcomes. However, realising these benefits requires caution—ethical and inclusive implementation strategies that address the complexities and risks unique to health and care settings. It throws up three fundamental challenges: How can healthcare leaders ensure AI tools are safe to use and that clinical staff can trust them? Who should be responsible if an AI system makes a mistake that affects a patient? How can healthcare organisations use technology to work better without losing the importance of human interaction and the skills needed for high levels of patient satisfaction and safety? In order to answer these questions, and deepen the discussion on harnessing technology responsibly to safeguard and improve patient care, there are some actions we can take to build on the report and begin to gain evidence and experience specific to healthcare. As the landscape of healthcare shifts and evolves, we should consider applying the following five actions (with examples of how to do this) so we can achieve the maximum benefits from technology for patient safety. 1. Foster collective, collaborative leadership across boundaries Leaders should actively promote cooperation and shared responsibility across organisational and professional boundaries, focusing on the overall patient journey rather than siloed departmental goals. This aligns with the report’s emphasis on human-machine collaboration and the need for integrative leadership cultures that support safe, seamless care delivery. By working collectively, leaders can ensure technology is implemented with broad input and oversight, reducing risks and enhancing patient safety. Implement interdisciplinary collaboration practices: Organise regular team meetings involving diverse healthcare professionals to discuss patient care holistically, ensuring all voices contribute to decision making. Create shared goals and aligned metrics: Develop common objectives focused on patient safety and quality that unify departments and reduce siloed working. Lead by example: Demonstrate collaborative behaviours and openness to input, encouraging a culture of trust and teamwork. 2. Embed ethical, human-centred use of technology Leaders must champion ethical principles in technology adoption, ensuring AI and digital tools augment rather than replace human judgment and empathy. This includes rigorous validation of new technologies, transparency in AI decision-making, and ongoing monitoring to prevent harm or bias. Prioritising patient experience and human values in technology deployment safeguards safety and trust. Prioritise transparency and clinician involvement: Engage frontline staff early in AI and technology design and deployment to ensure tools meet clinical needs and ethical standards. Establish continuous monitoring and feedback loops: Use data and user feedback to identify and mitigate risks or biases in technology that could impact patient safety. Promote ethical leadership training: Equip leaders with skills to balance innovation with patient experience and accountability. 3. Develop and support workforce readiness and engagement Preparing staff to work effectively alongside new technologies is vital. Leaders should invest in training that builds digital literacy, critical thinking and resilience, while also fostering a positive work climate where staff feel valued and supported. Engaged and confident clinicians are better able to use technology safely and maintain high standards of care. Invest in targeted training and digital upskilling: Provide contextual, in-app guidance and interactive training to help staff adopt new technologies confidently and efficiently. Foster a culture of psychological safety and empowerment: Encourage open discussion, honest feedback and staff involvement in decision making to build trust and resilience. Practice empathetic leadership: Focus on emotional and professional needs of staff to reduce burnout and improve engagement. 4. Set clear, aligned objectives focused on quality and safety Leadership should establish clear, challenging and aligned goals at every level that prioritise patient safety and quality improvement over mere efficiency or target-driven metrics. This clarity helps reduce staff stress and confusion, enabling teams to focus on delivering compassionate, safe care supported by technology. Communicate clear expectations and priorities: Use consistent, transparent communication to align teams around patient safety goals and reduce ambiguity. Implement continuous feedback and learning systems: Regularly review performance data and patient feedback to refine objectives and improve care quality. Balance efficiency with human factors: Ensure operational goals do not compromise critical human skills or patient-centred care. 5. Champion diversity, inclusion and accountability in leadership Inclusive leadership practices that promote equality and diversity are essential to fostering innovation and ethical decision-making in healthcare technology adoption. Leaders must also clarify accountability frameworks for technology-related decisions and errors, ensuring responsibility is shared and transparent to maintain patient safety. Promote inclusive leadership practices: Value diverse perspectives and foster equity to enhance innovation and ethical decision-making Clarify accountability frameworks: Define roles and responsibilities clearly, especially concerning technology-related decisions and errors, to maintain trust and safety Model human-centred leadership traits: Practice self-awareness, compassion and mindfulness to create cultures of excellence, trust, and caring. By integrating these strategies, human-centric leaders can effectively translate the insights from the Leadership Futures report into practical actions that improve patient safety, staff satisfaction and overall health system resilience. This approach embraces complexity and change as opportunities, not obstacles, which then enables sustainable progress in better health and care delivery. Further reading Amelia N. 6 Effective Leadership Strategies for Healthcare in 2025. Edstellar, 31 December 2024. West M, et al. Leadership in Healthcare: a Summary of the Evidence Base. Kings Fund; Faculty of Medical Leadership and Management; Center for Creative Leadership, 2015. LeClerc L, Kennedy K, Campis S. Human-Centered Leadership in Health Care: An Idea That's Time Has Come. Nursing Administration Quarterly 2020; 44(2):p 117-26.

