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The Royal College of Surgeons of Edinburgh (RCSEd) have drawn up their top 10 tips for surgical safety using the SEIPS (Safety Engineering Initiative for Patient Safety) model. Click on image to enlarge or download from the attachment below: See also: Safety in surgery series Top 10 priorities for patient safety in surgery Top 10 patient safety tips for surgical trainees

Patient Safety Learning asked the Patient Safety Group (PSG) of the Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top tips for patient safety in surgery to share on the hub. They came up with three useful resources for surgeons and surgical trainees: Top 10 priorities for patient safety in surgery Top 10 tips for surgical safety: Think Safety, think SEIPS Top 10 patient safety tips for surgical trainees In this blog, Anna Paisley, Consultant Upper GI Surgeon and RCSEd Council Member and Chair of the PSG, reflects on the process her and the team went through to collate these patient safety resources. We hope you find these resources useful.  When asked to do this by Patient Safety Leaning, we were delighted to contribute. However, what seemed initially to be a straightforward task, turned out to be rather challenging. Patient safety covers such a vast area, and it proved very difficult to select only 10 key tips. Each member of the multi-disciplinary surgical team will have a slightly different outlook and perspective; the safety principles most important to their specific practice will inevitably vary. No one size fits all. Each member of the PSG had a slightly different set of tips based on their experience, skill set and discipline. All submissions were of course valid and we thought it would be helpful to include the three main approaches. 1 Top 10 priorities for patient safety in surgery Manoj Kumar, Consultant General and Upper GI Surgeon in Aberdeen, PSG Educational Lead and Convenor of the RCSEd Team Based Quality Review workshop, spearheaded a comprehensive set of patient safety tips for surgery aimed primarily for surgical patient safety leaders. His strong belief is that improving patient safety in surgery requires more than isolated interventions—it demands a sustained cultural and systemic shift. His top 10 priorities are grounded in evidence-based practice and real-world experience, recognising that safer care emerges when we design systems that support people to do the right thing, every time. This approach combines Human Factors principles, team-based quality reviews and learning, psychological safety as well as leadership engagement to drive improvement from the ground up. It moves beyond reactive fixes to proactive action, reduces unwarranted variation and enables learning across all levels of the organisation. By embedding these principles into daily practice, surgical teams can move toward high reliability environments and deliver safer, more effective care for every patient. 2 Top 10 tips for surgical safety: ‘Think Safety, think SEIPS’” When asked to give her top 10 tips for patient safety in surgery, Claire Morgan, Consultant in Restorative Dentistry, PSG Deputy Chair and Member of RCSEd Dental Council, chose to structure her response using Carayon’s Systems Engineering Initiative for Patient Safety (SEIPS). The SEIPS framework allows us to consider any patient safety issue or question using a systems-based approach. This affords a broad view, including application of a Safety 2 thinking; i.e. why do things normally go well. From Claire’s personal perspective, ’Think Safety, Think SEIPS’ ensures a constant recheck of all factors that might contribute to any patient safety incident. SEIPS is a relatively simple tool to use with consideration of six contributory systems to patient safety: tasks tools and technology person organisation internal environment external factors. However, it does not stop there, as it is the interaction between all these systems and then processes that determines outcomes. This approach produced a visual map demonstrating the complexity of the socio-technical systems involved in surgical safety from a human factors perspective. 3 Top 10 patient safety tips for surgical trainees As a consultant Upper Gastro-intestinal surgeon from Edinburgh, RCSEd Council Member and PSG Chair, I compiled a simple list with trainee members of the surgical team in mind. Introducing key patient safety principles early in a training pathway is crucial to helping develop an appropriate patient safety culture in any workplace. I wanted to highlight the principle that patient safety is everyone’s responsibility, and not just that of the quality improvement team. I also wanted to emphasise the crucial point that all members of the team have an important voice and should feel empowered and able to speak up if they feel something is not right. So, the RCSEd PSG have used three separate approaches in defining our top ten tips for patient safety in surgery. I hope that you find them useful and that one will resonate with you from your own individual perspective. Share your resources and top tips What more is needed to support surgeons and trainees? Do you have a tool or policy, a personal reflection, peer-reviewed literature that we could share and highlight on the hub. What other top tips would be useful to surgeons, students and patients? Share your ideas in the comments below (you will need to be a hub member, sign up is free and easy) or contact our editorial team at [email protected].

