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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

At the beginning of 2025 we launched our video interview series Speaking up for patient safety. The series is hosted by Peter Duffy, NHS whistleblower and Chair of the Healthcare Working Group at WhistleblowersUK, and Helen Hughes, Patient Safety Learning’s Chief Executive.  In each interview we hear from someone who has raised concerns about patient safety in healthcare, often at great cost to their own career and personal life. They share their story and their reflections on what needs to be done to improve organisational cultures so that when staff raise patient safety issues, their concerns are responded to appropriately and not dismissed because they are inconvenient to address. Alongside the thread of bravery and tenacity that runs through each contributor, a number of common themes come up time and again as people share their experiences. In this blog, Helen and Peter look at some of these themes and outline their implications for people who speak up or whistleblow. We are now three months into the series, which seems like a good time to stop and reflect on what we have learned so far. Our introductory blog about ‘Speaking up for patient safety’ explains why we launched the series and what we hope it will achieve. It also explains in more detail what we mean when we talk about speaking up and whistleblowing. Briefly, speaking up in healthcare is when a member of staff raises concerns about something that is worrying them to a manager or someone else within, or outside of, their organisation. In some cases—but not all—when someone speaks up, it is also defined as ‘whistleblowing’. Whistleblowing always involves a concern that is in the public interest and might relate to a criminal offence, health and safety risks, failures to carry out legal obligations, a miscarriage of justice, or an attempt to conceal and cover up any of these things. Three key themes from the interviews so far These are the top three recurring themes we have noticed coming up in the interviews so far. Other issues we have noticed include the lack of clarity about who should take responsibility for whistleblowing and the reality of threats and bullying, and we will continue to explore these issues going forward. 1. “I didn’t realise I was speaking up, I was just doing my job!” Perhaps the comment we have heard most frequently is that people didn’t realise they were formally speaking up or whistleblowing—they just thought they were doing their job. Every healthcare profession has a set of professional standards which all practitioners are expected to keep to. For example, the General Medical Council (GMC) states that all doctors have a duty to take action by raising concerns if they believe patient care or safety are at risk.[1] In addition, each healthcare organisation has a code of conduct, which will include requirements for staff to be honest, open and accountable for their work. For the interviewees we spoke to, to not raise their concerns would be a failure to fulfil their duty to both their patients and their organisation. When people speak up, they often find themselves in the middle of a process that they had no idea they were entering. This can be very disorientating and leave them unprepared for the path ahead of them. At the end of this blog, we share some advice from our interviewees about what to do if you find yourself in this position. 2. There is a whistleblowing ‘playbook’ Most organisations have policies and support in place to listen to staff members who raise concerns, including access to a Freedom to Speak Up Guardian. We have interviewed Jayne Chidgey-Clark, the National Guardian, who described the good practice that many are developing. However, we are hearing about several common tactics that some organisations use when dealing with people who speak up or blow the whistle. The experiences of our interviewees suggest that these approaches may be deliberately designed to disadvantage the individual throughout the process—from investigation through to employment tribunals. Some of the key activities we have heard about include: Organisations not responding—or responding at the very last minute—to communications from the staff member. Interviewees said they received emails with key information at 5pm on a Friday, which left them with no opportunity to ask questions or respond until the next working week. They expressed their belief that this may be a deliberate tactic to exert pressure on the individual speaking up, which amounts to emotional bullying. The use of occupational health as a way to cast doubt on the mental state of the person. Occupational health providers are often very supportive, but we are concerned that organisations are fishing for reasons to question the believability and motives of staff who speak up. Over-focus on HR issues, rather than focusing on the patient safety issues someone has raised. Mandated isolation from colleagues while investigations take place. This can have a very damaging effect on the person’s mental health as well as restricting their ability to source evidence from other staff in support of the concerns they have raised. We have heard examples of colleagues agreeing to provide supportive testimony, but then feeling pressurised to withdraw this support. Retaliatory referrals against the person speaking up to professional regulators, such as the General Medical Council and Nursing and Midwifery Council, which can have a detrimental effect on a healthcare professional’s reputation and career. Regulators are aware of how such referrals can be used to intimidate whistleblowers and discourage them from raising concerns. Some have approaches to ensure that fitness to practice concerns are appropriately addressed without unfairly impacting doctors who have raised whistleblowing concerns. We believe it is important to identify and call out these tactics so that people raising concerns are aware of them and can seek support and advice. Organisational leaders need to look at their own practice and recognise the ethics of their approaches and whether their actions match their stated organisational values. They need to be aware of the significant damage these tactics cause to people who raise concerns and the chilling impact it might have on their organisational culture, effectively preventing others’ raising concerns. 