Learn how to spot the red flags for harmful cultures in healthcare. The Patient Experience Library's Responding to Challenge report reveals the patterns of behaviour that crop up time and again in healthcare disasters. It explains what poor cultures look like - in teamwork, compliance, accountability, organisational learning and more. It can support staff training and organisational learning - helping people to get a better idea of what "culture" actually means in healthcare, and how it can go wrong. Use the Red Flag Tracker to find real-life examples of warning signals, drawn from ten years of official inquiries in UK health and care settings. The tracker will be useful for people charged with the task of "reading the signals" of harm - complaints managers, patient experience staff, Freedom to Speak Up Guardians and local Healthwatch staff, as well as service managers and Trust Board members.

In this interview series, NHS whistleblower Peter Duffy and Patient Safety Learning’s Chief Executive Helen Hughes explore how the healthcare system responds when its staff raise concerns about patient safety. In each episode, Helen and Peter interview someone who has spoken up about patient safety issues in healthcare organisations, or who works to help staff raise concerns where they see unsafe care. In this interview, Peter and Helen speak to Helené Donnelly OBE, who spoke up about unsafe care she witnessed while working as a nurse at Mid Staffordshire NHS Foundation Trust. Helené contributed as a witness to the inquiry led by Sir Robert Francis KC into failings at the trust and was also an advisor in the Freedom to Speak up Review in 2015, where she called for the creation of Freedom to Speak Up Guardians in the NHS. Helené explains why she decided to raise concerns about the quality of nursing care at Stafford Hospital A&E and describes the bullying and threats she received from other staff as a result. She discusses with Peter and Helen the barriers that still prevent staff speaking up today and what can be done to create a more open and responsive culture in teams and organisations. Helené highlights the need to reform how human resources departments respond to staff raising concerns and the vital role of embedding speaking up and organisational culture in the curriculum of all healthcare professional training courses. Subscribe to our YouTube podcast to keep up to date with the latest episodes. View a transcript of this interview Read a blog from Peter and Helen about the interview series

In this interview, David Osborn, chartered occupational safety and health practitioner and member of the Covid-19 Airborne Transmission Alliance (CATA), speaks to Lotty Tizzard, Digital Content Manager at Patient Safety Learning, about how CATA was established during the pandemic to advocate for adequate respiratory protection for NHS employees.  David explains how CATA advocated for the government and heath service to recognise that Covid-19 is passed on by aerosol transmission (through microscopic particles in the air). He also outlines why surgical masks do not adequately protect people against catching airborne viruses and describes how inadequate respiratory protective equipment (RPE) contributed to thousands of NHS staff catching Covid-19 at work. As a result, many healthcare workers died and a large number still live with the ongoing symptoms of Long Covid. David describes CATA's involvement as a Core Participant in the Covid-19 Inquiry and outlines what he hopes will be done to ensure the UK is better prepared for future pandemics. Patient Safety Learning is also a member of CATA. Clarification David wishes to clarify a point raised in the interview: "When talking about the “IPC Cell” I said that they 'didn’t produce minutes'. In fact, notes or minutes were taken at all IPC Cell meetings. The point I was making is that they were not published ('produced' in the sense of being released into the public domain), when the minutes of most other groups such as SAGE and NERVTAG were published. The few IPC Cell minutes that have trickled into the public domain have mostly been as a result of Freedom of Information requests by a colleague and a few that I have managed to obtain myself. In some cases, public authorities have taken around 18 months to disclose documents, and it has required the intervention of the Information Commissioner's Office. I anticipate that more minutes will be disclosed for public scrutiny as time goes on." You can read more about CATA and the Covid-19 Inquiry in David's blogs and presentations on the hub: Respiratory protective equipment: An unequal solution for healthcare workers? A blog by David Osborn Healthcare workers with Long Covid: Group litigation – a blog from David Osborn Covid-19 : A risk assessment too far? A blog by David Osborn CATA and the UK Covid-19 Public Inquiry: Presentation from David Osborn Join the conversation Were you working in health and social care during the pandemic? We'd like to hear about your experience of health and safety at work. Were you provided with adequate PPE to carry out your job safely? Did you catch Covid-19 while at work? You can join the conversation by commenting below (you'll need to sign up first) or get in touch with us directly by emailing [email protected]