Patient safety is the core foundation of healthcare quality. Unsafe care is a significant challenge globally, due to unsafe practices, processes, or structural inefficiencies within healthcare organisations, which in turn lead to patient safety incidents. This white paper from ISQua aims to address these challenging issues by providing a comprehensive framework to improve patient safety in hospitals and other healthcare settings. The white paper focuses on four foundation pillars that it identifies as critical for embedding patient safety into healthcare systems: 1) Advocacy and Leadership Advocate for prioritisation of patient safety within hospital policies, practices, and culture. Ensure that patient safety is embedded as a core organisational value in every level of healthcare delivery. Establish a strong hospital governance structure that ensures leadership commitment to patient safety and accountability. 2) Health Worker Education and Safety To empower health workers with the knowledge, skills, and tools to be proactive agents of patient safety within healthcare organisations through continuous education and training programmes. It prioritises the physical and psychological well-being of healthcare professionals to enhance workforce resilience to deliver safe and effective care. 3) Patient, Family and Carer Engagement and Empowerment To empower and engage patients, families, and carers in patient safety efforts. To ensure effective collaboration between healthcare providers and patients to improve safety and quality of care delivery 4) Improvement in Clinical Processes Adopt evidence-based practices to manage patient safety risks in clinical care. Ensure standardising care, utilising technology, and measuring progress and effectiveness.

Nurses and nursing support workers in every setting have a vital role in improving outcomes for people with sepsis and with new guidelines published, there has never been a better time to update your knowledge and practice in this area. Why attend Latest information: Nurse specialists will give you the information on the signs and symptoms of sepsis and bring you up to date on the latest guidelines from NICE and the Academy of Royal Medical Colleges Practical application: Gain practical strategies for raising concerns effectively, including the latest information about Martha’s Rule Expert advice: Our experts offer advice on how to spot a deteriorating patient in a range of settings, including hospital, community and care homes PLUS all your clinical questions answered by our panel and networking. Register

Dr Kirsten Howson, Specialist Education Lead at SimComm Academy, discusses the role Simulation-Based Education (SBE) can have in patient safety. Kirsten highlights some of the techniques used in SBE, the benefits for staff and patients, and the importance of involving people with lived experience in the design and delivery of SBE. Background Initially used within the aviation industry, Simulation-Based Education (SBE) has now been adopted within healthcare education and training.[1] Clinical SBE began several decades ago[2] and has continued to successfully grow, providing learners with the opportunity to put their knowledge and skills into practice within a psychologically safe environment. Effective SBE includes a debrief following on from the simulated exercises. Research outlines that the debrief has been identified as a key component of impactful SBE, with the simulated scenarios acting as a catalyst for further reflection, conversation and sharing of experiences and ideas.[3] There are a range of techniques used within SBE: Forum theatre: Participants observe a complete simulated scenario played out in front of them, followed by a group reflection. The scenario is then run again, giving participants the opportunity to pause the scenario at multiple points and change the behaviours and language of one of the simulated characters in an attempt to improve the outcome of the interaction. Fishbowl simulation: Participants are given a scenario and task and interact with simulated characters while their peers observe the interaction and completion of the task. This is followed by a facilitated debrief in which participants are able to explore alternative methods, obtain feedback, discuss learning objectives, and reflect and share ideas. Observational simulation: Participants observe a simulated scenario which is then followed by a facilitated debrief in which participants are able to explore alternative methods, discuss learning objectives, and reflect and share ideas. Monologues: Participants observe while a simulated character delivers a monologue, which may include the character’s reflections, experiences or feelings. This is then followed by a facilitated debrief in which participants are able to explore alternative methods, discuss learning objectives, and reflect and share ideas. How simulation-based education impacts on patient safety SBE has been shown to have a wide range of benefits, many of which impact on patient safety, including: Participant skills and knowledge: SBE enhances participant skills[4] through practice, reflection and feedback, and can span not only technical skills, such as performing procedures and examinations, but also non-technical skills, such as leadership, communication skills, teamwork or prioritisation.[5] Enhancement of the skills and knowledge of clinical staff will likely result in an increase in patient safety. Participant confidence: Simulation training can increase the participant's confidence by providing participants with the opportunity to practise a new skill in a simulated setting in which there will be no safety implications; participants can build their confidence to the point at which they feel safe to use the skills in a non-simulated environment.