3. Employment tribunals are unfit, unfair and imbalanced Every person we spoke to who had attempted to pursue justice at an employment tribunal commented that the process was unfit for purpose and not the right place for whistleblowing cases to be heard. Employment tribunals take no interest in the safety issues being raised. The main issue we keep hearing is that the tribunal system is weighted in favour of whichever side has the most financial resources—which will almost always be the employer. A single individual who has lost their employment can rarely succeed against the millions of pounds that organisations are willing to spend on highly specialised lawyers who have tried and tested ways of winning. The playbook we identified above also runs into employment tribunals, with whistleblowers reporting: The employer and their legal advisers withholding key documents, and emails, minutes, notes and other vital information going missing. Key witnesses, often in senior leadership positions, being unable to recall events. Receiving last minute threats from their former employer to come after them for costs and often being given a limited time to consider signing a non-disclosure (NDA) to settle a case. If rejected, often the NHS organisation will seek the full costs from the whistleblower, including expensive external legal costs and internal staff costs, which can amount to thousands of pounds—few whistleblowers can afford to take this financial risk, even if they and their advisers think they have a strong case. Advice from our interviewees if you find yourself speaking up Reflecting on their experiences, our contributors have made some observations about how you can protect yourself when speaking up, should the issue escalate. Try to resolve issues locally first. This is not always possible, but if a concern can be raised and dealt with within a team or with a manager, in some cases this will prevent the situation from escalating to a formal process. Keep a record of concerns and events as they happen. This means you will have some facts and clear observations to refer back to, if the situation does escalate. Don’t go to meetings alone. Take a trusted colleague with you so that every conversation is witnessed. Get your union involved if you are called to meetings about your concerns or receive counter-complaints or accusations. Regulation of NHS managers Some of the interviewees highlighted that regulating NHS managers may be a potential means of tackling some of these issues. The Department of Health and Social Care recently held a public consultation on proposals that could see managers who use misconduct to silence whistleblowers barred from working in the NHS. Patient Safety Learning has formally responded to the consultation, stating that there is a clear case for the regulation of NHS managers, for the protection and benefit of both staff and patients. Everyone in healthcare should be honest and transparent when something goes wrong. Patient Safety Learning’s response expressed support for a professional register of NHS managers and the requirement for individuals in NHS leadership to have a professional duty of candour. These measures would be a positive step in increasing accountability for healthcare organisations in how they respond to staff raising patient safety concerns. But this is only one part of a much wider set of changes needed—significant cultural change also needs to take place in tandem with these reforms. Staff across many organisations are still afraid to speak up, as indicated by the most recent NHS staff survey results. Thank you to our contributors, and an invitation to get involved We’d like to take this opportunity to express our gratitude again to each person who has been willing to share their experiences and insights with us—it can be very difficult to retell traumatic events that have changed the course of your life. We are also aware that there are many other individuals who have experienced unjust treatment because they have spoken up for safety. If that’s you, thank you for your commitment to standing up for safe, ethical care. We invite everyone with experience in this area to contribute to this vital conversation. We would particularly like to hear from: Allied health professionals. Staff from Black and minority ethnic backgrounds Staff in non-clinical roles such as administration. If you would like to share your story, you can: Contribute to our community conversation (you’ll need to sign up first). Comment on any hub post (you’ll need to sign up first). You can find information about organisations that offer support and guidance for staff about speaking up and whistleblowing on the hub. Watch the interviews Helené Donnelly Martyn Pitman Jayne Chidgey-Clark Gordon Caldwell Bernie Rochford Beatrice Fraenkel References General Medical Council. Professional Standards: Raising and acting on concerns about patient safety, 13 December 2024

In this podcast 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 episode, Beatrice Fraenkel, ergonomist and Non Executive Director at Stockport NHS Foundation Trust discusses the importance of understanding the issues that lead to poor culture and harm in healthcare organisations. She describes the Board's radical approach to establishing a Just Culture during her time as Chair of Mersey Care NHS Foundation Trust and the huge investment needed to build trust between healthcare staff and their employers. She also talks with Peter and Helen about the importance of understanding the needs, views and emotions of people in the wider community that each trust serves. They discuss the universal impact of fear and anxiety on human behaviour and the need to ensure lessons are really understood before attempting to put solutions in place to tackle issues, on any scale. 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 episode Dr Paul Grime, Chairman of the Safer Healthcare and Biosafety Network, is joined by Professor Peter Brennan, consultant surgeon and leading voice on Human Factors in healthcare. Together they explore how better understanding of Human Factors can improve staff and patient safety, reduce error, and shift culture away from blame. Drawing on insights from aviation, real-life NHS incidents, and Peter’s extensive research, this conversation tackles everything from toxic hierarchies and communication breakdowns to the power of kindness and just culture. Safety Talks is a podcast series as part of the Safety for All Campaign, launched to shine a light on the symbiotic relationship and benefits of integrating the approach to deliver healthcare worker safety and patient safety.