Derek Richford’s grandson Harry died in November 2017 at just a week old. Since Harry’s death, Derek has worked tirelessly to uncover the truth about what happened at East Kent Hospitals University Foundation Trust (EKHUFT) to cause Harry’s death. His efforts resulted in a three-week Article 2 inquest that found that Harry had died from neglect. In addition, the Care Quality Commission (CQC) successfully prosecuted the Trust for unsafe care and treatment and Derek’s work has contributed to a review into maternity and neonatal care services at EKHUFT. In this interview, we speak to Derek about how EKHUFT and other agencies engaged with his family following Harry’s death. As well as outlining how a culture of denial at the Trust affected his family, he talks about individuals and organisations that acted with respect and transparency. He highlights what still needs to be done to make sure bereaved families are treated with openness and dignity when a loved one dies due to avoidable harm. Hi Derek, thank you for speaking to me today. Firstly, can you describe the attitude of managers and senior clinicians at the Trust towards your family after Harry’s death? Leaders and staff at EKHUFT were closed off to us from the beginning. At every step, it very much felt like they were saying, “There’s nothing to see here.” Looking back, I realised very soon after Harry’s birth that we needed to start documenting what was happening because the Trust was not being honest. When I arrived at the hospital, we asked a nurse for the name of the doctor who had overseen my daughter-in-law Sarah’s care, and who my son Tom had expressed concerns about. The nurse told us, “You can’t have that information, it’s confidential.” At that point I started photographing Sarah’s notes as I wanted to make sure we had a record. Once the Trust’s internal investigation into Harry’s death started, they told us they couldn’t talk to us while it was ongoing. When we said that we wanted to contribute, we were totally shut out. It was upsetting that the investigation was used as a reason to avoid engaging with us, but we allowed them to get on with it for four months until they released the root cause analysis report into Harry’s death. We were offered a meeting at the Trust in March 2018, so we requested to see the report beforehand. After initially saying they would just show us the report at the meeting, they eventually agreed to send us a hard copy by post, saying they couldn’t send it by email. When we finally got to read it, the report was full of errors and just didn’t add up. At the meeting, it became clear that we knew more about their report than the consultants in the room did. They were totally in denial that Harry’s death could have been avoided and were told that there was no way it needed to be referred to the Coroner. I couldn’t put my finger on exactly what was going on, but I just knew something was wrong with the way Harry’s death was being treated. I began to suspect that what happened to us had happened to many, many families before us—the Trust had avoided taking responsibility and failed to make referrals to the Coroner for years, saying that baby deaths were ‘expected’. Their argument that Harry’s death was expected was that they didn’t have to factor in anything that happened more than 24 hours before they withdrew life support. Later we found that, on their internal notes, Harry’s death was described as an unexpected outcome. It is undoubted that there had been a cover up in the maternity department for many years and I don’t think anyone would deny that now. To quote the Kirkup report, “This pattern of behaviour by the Trust, clearly evident in this case, recurred in many others that we examined. It included denying that anything had gone amiss, minimising adverse features, finding reasons to treat deaths and other catastrophic outcomes as expected, and omitting key details in accounts given to families as well as to official bodies. Although we did not