[6] Participant teamwork: Teamwork skills are often a key focus and improve through the use of simulation training.[7] Dependent on the participant group, this can be on both an intraprofessional and interprofessional basis. Although these skills can be practised within the simulation scenarios, the debrief period also provides the opportunity to share differing points of view within the team, which can enhance teamwork, and again will likely result in an increase in patient safety. Participant mental health, burnout and sick leave: Medical and allied healthcare staff face high levels of mental health concerns and burnout, with the recent General Medical Council (GMC) report, 'The State of Medical Education and Practice in the UK Workplace Experience 2024' stating, “a third of doctors are struggling and feel unable to cope.”[8] Staff burnout impacts negatively on patient safety.[9] Simulation training has been found to have beneficial effects on anxiety, stress and burnout among some staff groups[10] and could also act as a protective factor against sick leave.[11] The importance of co-design and co-production in simulation-based education In 'Learning from Experience', The Royal College of Psychiatrists states, “The involvement of people with lived experience of mental illness either as a patient or carer in educational programmes can provide unique and relevant learning opportunities and teaching experience for doctors and psychiatrists in training.”[12] The GMC have also outlined the patient role within education in 'Patient and Public Involvement in Undergraduate Medical Education.[13] We believe that this concept should be extended across healthcare education. We endeavour to include the perspectives of a range of people with lived experience in the design and delivery of our courses, such as members of staff, parents, relatives, carers and patients where possible and appropriate. Not only does this enrich the quality of the education, bringing a broader perspective, but it also carries benefits to the patients involved, including a sense of fulfilment.[14][15] Some examples of the methods of co-design, co-delivery and stakeholder involvement we have used in our training, include The involvement of one of our Equity and Inclusivity Advisors, who is also a member of the transgender and gender diverse community, in co-design and co-delivery of courses aimed at exploring and outlining the challenges and assumptions that LGBTQIA+ individuals face. The incorporation of staff reflections and experiences into scenarios when designing courses on the following topics:: - cultural allyship - fostering workplace belonging - Band 5 and 6 leadership - managing disability - supporting internationally educated nurses. The incorporation of patient and carer feedback and experiences when designing our course, 'What Matters to Me'. The incorporation of parent experience when designing filmed training scenarios surrounding communication with parents during neonatal resuscitation. You can read more about one of our co-design projects in 'Involving patients and relatives by translating their experiences into simulation-based education'.[16] Conclusions SBE is now widely used across healthcare training to a variety of multi-disciplinary professionals, within a range of specialities, covering both technical and non-technical skills, which demonstrates the degree of versatility of SBE. It is important to incorporate the voice and perspective of people with lived experience where possible to ensure authenticity. This is an extremely exciting time for SBE as new innovative methods, uses and programmes are developed with the ultimate aim of continuing to enhance patient safety. References Oman S P, Magdi Y, Simon L V. Past Present and Future of Simulation in Internal Medicine. In StatPearls. StatPearls Publishing, 2023. Nehring WM, Lashley FR. Nursing Simulation: A Review of the Past 40 Years. Simulation & Gaming, 2009; 40(4): 528-2. Jaye P, Thomas L, Reedy G. 'The Diamond': a structure for simulation debrief. The Clinical Teacher 2015; 12(3): 171–5. Issenberg SB, et al. Simulation technology for health care professional skills training and assessment. JAMA 1999; 282(9): 861–6. Pearson E. McLafferty I. The use of simulation as a learning approach to non-technical skills awareness in final year student nurses. Nurse Education in Practice 2011; 11(6):399–405. Alrashidi N, et al. Effects of simulation in improving the self-confidence of student nurses in clinical practice: a systematic review. BMC Medical Education 2023; 23(1); 815. Gilfoyle E, et al. & Teams4Kids Investigators and the Canadian Critical Care Trials Group. Improved Clinical Performance and Teamwork of Pediatric Interprofessional Resuscitation Teams With a Simulation-Based Educational Intervention. Pediatric Critical Care Medicine 2017; 18(2): e62–9. General Medical Council. The State of Medical Education and Practice in the UK Workplace experience, 2024. Garcia CL, et al. Influence of Burnout on Patient Safety: Systematic Review and Meta-Analysis. Medicina (Kaunas, Lithuania) 2019; 55(9): 553. Couarraze S, et al. Short term effects of simulation training on stress, anxiety and burnout in critical care health professionals: before and after study. Clinical Simulation in Nursing 2023; 75: 25–32. Schram A, et al. Exploring the relationship between simulation-based team training and sick leave among healthcare professionals: a cohort study across multiple hospital sites. BMJ Open 2023; 13(10): e076163. The Royal College of Psychiatrists. Learning From Experience. Working In Collaboration With People With Lived Experience To Deliver Psychiatric Education, May 2021.   