In Celebration of International Women’s Week, join Bevan Brittan and Howden for an inspiring conversation with a panel of leading women in healthcare. Our expert panel will explore 'Just Culture' and its impact on healthcare professionals and medical malpractice claims. Our expert speakers will share their insights and experiences, examining how both the independent and public sectors can learn from mistakes to avoid future adverse outcomes for both the workforce and their patients: Julie Charlton, Partner at Bevan Brittan Oonagh Sharma, Partner at Bevan Brittan Sabrina Meetaroo, Solicitor and Head of Risk and Claims Advocacy at Howden Dr Cathy Cale, Group Medical Director at Spire Healthcare Claire Damen, CEO at Independent Health Group and Chair of IHPNs Women Leader’s Network Register

In this blog, Patient Safety Learning’s Associate Director Claire Cox looks at how corridor care within the NHS is affecting safety culture, examining its implications for both healthcare professionals and patients. She underlines the need to understand these dynamics so that we can identify strategies to address causes of corridor care and promote a culture that prioritises safety and high-quality care for all. Corridor care is a term used to describe the practice of providing medical attention to patients in hallways or other non-designated clinical areas due to overcrowding or resource shortages. In the context of the NHS, this phenomenon has become increasingly common due to rising patient demand, workforce challenges and limited bed capacity.[1] While corridor care may seem like a necessary stopgap measure to address acute pressures on healthcare services, it raises significant concerns about patient dignity, privacy and the overall quality of care. We set out these issues in more detail in a blog published earlier this month reflecting on the extent of corridor care in the UK.[2] Corridor care reflects deeper systemic issues within the NHS, including funding constraints, staffing shortages and inefficiencies in patient flow. Its growing prevalence has led to widespread debate about its impact not only on patient outcomes but also on the morale and functioning of healthcare teams. Safety culture An organisational culture that seeks to assign blame when things go wrong makes patient harm more likely to happen again. In our report, A Blueprint for Action, we identify just culture as one of the six foundations of safer care to improve patient safety.[3] A just culture considers wider systemic issues when things go wrong, enabling professionals and those operating in the system to learn without fear of retribution. Just culture aligns with creating a safety culture, where shared values, attitudes and behaviours within an organisation prioritise safety as a fundamental component of its operations. In healthcare, a strong safety culture is critical to minimising risks, preventing harm and ensuring that patients receive the highest standard of care. Published in July 2019, the NHS Patient Safety Strategy identifies a patient safety culture as one of the two core foundations required in working towards its safety vision “to continuously improve patient safety”.[4] Safety culture directly influences how staff respond to pressures, make decisions and balance competing priorities. When safety culture is strong, staff feel empowered to speak up about concerns and systems are in place to mitigate risks. However, practices like corridor care can undermine these principles by creating environments where safety is compromised, staff morale declines and patient outcomes suffer. Corridor care and safety culture: Impact on teams Corridor care significantly affects safety culture among different healthcare teams, including ambulance staff, ward staff and emergency department (ED) staff. These groups must collaborate in high-pressure, resource-limited environments where patient safety is already at risk. However, the dynamics created by corridor care can undermine trust, communication and efficiency, all of which are critical components of a strong safety culture. Ambulance staff Ambulance staff are often the first point of contact for patients entering the healthcare system. When EDs are overcrowded and patients are treated in corridors, ambulance staff may face delays in transferring patients to hospital care. Long ambulance handover delays have been a persistent component of the problems faced by the NHS in recent winters.[5] [6] [7] Prolonged handover times can prevent ambulance crews from responding to new emergencies, creating frustration and moral distress. Corridor care also limits the ability of ambulance staff to provide a full clinical handover, leading to communication breakdowns and potential gaps in patient care. These delays can result in tension between ambulance crews and ED staff, as both teams struggle to manage their workloads under significant pressure. The lack of structured processes during corridor care undermines teamwork and fosters an environment where safety protocols may be bypassed to save time. Emergency department staff ED staff endure the most of corridor care's challenges, as they are tasked with managing patients in overcrowded spaces. The need to oversee patients in hallways stretches resources and divides attention, making it harder to maintain comprehensive monitoring and timely intervention. This environment increases the likelihood of errors and reduces the capacity to provide high-quality care. The presence of patients in corridors can also create role ambiguity and conflict between team members, as the usual boundaries between clinical responsibilities become blurred. For example, junior staff might feel unsupported when managing corridor patients, while senior staff may struggle to oversee all aspects of care effectively. The resulting stress and burnout among ED staff can weaken safety culture by diminishing morale, collaboration and the willingness to speak up about concerns. Ward staff Ward staff are often involved in the downstream effects of corridor care when patients are eventually transferred from ED corridors to inpatient wards. These staff members frequently face increased pressure to admit patients quickly to alleviate ED overcrowding, potentially without adequate preparation or information. This rushed process can compromise continuity of care and increase the risk of adverse outcomes. Many Trusts are now admitting an extra patient onto the wards to alleviate ED pressures, which also has implications for safety, privacy and dignity. Moreover, the systemic strain caused by corridor care can exacerbate existing tensions between ward staff and ED teams. Ward staff may perceive themselves as being unfairly burdened, while ED teams may feel unsupported in their efforts to manage patient flow. This misalignment can erode interdepartmental relationships and hinder the development of a cohesive safety culture. Corridor care and safety culture: Impact on inter-team collaboration Corridor care amplifies the challenges of inter-team communication, trust and collaboration, all of which are essential to maintaining a robust safety culture. When teams operate in silos or perceive themselves as competing for limited resources, it becomes harder to prioritise patient safety as a shared responsibility. The relationship between safety culture and corridor care is deeply intertwined; safety culture can be significantly undermined by the systemic and operational challenges posed by corridor care. Understanding this connection is essential to addressing the negative impact of corridor care on patient safety and team dynamics. This can be seen when considering how core principles associated with safety culture compare with the realities posed by corridor care: Open communication: A strong safety culture relies on clear communication among teams to ensure patient needs are met and risks are minimised. However, in the context of corridor care, chaotic and overcrowded environments can hinder effective communication. Ambulance staff may not have the opportunity to provide thorough handovers, ED staff may miss key patient details in the rush and ward staff may receive incomplete or delayed information about incoming patients. These communication breakdowns increase the risk of errors, undermining safety culture and compromising patient safety. Teamwork and collaboration: Safety culture emphasises collaboration across all levels of healthcare. Corridor care disrupts this by placing teams under excessive strain, leading to interdepartmental tensions. For example, ambulance staff may feel unsupported during prolonged handovers, while ED staff are overwhelmed managing corridor patients. This strain and associated incivility erode trust and reduces the cohesion necessary for a positive safety culture. Proactive risk management: A proactive safety culture involves identifying and mitigating risks before they lead to harm. Corridor care creates environments where risks—such as patient deterioration, falls and inadequate