find evidence that there was a conscious conspiracy, the effect of these behaviours was to cover up the truth.” When it came to Harry’s inquest, the Trust didn’t expect or want it to happen and were obstructive throughout the process. When the Coroner suggested that it should be an Article 2 inquest, the Trust disputed it, arguing that it didn’t even come close to the criteria, which was obviously untrue. If the hospital had been upfront with us about what had happened in Harry’s case right at the beginning, we would have been able to forgive the staff and move on. But they didn’t do that. Instead, it felt like a battle from day one and I had to force myself into areas they did not want me to look. At times, I have been painted by Trust staff as a trouble maker. The Trust’s Chief Executive had to apologise to me after writing to our local MP Sir Roger Gale that I was trying to “undermine the reputation of the entire hospital.” This was in response to a letter Roger wrote to the Trust when I raised concerns that they were rating their maternity department 10/10. When NHS Resolution finally investigated, they found that the Trust was actually only scoring 6/10, and the Trust had to repay the large rebate the maternity department had been awarded for their self-audited high score. How were you able to keep pushing for answers in the face of the Trust’s attitude to your family? As Harry’s grandfather, I was one step removed from the situation. That enabled me to stand back and look at what was going on, to ask questions and raise issues that newly bereaved parents would struggle to raise. I call it ‘the grandparent effect’, and it made a huge difference in this case. I was able to be an advocate for Harry’s parents Sarah and Tom, who were obviously severely affected by losing their baby. I looked into the various reviews and audits the maternity unit had been through, and kept uncovering more evidence. The Trust was lacking in so many areas—I dug and dug and with every layer of the onion I took off, I found more rot beneath. I feel it’s so important to share what we’ve been through and what we managed to achieve by not backing down. Once the inquest was over, I learned how to set a website up and published Harry’s Story. I wanted to collect all the information and evidence we had gathered in one, accessible place. I’m still working with EKHUFT now, trying to help them make improvements and deliver Bill Kirkup’s Reading the Signals report, but there’s still such a long way to go. How easy was it to find out which organisations you could refer your concerns about Harry's care to? The Trust left us to our own devices, so I took any route I could to try and find out the truth about what happened to Harry. I went to many organisations such as AvMA and kept being told, “Yes, we hear of these things happening, have you tried X organisation?” We were being sent from pillar to post, but kept trying to find out how we could take it further. I happened to have a relative working for an unrelated department of the Care Quality Commission (CQC) and she recommended that I make a report to the CQC. It was an uphill struggle to be heard by them and I initially found that they really didn’t want to engage with me. They eventually, after 10 months, got back to me saying there was nothing for them to investigate, and at that point I replied by copying in Professor Ted Baker, then Chief Inspector at the CQC. At that point, things started to change! Although the CQC eventually started to engage with us, I’m struck by how we were expected to go to them. We were invited to a meeting in London—we paid our own train fares and Tom had to take a day off work, which is difficult as a teacher. Were there individuals who engaged with you and your family well? What was it about their response that was positive? The individuals who engaged well with us were honest and listened to what we had to say. The Director of Maternity for Healthcare Safety Investigation Branch (HSIB), Sandy Lewis, was so helpful. She would call me with regular updates and communicate how much Harry’s case mattered to her. I could sense her commitment to seeing change. HSIB in general were exceptionally helpful, but there were hurdles to overcome there too. Harry was born in November 2017, but HSIB only had the remit to investigate cases from April 2018. I spoke with various individuals at the organisation including the medical director, who was keen to take on Harry’s case as he recognised its seriousness. They eventually found a way to take it on, by carrying out a learning investigation rather than a maternity investigation. The coroner’s