General Medical Council. Patient and Public Involvement in Undergraduate Medical Education, February 2011. Dijk SW, Duijzer EJ,  Wienold M. Role of active patient involvement in undergraduate medical education: a systematic review. BMJ Open, 2020;10(7): e037217. Gutteridge R, Dobbins K. Service user and carer involvement in learning and teaching: a faculty of health staff perspective. Nurse Education Today, 2010; 30(6): 509–14. Hamilton CJ, et al. Involving patients and relatives by translating their experiences into simulation-based education. A31. Abstract from Association for Simulated Practice in Healthcare Annual Conference 2018, Southport, United Kingdom.

Patient safety and high-quality care is the foundation of healthcare delivery, aimed at minimising risks, errors and harm to patients. It is important for students in their pre-registration education to understand that the principles of patient safety, and delivering safe and high-quality care, is not merely an academic requirement but a professional and ethical duty. By embedding patient safety into the core of pre-registration learning, educational establishments can ensure that the healthcare professionals of the future are equipped with the knowledge, skills and attitudes necessary to deliver high-quality, safe and effective care. The guiding principles of effective patient safety encompasses a wide range of practices, including the prevention of medical errors, learning from those errors, effective communication among healthcare teams and fostering a culture that has the patient’s wellbeing at its heart. Medical errors, which often range from diagnostic inaccuracies to medication mistakes, with equal deviations of harm, are a leading cause of preventable harm worldwide. Teaching students early in their careers to recognise and mitigate these risks is essential for building a resilient healthcare system with deep-rooted patient safety practices at its heart. Learning ‘on the shop floor’ should never be underestimated for its importance in pre-registration learning. Classroom and simulation-based learning both provide a safe environment for students to practice procedures and decision-making without risking patient safety. Life-like mannequins and virtual reality tools imitate the real-world scenarios, enabling pre-registration students to gain confidence and competence in handling complex situations. The importance of collaborative learning experiences between all healthcare professional students fosters teamwork and communication. Patient safety often hinges on effective partnerships, as errors can occur when information is not adequately shared among team members. By ensuring patient safety is an integral part of any pre-registration programme enables the students to develop a mutual respect and understanding of other healthcare professionals’ roles and the impact they have in the delivery of safe and effective patient care. Pre-registration education highlights the development of critical thinking skills. Encouraging students to explore case studies, reflect on errors and propose solutions nurtures a proactive approach to patient safety. The educational programme must provide opportunities to explore the ethical principles and legal responsibilities underpinning patient care, ensuring students understand the gravity of their actions and that accountability and transparency are integral to a culture of safety. Educators and patient safety specialists play a pivotal role in cultivating an environment where patient safety is a shared priority. Open and supportive discussions about errors, near misses and system failures help normalise the learning process and reduce stigma. Encouraging students to report, reflect and learn from near-misses and mistakes fosters a mindset focused on continuous improvement rather than blame. Despite its obvious importance, integrating patient safety into pre-registration learning can be challenging. Factors such as limited resources, time constraints and varying levels of expertise may hinder comprehensive training. However, advancements in technology and the growing recognition of patient safety’s importance provide opportunities for innovative approaches. Online modules, augmented reality, and mentorship and working placements within the local governance/quality teams can supplement traditional teaching methods. It is important that influential bodies such as the Nursing and Midwifery Council (NMC), General Medical Council (GMC), Health and Care Professions Council (HPCP) and other accreditation bodies ensure that patient safety within pre-registration education is an integral part and meets rigorous standards. In mandating specific competencies and assessments related to patient safety, these entities hold institutions accountable for producing competent healthcare providers. The integration of patient safety into pre-registration education is vital for preparing future healthcare professionals to navigate the complexities of modern healthcare. By prioritising safety at the earliest stages of education, institutions not only protect patients but also empower students to become confident, ethical and effective practitioners. In an era where the stakes are higher than ever, investing in patient safety education is an investment in the future of healthcare itself.