monitoring—are more likely to occur. The lack of resources and time for proactive measures further weakens the ability to uphold safety standards. As well as coming into conflict with some of the core principles of a safety culture, corridor care can also erode this further by: Compromising patient safety: Corridor care forces healthcare professionals to provide care in suboptimal conditions, where monitoring equipment, privacy and basic patient needs are often lacking. This creates a pervasive sense of vulnerability among staff as they are unable to deliver the standard of care they aim to achieve. Over time, this can normalise unsafe practices and dilute an organisation’s safety culture. Increased stress and burnout: Staff operating in these environments experience heightened stress and emotional exhaustion, which can lead to burnout. Burnout can negatively impact engagement, communication and decision making—all critical components of safety culture. Blame culture: In the absence of systemic solutions to corridor care, a culture of blame may develop. Teams or individuals may be scapegoated for adverse outcomes, discouraging the reporting of safety concerns. A blame culture directly contradicts the transparency and learning focus that underpin a strong safety culture. Undermining the opportunity to learn from staff speaking up: In a pressurised environment, staff may not feel that they have the time or confidence that their concerns about unsafe care will be welcomed or listened to. It is important that both healthcare providers and system leaders understand the reality of delivering corridor care and its patient safety consequences. This requires staff to be supported to raise issues through formal reporting systems, contribute to patient safety incident reviews and investigations, and speak up when they need to do so in line with their professional responsibilities. As noted earlier, corridor care often reflects deeper systemic issues, such as funding constraints, staffing shortages and inefficiencies in patient flow due to multifactorial issues outside of the control of an individual organisation. Systemic factors that challenge the ability of healthcare organisations to maintain a robust safety culture can include: Overcrowding in emergency departments—this can be a symptom of wider systemic problems—mental health crisis, an aging population, unaddressed health inequalities, access to primary care, staffing and funding crisis, etc. Insufficient staffing levels and expertise—resulting in compromised care and reduced opportunities for collaboration, communication and oversight with systems in place to review patient acuity and appropriate escalation. Limited resources—preventing the implementation of solutions, such as expanding capacity or improving triage processes, further entrenching corridor care as a stopgap measure. When systemic problems are not addressed, staff may feel disillusioned, which may undermine their commitment to the principles of safety culture. Corridor care and safety culture: What can be done? Maintaining a safety culture is an essential component of keeping patients safe from avoidable harm. In the current circumstances where corridor care is increasingly prevalent in the NHS, this is now more important than ever. This can be supported by: Encouraging open reporting and speaking up: Creating a non-punitive environment for reporting safety concerns allows teams to identify risks associated with corridor care and work collaboratively to address them. Improving communication: Structured handover protocols and enhanced use of digital tools can ensure critical patient information is not lost, even in corridor settings. Fostering interdepartmental collaboration: Training sessions, joint meetings and shared goals can build trust and reduce tensions between ambulance, ED and ward staff. Investing in staff well-being: Providing mental health support and ensuring adequate staffing levels can alleviate burnout, enabling staff to uphold safety principles. At Patient Safety Learning we are clear that corridor care must not become the norm. The negative effects on staff, patients and families can be significant and long lasting. This requires action from healthcare leaders, not only to support real time improvements, but to identify the deep-rooted causes and commit to longer-term solutions. References 1. Royal College of Nursing. On the frontline of the UK’s corridor care crisis, 16 January 2025. 2. Patient Safety Learning. Response to RCN report: on the frontline of the UK’s corridor care crisis, 17 January 2025. 3. Patient Safety Learning. The Patient-Safe Future: A Blueprint For Action, 2019. 4. NHS England, The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019. 5. Discombe, M. Ambulance handover delays hit record high. Health Service Journal, 9 January 2025. 6. Nuffield Trust. Ambulance handover delays, 25 April 2024. 7. Health Services Safety Investigations Body. Harm caused by delays in transferring patients to the right place of care, 24 August 2023.

In this podcast 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 episode, Helen and Peter speak to Dr Jayne Chidgey-Clark, the National Guardian for the NHS about how to create organisational cultures where staff are safe, and feel safe, to speak up about concerns. They reflect on the results of the latest NHS Staff Survey and discuss some of the issues relating to NHS manager regulation. They also talk about how regulatory bodies and other national organisations can work together to streamline safety and improvement recommendations so that they are simpler for organisations to implement. Reflecting on the gap that exists between organisations identifying cultural problems and finding solutions that make a difference, Jayne describes the need for a multi-layered approach that places safety and quality on an equal footing with financial and productivity targets.  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

This one-day masterclass focuses on the Principles and Practice of a Restorative, Just, and Learning Culture, emphasising how empathy is crucial to fostering a fair and psychologically safe environment. Through experiential learning using a true story, participants will have the opportunity to see things differently; examining how empathy and compassionate leadership underpin a Just Culture, helping organisations move from blame to learning, accountability, and system improvement. The session will bring empathic thinking into real-life practice, guiding attendees to understand the emotional complexities of patient safety incidents, staff fears and wellbeing and working with human reactions. It will highlight the difference between retributive and restorative practices and how adopting restorative approaches can enhance both patient and staff outcomes. In a safe, supportive environment, participants will reflect on how personal biases affect communication, and explore how culture change can be achieved and the challenges. The session will integrate self-reflection activities to strengthen personal well-being, emotional resilience, and inclusive leadership skills, which are vital for creating a compassionate, high-performing team. Using emotive and thought provoking material, balanced with the science of emotional intelligence, the real impact of a restorative, just and learning culture principles are felt, ensuring attendees leave with actionable insights, combined with emotional understanding to drive systemic change in their teams and wider organisations. KEY LEARNING OBJECTIVES Understanding of Restorative vs. Retributive Practices: Dig deeper into a thought-provoking journey through a patient safety incident, understanding some of the complex emotional component, demystifying some of the myths. What is a Just Culture and Empathy in Practice: Participants will explore develop the ability to apply and promote empathetic practice and the psychological benefits of restorative practices that foster trust and transparency. Seeing Perspectives for Culture and Change: Understand emotional motivations within behaviour and how easily we all see things differently and come from a place of fear. Unpacking the ‘Funnel of Life’: Enhancing Compassionate and Inclusive Leadership while Cultivating Self-awareness of Our Own Funnel Restorative Care - Emotions at the Heart of Stakeholder Support: Explore how a restorative culture nurtures patients, carers, and staff by addressing emotional challenges and managing difficult incidents. Psychological Safety for Team Health: Understand how a lack of civility, empathy and emotional awareness has the potential to cause psychological harm, negatively impacting on being a just, fair and learning culture Shifting Perspectives: From Surface Critique to Systemic Restorative Thinking: Explore how psychological safety influences professional communication, and is all empathy useful for a restorative, just and learning culture? Register hub members get a 20% discount. Email [email protected] for discount code.