officer was also fantastic—she listened and was so encouraging. I was constantly emailing new evidence over and in every email I would apologise for the extra reading, but she was so affirming and would say, “Send me whatever you want, I’ll make sure the Coroner sees everything.” The Coroner was also very respectful and told me what a difference I was making; after Harry’s inquest, he said to me, “You’ve done a good thing. Without you this wouldn’t have come before me Mr Richford.” I get very emotional thinking about it even now. You and your family suffered a terrible loss. How did the responses of the Trust following Harry's death affect your family further? We’ve discussed this as a family before. The loss of Harry was on one level, but the denial and the way we were treated by the Trust was almost worse—I would say it added at least 50% to the trauma. The approach taken by the Trust was to deny, delay and defend, and the damage that has caused us as a bereaved family is immense. Have you seen any positive change in how bereaved families are treated by the system? One positive move is that I was recently involved in the panel to appoint the new Chief Midwife for England. It was a privilege to be part of the process, and it felt like being told, “You are welcome at this table.” So maybe we are making a difference, but progress is far too slow. For patients and families, the cost of engaging is far more than it should be, both emotionally and financially, as I mentioned earlier. It’s only because I run my own business that I was able to do what I did. I spent hours and hours investigating Harry’s death. We need the NHS to actively help make it easier for people to engage, and to overcome barriers such as financial cost and working hours. During our first meeting with the CQC, I realised that we had access to information that they didn’t—for example, they weren’t aware of a Royal College of Gynaecologists (RCOG) report about EKHUFT that was referenced in the Trust’s board papers. I had done the legwork to draw all the evidence together, which none of the statutory organisations had done. Eventually the CQC agreed to prosecute the Trust for unsafe care and treatment. The prosecution was successful, and the evidence we had collected contributed significantly to that. Lots of families whose babies have died due to harm in or after labour get in touch with me, and their experiences tell me that bereaved families are still being treated with suspicion and a lack of care. I recently discovered that some of the families who took part in the EKHUFT Kirkup investigation—and whose cases featured in the final report—are having to go through a whole new investigation process to claim compensation through NHS Resolution. That means reopening case notes and revisiting yet again the harrowing events that led to the deaths of their babies. The level of trauma this will cause for parents who had hoped the inquiry would bring the justice they need is huge. It is yet another example of how the system is not designed to support victims of harm, and how it fails to place compassion and dignity for patients and their families at the centre of pathways and processes. What do we still need to see change in how organisations respond to families when a loved one dies due to avoidable harm? We need people like me (but not me!) at the top of the NHS—‘real-life’ people who can represent the patient perspective at local board level and right up to the top of the NHS. Most of the people who are currently in leadership have only ever worked for the NHS or have worked there for years, and they don't know any other way of working. There’s an extent to which NHS leaders are institutionalised—they accept the foibles of the system as normal. In the face of serious patient safety concerns many seem to simply say, “No, that’s not what goes on here.” We need leaders who are upfront and honest and will say, “We made a mighty mistake and we’re sorry. We’ll do something about it.” We also need to see trust leaders being held to account. During our experience, we heard the phrase, “the Trust has done this,” a lot, with no individuals taking ownership of actions and decisions. Ultimately, people in leadership were responsible for so many of the lies we were told, but they never had to answer for that. In any other business, people would be held to account, but I am concerned that NHS leaders are allowed to do whatever they want. If this doesn’t change then very little else will. You can read more about the investigations into Harry’s death and Derek’s work to improve the safety of maternity care on the Harry’s Story website.