On the 8 September 2023, following on from the success of the Patient Safety Management Network, the Patient Safety Education Network (PSEN) was created. The PSEN is a network for those in patient safety education and training. Chris Elston, Patient Safety Education Lead for University Hospital Southampton NHS Foundation Trust, reflects on the past year that has seen the Network grow to over 470 members. Wow, as a colleague of mine used to say “Tempus fugit.” Time flies, doesn’t it just. Can it really be one year that the Patient Safety Education Network (PSEN) has been meeting and supporting each other? All I can say is that it has given me a range of emotions: Fear—what if it falls flat on its face? What if nobody turns up? Please no technical issues! Apprehension— it's 2 minutes before the meeting starts and the person presenting has not logged in yet? What can I do to fill the gap? Confidence—everyone turns up and the meeting is ended with great feedback from the audience. Pride—proud to have listened to the team that set this Network up and proud to be currently leading it. Surprise—that there are so many people willing to share information, resources and experiences, and all wanting to improve the way healthcare keeps our patients safe. We had humble beginnings following someone on the FutureNHS platform asking if there was any way that Trusts could share learning. Several discussions later, we had decided as a group that we would set up a Patient Safety Education Network and use this Network to share lessons, teaching methods and subjects. Learn from each other to promote good quality teaching, share lessons learnt, findings from learning responses and provide some peer mentoring and support. So how have we done? Have we achieved our initial plans? As a former military man, there is a phrase that has stuck with me from those days: No plan survives first contact! There is nothing false about that statement. The greatest part of this adventure has been the sharing of information. At our monthly meetings we have shared a Patient Safety Incident Response Framework (PSIRF) journey, observations and walk through talk throughs (WTTT or WT3, depending on your choice of acronym), engagement, a falls project, culture, SEIPS and AcciMaps, Swarms, Initial Safety Reviews, how to share learning. (As a member of the Network, if you miss a meeting you can access all the notes and presentation slides from these meeting—you will need to be signed into the hub.) I am not sure we have managed to provide everything we set out to, for example, the mentoring aspect of the Network, although the proof will be asking the Network members if we have. We have shared some learning from incidents but not much. There is scope to increase this and maybe we should have a standing item in the meeting for sharing these lessons. But we need to ensure that we keep to the Network rules of ensuring it is a safe space for all to be able to share their thoughts, worries and concerns. However, I think if we dedicated 10 minutes for the sharing of findings then it could strengthen the Network. It will need discussion and a decision from the Network members, as this is not a one-man band. I'd love to hear your thoughts. Highlights from the past year So, what has been my highlight, apart from getting this up and running? I would say there are two. I am not too keen on being in the limelight and leading things. I can and do, but I much prefer being a team member and offering help, support and guidance. So doing this, and having you all come back time after time, is a highlight. The second may be a little unusual. At the beginning of the year, I presented a slide about mittens—the now notorious mittens case. Someone asked a question about what this would look like as an AcciMap or SEIPS. So why is this a highlight? Well, it made me think. I made up an AcciMap and a SEIPS, it provided a kick start to my teaching and persuaded me that a new workshop/lesson was required at work. From this Network, my SEIPS and AcciMap Master Classes were born. Looking forward Future topics for the PSEN include venous thromboembolism (VTE), a culture change workshop, and change management and staff support. I am always on the lookout for new topics and people to present. I find myself listening to presentations and wondering how it would land with you, the Network members. Looking at my own development, I have had to improve my skills. My time management is a little wayward at times and that causes me a lot of discomfort. Everybody’s time is precious and I need to get the communications out to everyone, early enough to make a difference. Here is my opportunity to apologise for the late communications, at times. Final thoughts In summary, this has been a busy 12 months, a year of firsts (many firsts) and we have just had our first PSMN/PSEN symposium where I got to meet many of you face to face. The work that we are doing to improve the safety in healthcare for patients and their families, with the same effort put into the wellbeing of the staff, is immense and gathering pace. I am glad to be part of it and proud to be involved. I feel that we can move mountains with the tenacity, passion and knowledge that we possess, but the key for me, is the mutual support we give each other. From the smallest of roots grows the strongest of trees. Friday 8 September 2023 saw the first meeting of the PSEN with 28 members attending and a Network membership of 52. Today we have a membership of 479 and the meeting on the 13 September 2024 had 65 Network members attend. There remains only one other thing to say: Thank you and here is to another 12 months! How to join the Patient Safety Education Network Do you work in patient safety? If you are interested in joining the Patient Safety Education Network, you can join by signing up to the hub today. If you are already a member of the hub, please