Adverse event reporting is critical for advancing patient safety within healthcare systems. A significant factor in enhancing reporting rates is establishing a 'just culture'; a framework that emphasises accountability and learning over punitive measures. While just culture significantly enhances adverse event reporting, its successful implementation requires robust commitment at all organisational levels. Reporting adverse events is essential for ensuring patient safety and fostering a culture of continuous improvement in healthcare. Adverse events, defined as unintended injuries or complications arising from healthcare management, offer crucial insights into systemic weaknesses that, if addressed, can prevent future harm. However, underreporting such events remains a significant challenge, often driven by fear of punitive actions, reputational damage or legal repercussions. To address these concerns and promote a robust reporting culture, healthcare organisations must adopt a just culture by implementing standardised frameworks for evaluating errors and establishing robust reporting systems. Transparency in handling reported incidents is critical for building trust among healthcare professionals. Understanding just culture Just culture represents a shift from a blame-oriented approach to one that balances accountability with a focus on systemic improvement. Originating in high-risk industries such as aviation, the concept emphasises that errors result from flawed processes rather than individual negligence. In a just culture, individuals are held accountable for their actions within a fair and transparent system that prioritises learning and improvement. Central to the philosophy of just culture is the idea of psychological safety. When healthcare professionals feel confident reporting errors will not lead to unjust punishment, they are more likely to disclose incidents. This openness enables organisations to identify trends, address root causes and implement preventive measures. Moreover, just culture recognises the distinction between human errors, at-risk behaviours, and reckless conduct, advocating for tailored responses that align with the nature of the behaviour. Barriers to adverse event reporting Despite its potential, the implementation of just culture faces several obstacles. A predominant challenge is the deeply ingrained blame culture within many healthcare organisations. Historical reliance on punitive measures has created an environment where professionals fear repercussions, discouraging transparency. Additionally, managerial inconsistency in addressing errors often undermines trust in the system. For instance, discrepancies in how similar incidents are handled can create perceptions of unfairness, further discouraging reporting. Another barrier is the lack of understanding and awareness of just culture principles among healthcare staff. Without proper training and education, employees may misinterpret the approach as being lenient or as failing to hold individuals accountable. Legal and regulatory pressures also pose challenges, as concerns about litigation can deter organisations from fully embracing non-punitive reporting frameworks. Strategies for implementing just culture Implementing a just culture in healthcare requires a multifaceted approach that addresses organisational, managerial and individual factors. Leadership commitment is paramount; leaders must model just cultural behaviours, demonstrate accountability and prioritise safety over blame. Developing clear policies and guidelines for error classification and response is equally important as it ensures consistency and fairness in how incidents are addressed. Education and training programmes are vital in promoting awareness and understanding of just culture principles. These programmes should emphasise the distinction between human errors, at-risk behaviours and reckless conduct, providing staff with the tools to respond appropriately. Role-playing scenarios, workshops and case studies can help reinforce these concepts and demonstrate their practical application. The integration of non-punitive reporting systems is another critical component. Such systems should be designed to facilitate easy and confidential reporting, with mechanisms to protect the anonymity of reporters when appropriate. Feedback loops are essential for ensuring that staff are informed about the outcomes of reported incidents, which can reinforce the value of reporting and build trust in the system. Measuring the impact of just culture Assessing the effectiveness of just culture initiatives requires the development of standardised metrics and evaluation tools. Key performance indicators may include reporting rates, staff perceptions of psychological safety and the frequency of systemic improvements resulting from reported incidents. Periodic surveys and interviews can provide valuable insights into staff attitudes and identify areas for improvement. Case studies from organisations that have successfully implemented just culture can also serve as benchmarks for best practices. For instance, hospitals that report significant increases in adverse event reporting rates following the adoption of just culture principles often attribute their success to strong leadership, comprehensive training, and consistent application of policies. Sustaining cultural change Sustaining a just culture requires ongoing commitment and adaptability. Organisations must regularly evaluate their policies and practices to ensure alignment with just culture principles. Staff feedback should be actively sought and incorporated into decision-making processes, fostering a sense of ownership and engagement. Continuous education and training are essential for reinforcing just culture behaviours and addressing emerging challenges. Additionally, leadership succession planning should prioritise candidates who are committed to upholding just culture principles, ensuring continuity in organisational values. Conclusion Adverse event reporting is a fundamental component of patient safety, and the principles of just culture provide a robust framework for enhancing reporting rates and fostering systemic improvements. By balancing accountability with a focus on learning and improvement, just culture creates an environment where healthcare professionals feel empowered to report incidents without fear of retribution. Leadership commitment, staff education and integrating non-punitive reporting systems are critical for overcoming barriers and sustaining cultural change. A just culture represents a paradigm shift in addressing adverse events, emphasising systemic improvement over individual blame. Its successful adoption has the potential to transform healthcare organisations, making them safer and more resilient. Future research should focus on developing standardized metrics to evaluate just culture initiatives and exploring their applicability across diverse healthcare settings.