email [email protected]. You can also find out more about the growing number of informal peer support networks hosted and supported by Patient Safety Learning. These networks now include: Patient Safety Management Network – this is an innovative network for patient safety managers and everyone working in patient safety. In just over three years this has grown to now over 1700 members from more than 650 different organisations Patient Safety Partners Network – a group for Patient Safety Partners, paid and voluntary roles within NHS organisations aimed at improving patient safety. National NatSSIPs Network – a group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. Patient Safety Paediatric Leaders Network – an invited network for anyone who is a strategic-level decision maker in a specialist children’s hospital or unit with a leadership responsibility for patient safety and/or quality in the UK. VTE Specialists Network. The networks provide a forum for people involved in patient safety to meet up, share ideas and initiatives and learn from others. Related reading Application of SEIPS and AcciMap to a patient safety incident Is the NHS ready for PSIRF? A blog by Chris Elston “We’ve created an incredible pool of talented safety people who are up for collaboration.” Marking three years of the Patient Safety Management Network The voice of the patient safety frontline—An introduction to the Patient Safety Partners Network Patient Safety: Emerging Applications of Safety Science

Normalisation of patient care refers to the process of standardising healthcare practices to ensure consistent, high-quality care for all patients, regardless of their background or condition. This concept is vital in today’s healthcare systems, where variability in care can lead to disparities in outcomes. By normalising care, healthcare providers aim to reduce these disparities, improve patient outcomes and enhance the overall efficiency of healthcare delivery. However, if poor care becomes normalised; i.e., treated as routine, it can have detrimental effects on patients and their outcomes. In this blog, Dawn Stott discusses the importance of consistency in care delivery, why healthcare systems must continue to develop and refine strategies for normalising care, and how she and her colleagues are developing global guidance on securing an airway when delivering anaesthesia.  Consistency in care delivery One of the primary goals of normalisation is to ensure that every patient receives the same standard of care. This means that the treatment a patient receives should not depend on the time of day, the healthcare provider’s experience or the facility where they are treated. Standard protocols and guidelines help to minimise variations and ensure that all patients receive evidence-based care. When care is standardised, it often leads to better health outcomes. For instance, standard protocols for managing chronic diseases like diabetes or hypertension ensure that all patients receive the most effective treatments, reducing the risk of complications and improving long-term health. Normalisation also enhances the efficiency of healthcare delivery. Standardised protocols streamline processes, reduce the need for unnecessary tests or treatments, and make it easier for healthcare providers to coordinate care. This, in turn, can reduce costs and improve the overall functioning of healthcare provision. An example of a change to a standardised way of working is the securement of an intravenous (IV) cannula. Many articles have been written on the subject of IV securement, which essentially broke down the silos and made it clear, based on evidence, that after insertion of the cannula, the next most significant consideration was the securement of the device.[1][2] Historically securement was achieved with tapes, ties or sutures. Adhesive securement devices became the preferred method over sutures because they offered securement without additional skin punctures. The introduction of the IV dressing for cannula securement was revolutionary and is now a custom practice internationally. Developing global guidance on securing an airway In a recent survey, and following several professional focus groups, our project team have found that inflammatory damage to a patient’s skin following anaesthesia was a ‘real’ problem because of the way the airway was secured. There is a risk of these practices becoming normalised and therefore not being reported as a patient incident. As a result of a freedom of information study undertaken by the project team, the information gained suggests that many hospitals do not measure poor airway management outcomes and there does not appear to be any central database to support this either. There is a risk of damage to a patient’s skin when tapes are used to secure the airway. However, this is often not reported because it is ‘just the tape’ causing the harm. As a result of this type of practice happening quite often, it has become accepted and engrained into healthcare practice, similar to how it used to be with an IV cannula, and is another example of where normalisation of a practice is detrimental to a patient’s care. To improve this, a group of individuals have come together to work on developing global guidance on securing an airway and delivering anaesthesia safely in the pursuit of precision and vigilance. The idea was that as a project team we could, together, envision a future where anaesthesia safety is not just an aspiration but a standard of care that we exceed every single time.