The culture of a healthcare organisation can determine how safe its staff members feel to raise concerns about patient safety. Bella Knaapen, Surgical Support Governance & Risk Management Facilitator and Sarah Leeks, Senior Health & Wellbeing Practitioner at Norfolk and Norwich University Hospitals NHS Foundation Trust, have developed ‘Speak Up For Safety’, a Just Culture training workshop that aims to help staff, at all levels, understand the importance of creating an environment that encourages people to share concerns and feedback. In this blog, Bella describes why they thought a training course was needed, outlines the approach she and Sarah took to develop the workshop and introduces the topics covered. I am an Operating Department Practitioner by background, but in recent years I have moved from operating theatres into clinical governance. This is where I learnt more about the term ‘Just Culture’, which refers to a culture of fairness, openness and learning that helps staff feel confident to speak up when things go wrong. It is about supporting staff and treating them fairly, rather than blaming them. Just Culture allows staff to be open about mistakes and allows us to learn valuable lessons that help prevent the same errors from being repeated. Culture, blame and accountability can seem like huge topics to explore, so it’s important to make them accessible. Enhancing Just Culture is key to improving patient safety, because if we are all fearful of blame when things go wrong, we aren’t focusing on removing the system errors that result in incidents. Improving Just Culture allows teams and individuals to take ownership of their learning and practice. Rather than waiting for things to go wrong it gives people the confidence and psychological safety to say, “Can you help me get better?” which in turn will improve the quality of patient care. Why we developed a Just Culture training workshop We all understand the deep impact that the Covid-19 pandemic had on individuals, teams and the NHS, through ever-increasing pressures and reduced resources. In my role at that time as local governance lead, myself and Sarah—who was a Trust Professional Advocate at the time—started to notice a thematic issue relating to staff speaking up. Individuals and teams sometimes didn’t feel confident or safe to speak up at the time of a patient safety incident, or they were being reassured by someone more senior that their concern was nothing to worry about. This is not to say that staff were not heard, but that their concerns and feedback were not always being acted upon to improve safety. As a result, we were seeing a slight increase in certain types of patient safety incidents and we wanted to address this concerning trend. Sarah and I decided to develop “Speak Up for Safety” (SUFS), a face-to-face workshop designed to raise awareness of existing topics covered in the NHS governance agenda relating to Just Culture. The workshop looks at how to understand and apply aspects of the NHS Patient Safety Syllabus and the new Patient Safety Incident Response Framework. It also covers Human Factors, emotional intelligence and introduces specific communication tools staff can use to highlight their concerns. Empowering staff to share their concerns about patient safety The main aim of the project is to ensure that all staff feel safe and empowered to speak up if they are involved in a patient safety incident. We want to continue to develop psychological safety and Just Culture within our Trust by changing staff mindsets around safety culture. We believe SUFS will equip teams to better identify and prevent harm before it occurs and as a result, better advocate for their patients. The best bit is that any staff member, regardless of role, profession, grade, team or department is welcome at a SUFS workshop. The workshop has been designed to help individuals think about the topics described and apply these principles to their own area of work. SUFS is aimed at everyone as we need all staff to feel safe and empowered to speak up when raising safety concerns. Developing the Speak Up for Safety workshop Using the Model for Improvement, Sarah and I developed several different ideas before finalising the finished SUFS workshop. The process included running an anonymous pre-workshop survey to understand local teams’ current perception of safety culture, producing summary reports to feed back survey data and a workshop and evaluation. Following several Plan-Do-Study-Act (PDSA) cycles, we were able to make changes to the workshop to develop something that really works for local teams. Psychological safety is paramount for both Sarah and me, and when we run the workshop, we set key ground rules at the start. As we are teaching Just Culture we need to practice what we preach. We try to approach the sometimes challenging discussion topics in the workshop with the utmost sensitivity and empathy. We want to help people understand that when things go wrong, it’s often due to a failure of process, not people! It important to recognise that most people don’t come to work wanting to intentionally be involved in a safety incident and we need to change the perception of blame and accountability. Since we launched the project in September 2022, we have run Speak Up for Safety for multiple teams within three out of four Trust Divisions. There has been tremendous positive feedback from the teams that have completed the workshop, and we continue to receive new requests from other teams. Having trialled and tested this project for two years, we are confident that we can now share it with other organisations who are looking to improve staff understanding of Just Culture. You can view the presentation we use to deliver Speak Up for Safety at your trust on the hub.

On 23 October 2024, the Patient Safety Commissioner for England published a set of Patient Safety Principles. In this blog, Patient Safety Learning sets out its reflections on these principles, highlighting key points included in its response as part of the public consultation process earlier this year. The Patient Safety Commissioner’s new Patient Safety Principles are intended to act as a guide for leaders at all levels on how to design and deliver safer care for patients and reduce avoidable harm, in a just and learning culture.[1] They are as follows: Create a culture of safety Leaders have a responsibility to lead by example to inspire a just and learning culture of patient safety and quality improvement. They should set out to keep people safe through the adoption of a safety management system and by embedding continuity of care, a culture of compassion and civility, effective listening, and restorative practice. Put patients at the heart of everything Leaders should put the patient at the heart of all the work that they do, with patient partnerships the default position at all levels of the organisation. They should consider the needs of patients and communities to deliver person-centred care. Leaders should ensure that the patient voice is central in the design of services, in obtaining fully informed consent and to the implementation of shared decision making. Treat people as equals People should be treated with respect, equity and dignity. Leaders should incorporate the views of all, and proactively seek and capture meaningful feedback from patients, workers, and communities, acknowledging that those from disadvantaged groups may need specific support and encouragement to contribute. They should act upon feedback, to embed equity of voice. Identify and act on inequalities Health inequalities, and their drivers, should be identified and acted upon at every stage of healthcare design and delivery to drive improvements in patient safety and experience. Identify and mitigate risks Targeted and coordinated action should be directed towards patient safety risks. Patients, workers and communities should be encouraged and empowered to proactively identify and speak up about risks, hazards and potential improvements. Leaders should promptly escalate new and existing risks to the most appropriate person or body. Be transparent and accountable Leaders should acknowledge that creating a culture of safety requires honest, respectful and open dialogue, where candour is the default position. This transparency should support a model of continuous improvement, which learns from both successes and events, and ensures that patients, workers and communities do not face avoidable harm due to a cover up culture. Use information and data to drive improved care and outcomes for patients and help others to do the same Leaders should enable patients to have access to their personal and other data to help them improve their own care. They should ensure that good quality data is collected and meets the needs of all patients, including those from underrepresented and inclusion health groups. Workers should be supported to use and share information and data to drive improved care and outcomes for patients, in accordance with the Caldicott Principles. Shared principles These principles were subject to a publication consultation, which we responded to on the 5 September 2024. You can find our full comments on each principle here. We welcome the principles that the Patient Safety Commissioner has set out today. There is significant overlap between these seven principles and the six foundations of safer care we identify in our report, A Blueprint for Action.[2] For example: “Put patients at the heart of everything” aligns with our foundation on “Patient engagement”. We believe that patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account. “Use information and data to drive improved care and outcomes for patients and help others to do the same” aligns with our foundation on “Data and insight for patient safety”. We would also consider that these principles, when taken together, align with our view set out in A Blueprint for Action about the need for a transformation in our approach to patient safety placing this as a core purpose of health and care. The Patient Safety Commissioner’s proposed principles also share much in common with the World Health Organization’s (WHO) Global Patient Safety Action Plan.[3] This sets out a vision of a “world in which no patient is harmed in healthcare, and everyone receives safe and respectful care, every time, everywhere” and a goal of achieving the maximum possible reduction in avoidable harm as a result of unsafe care. There is again significant overlap between the points included in its seven strategic objectives and these principles. The principle “Put patients at the heart of everything” also reflects a wider international initiative in patient safety, the WHO Patient safety rights charter that was published earlier this year.[4] The Charter aims to outline patients’ rights in the context of safety and promotes the upholding of these rights, as established by international human rights standards, for everyone, everywhere, at all times. Areas not covered by the principles In our consultation response we also highlighted several areas not included in these principles. We would suggest these should also be considered when creating guidance for senior leaders on how to deliver safer care for patients and reduce avoidable harm. Shared learning This is one of the six core foundations of safer care we identify in A Blueprint for Action. Healthcare is systematically poor at learning from harm. If patients are to be safer, we need people and organisations to share learning when they respond to incidents of avoidable harm, and when they develop good practice for making care safer. It is vital that patients, clinicians, managers, and health and social care system leaders share learning about safety practice and performance to make care safer. This was the key driving force behind the creation of the hub, our platform to share learning for patient safety. Patient safety standards One of the primary reasons for the persistence of avoidable harm is that healthcare does not have or apply standards of good practice for patient safety in the way that it does for other issues. Standards that do exist are insufficient and inconsistent. At Patient Safety Learning, we believe that health and social care organisations need to have standards for patient safety. These can inform 'what good looks like' and enable organisations to self-assess against them.[5] Designing for safety and safety in use Treating patient safety as a core purpose of health and care requires us not just to respond to and mitigate the risk of harm, but also to design healthcare to be safe for patients and the staff who work within it. This would include greater use of human factors expertise and systems thinking to inform the safe design, safety management and approaches to investigating unsafe care. This is also covered in depth as part of the Global Patient Safety Action Plan’s second strategic objective, ‘High-reliability systems’. Challenge of implementation Publishing these principles, the Patient Safety Commissioner said that: “The Patient Safety Principles act as a guide for leaders at all levels on how to design and deliver safer care for patients and reduce avoidable harm, in a just and learning culture. They are relevant to healthcare providers as well as commissioners, regulators, manufacturers, and the broader supply chain. The principles provide a clear framework for planning, decision-making, and working collaboratively with patients as partners.”[1] While we welcome this aspiration, how these are used in practice will determine their success. We need everyone—politicians, policymakers, patients, families and communities, clinicians, managers, system and professional regulators, researchers and academics, and health and social care system leaders—involved in this effort. All too often when it comes to patient safety, there exists an implementation gap between what we know improves patient safety and what is said about this compared to what is done in practice.[6] An example of this can be seen concerning the first of these principles, “Create a culture of safety”. This emphasises the role of leaders having a responsibility to lead by example to inspire a just and learning culture of patient safety. A similar aspiration is also identified in the NHS Patient Safety Strategy, which includes patient safety culture as one of the two foundations required in working towards its safety vision “to continuously improve patient safety”.[7] However, despite this commitment in the NHS, blame cultures and a fear of speaking up continue to persist. As highlighted in our recent report analysing the NHS staff survey results, there often exists a significant gap in this respect between what organisations say about their approach to safety culture and how staff feel.[8] If these principles are to be realised, they will need not just to be accompanied by a endorsement from the Department of Health and Social Care and the NHS, but also clear action. References Patient Safety Commissioner for England, Patient Safety Principles, 23 October 2024. Patient Safety Learning. The Patient Safe Future: A Blueprint for Action, 2018. WHO. Global Patient Safety Action Plan 2021-2030, 3 August 2021. WHO. Patient safety rights charter, 18 April 2024. Patient Safety Learning. Standards, Last accessed 4 September 2024. Patient Safety Learning. Mind the implementation gap: The persistence of avoidable harm in the NHS, 7 April 2022. NHS England. The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019. Patient Safety Learning. We are not getting safer: Patient safety and the NHS staff survey results, 26 March 2024.