[2] Our goal is to standardise securing an airway to eliminate harm to a patient’s skin, airway displacement and infection risks. Although the project team appreciate that anaesthetics is deemed to be one of the safest areas of healthcare practice, our project’s aim is to provide evidence that current practices in airway securement are unsafe and are leading to patient harm, and that a better, licenced and regulated, solution is needed. Tapes and ties are still the mainstay for securing an airway in operating theatres and these methods are unlicensed with varying adhesive capabilities, which could cause inadequate safety to the patients. With this evidence we hope to influence nationally recognised bodies to establish clear guidelines and recommendations to support safer patient outcomes through education and learning. Strategies for effective normalisation of care Healthcare providers may resist the implementation of standardised protocols, particularly if they feel that these protocols limit their clinical judgment. Overcoming this resistance requires effective communication and education about the benefits of normalisation, including: Developing and implementing clinical guidelines, which should be evidence-based with regular updates. These guidelines will serve as the foundation for standardisation of procedures across different settings and providers. Ongoing training and education, which are crucial to ensuring that providers understand and can effectively implement standardised protocols. The education should form the basis for induction as well as continuous professional development. Continuous monitoring and evaluation, which are essential to ensure that normalised efforts are effective. This will involve tracking outcomes, gathering feedback from both patients and providers, and adjusting care protocols as required. Moving forward, healthcare systems must continue to develop and refine strategies for normalising care, balancing the need for standardisation with the importance of individualised, patient-centred treatment. By doing so, a more equitable and effective healthcare system can be provided for all. Conclusion This year’s World Patient Safety Day slogan is ‘Get it right, make it safe’. Our project is all about getting it right and making the securing of an airway safe for the patient. The team are aiming to highlight the importance of prioritising patient safety over financial constraints. As healthcare professionals it is important to raise awareness of the value it will have to the patient; i.e., the quantity of harm to the patient to promote the value of the quality outcomes for the patient versus the cost of the product. Healthcare is a high-risk industry and professionals should follow guidance developed from the best available evidence (NICE guidance) rather than any traditional or ritualistic practice. As practitioners we are accountable for our actions and safety is everyone’s responsibility. References Barton A. Universal Adhesive Vascular Access Securement with GripLok Devices. BJN, 2020. https://doi.org/10.12968/bjon.2020.29.8.S28 Docherty V. The Importance of Airway Training. CSJ, 2024.

Energising excellence. Bringing research, education, practice and leadership to life The RCM conference is back for 2024. Professional and educational standards of proficiencies have made clear the importance of midwives working across the professional pillars of the profession: research, education, clinical practice and leadership. Safe and effective care needs an evidence base from research, which is then disseminated and supported through education and strategically implemented into clinical practice and sustained through effective leadership. Furthermore, understanding midwifery professional pillars is relevant for promoting career pathways and ensuring professional recognition alongside our multi-disciplinary colleagues. Register

This global webinar is organised to promote and mark the launch of "My 5 Moments: The Game," an innovative digital game developed through a collaboration between the WHO Infection Prevention and Control Unit and Hub, WHO Academy, game designer, learning game expert, and end users. Aimed at revolutionising hand hygiene education, this game-based learning programme integrates the concept of "My Five Moments for Hand Hygiene" into an engaging, compassionate, and scientifically-backed gaming experience. Set in the futuristic International Alien Hospital, the game challenges players to maintain optimal hand hygiene practices to ensure the safety of both alien patients and the Earth. This session aims to introduce healthcare professionals, educators, and other relevant stakeholders to the game's unique approach to infection prevention and control through gamification, design insights, and the importance of empathy in healthcare. Objectives: To introduce "My 5 Moments: The Game" to healthcare professionals, IPC practitioners, educators, and stakeholders, highlighting its innovative approach to hand hygiene education through gamification, and demonstrating how it can transform traditional learning methodologies in IPC. To provide insights into the game's design and development process, emphasizing the integration of compassion, care, and empathy into its gameplay, and illustrating the importance of these elements in creating a more effective and engaging learning experience for healthcare workers. To encourage the adoption of "My 5 Moments: The Game" within healthcare training and education programmes, to bring behavior change among healthcare workers, and offering guidance on integrating this innovative tool into existing IPC efforts. Register

'The Family Oops and Burns First Aid' is a free children's book written by Kristina Stiles, beautifully illustrated by Jill Latter, created to support children and their families learning about burns prevention and first aid principles together. The book describes an accident prone family who are not burns aware, who have to go to school to learn about burn safety and first aid principles within the home. The book is aimed at KS1 children and their families, and is available as hard copy book by request from Children's Burns Trust and also as an audio/video book via YouTube.

NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. In this blog, Kenny Fraser, CEO of Triscribe, explains why we need to deliver quick, low-cost improvement using modern, open source software tools and techniques. We don’t need schemes and standards or metrics and quality control. The most important thing is to build software for the needs and priorities of frontline pharmacists, doctors and nurses. A study in 2018 found that 237 million medication errors occur each year in the NHS in England alone. Three quarters of these cause harm and there are 1,700–22,303 deaths from avoidable adverse drug reactions. Two things immediately strike me about these numbers: Medication safety is a huge issue. The breadth of the estimate suggests that data about the scale and impact of medication safety errors are incomplete and unreliable. I have not seen a similar published study since. My experience working with NHS hospitals since 2018 suggests slow progress. There are four reasons: The spaghetti medusa of data. Millions of staff hours spent to capture and store medicines data in a variety of legacy siloed hospital systems such as EPMA, pharmacy stock and EPR. The NHS employs 1.5 million people and at least the same number again work in social care. Yet there are almost no tools specifically built for either NHS or social care workers. Slow progress of clumsy digital initiatives that focus on the wrong thing, made worse by the fear of digital monsters. Lack of change and innovation. Lots of noise around schemes and gateways rather than actual solutions for real people. Layer the pandemic impact over these underlying issues and the position seems hopeless. It's not. “Data isn’t oil, it’s sand.” The tech industry has invested trillions of dollars and the time of millions of the world’s smartest experts. Much of this goes into solutions that capture and use epic quantities of data. Over the past 15 years, multiple standard, open source software tools and techniques have emerged that tackle exactly this kind of problem. Behind all the hype, hysteria and scaremongering, the current AI boom is just a manifestation of all this money and intellectual capital. It is outrageous that this is not used for the benefit of hard pressed frontline hospital staff. So what does this mean in practice? How can tools, like Triscribe, actually improve medication safety? Those 237 million errors include a lot of different things. Adverse drug reactions are just a small portion and the severe reactions are pretty rare. Using the existing data collected from a multiplicity of systems, we believe that more meaningful analysis is possible by: Reporting of adverse drug risks updated at least daily. Note: using a little AI, we can predict the risk of adverse drug reactions and give clinicians the information needed to stop at least some from happening. Much better than just reporting the incidents. Monitoring adherence key safety policies and guidelines. For example, VTE prophylaxis, allergy reviews and oxygen prescribing. Tracking and reporting late and omitted doses every day across all systems, including ward comparisons to identify learning and share better ways of working. Safe use indicators for specific medications; for example, early/ late administration of Parkinson’s medicines and opioid deprescribing. Reporting key compliance measures, including IV to oral switching for antibiotics, high dose prescribing of opioids and usage of methotrexate The possibilities are limitless. There is no shortage of data in the NHS. However, the ability to share that data between systems and organisations is something the health and care sector still lacks. It’s a solvable problem. Deliver quick, low-cost improvement using modern, open source software tools and techniques. We don’t need schemes and standards or metrics and quality control. The most important thing is to build software for the needs and priorities of frontline pharmacists, doctors and nurses. Keep learning and keep improving every day.