Speak Up For Safety is a Just Culture training workshop that aims to help staff at all levels, understand the importance of creating an environment that encourages people to share concerns and feedback. It was developed by Bella Knaapen, Surgical Support Governance & Risk Management Facilitator and Sarah Leeks, Senior Health & Wellbeing Practitioner at Norfolk and Norwich University Hospitals NHS Foundation Trust. This presentation has been shared by the authors and is designed to be used in Speak Up for Safety training workshops. Bella has also written a blog for the hub about how Speak Up for Safety was developed and how it is helping staff feel safe and empowered to speak up.

Restorative practice - learning culture, how do you create a culture where people feel able to speak up and be listened to. Freedom to speak up, enabling a culture where people feel able to speak up, governance, board assurance, Culture and Good Governance - OFLOG dept launched in July which will look at governance in local authorities. There’s been an incident in your organization. People are impacted. You need to do something. How do you avoid blame, and how do you start learning and improving? This session will explore the principles and theory behind a just and learning culture and give you some insights into how this can be implemented. Alongside an international thought leader on this subject we will hear from an NHS organisation’s experience of developing and sustaining their approach to this. This session will help you understand how your teams/services/organisations can create cultures that foster learning when things don't go as expected. People will leave with an understanding of a just and learning culture alongside insights around implementation in their own organisations. Register

In a new report analysing healthcare complaint investigations, the Parliamentary and Health Service Ombudsman (PHSO) have set out the need for the NHS to do more to accept accountability and learn from mistakes in cases of avoidable harm. This blog sets out Patient Safety Learning’s reflections on this report. In the report Broken trust: making patient safety more than just a promise, PHSO examines 22 NHS complaints cases where patents died due to avoidable errors.[1] After analysing these cases, they have identified four broad themes of clinical failing leading to avoidable deaths: failure to make the right diagnosis, delays in providing treatment, poor handovers between clinicians and failure to listen to the concerns of patients or their families. The report also considers the issue of compounded harm, the additional harm that people experience when interactions following patient safety incidents feel closed and defensive. From their findings, they identify the following scenarios that are likely to contribute to compounded harm: failure to be honest when things go wrong a lack of support to navigate systems after an incident poor-quality investigations a failure to respond to complaints in a timely and compassionate way inadequate apologies unsatisfactory learning responses. Considering these findings, the PHSO make several recommendations at the end of their report aimed at tackling these issues. Patient Safety Learning’s reflections We welcome this new report from the PHSO. Sadly, the patient safety themes that it raises are all too familiar. Avoidable harm resulting from delays in providing treatment and failing to listen to patient concerns come up time and time again in reports into patient safety incidents. As do failures to respond appropriately after harm occurs, such as poor-quality investigations that do not result in learning or improvement. We see many of the issues that this report raises also feature prominently in recent reports into major patient safety scandals, such as those in East Kent and Shrewsbury and Telford.[2] [3] Below we share our thoughts specifically on the report’s recommendations for change. Investigations and PSIRF The report highlights that while there have been some positive developments in seeking to improve investigations in the NHS, and welcomes the introduction of the new Patient Safety Incident Response Framework (PSIRF), there remains “a gap between the welcome rhetoric in PSIRF guidance documents and the defensive behaviours from some NHS leaders we still see in our casework”.[1] PHSO note concerns about the additional flexibility that PSIRF offers, suggesting that this may present a risk at Trusts with poor cultures who do not carry out investigations when they should. In response to these concerns, it makes recommendations around the need for close monitoring of the rollout of PSIRF by Integrated Care Boards and Board members who lead on PSIRF in their organisations. Patient Safety Learning agrees with these recommendations. Although there are many welcomed elements to PSIRF, its success to a large part will depend on having the right organisational leadership and resources to support the transition to this new approach to investigations. We believe that this initiative should be judged on its implementation in supporting culture change and in translating learning from investigations into reduction of avoidable harm. Duty of candour and support for patients Duty of candour is intended to ensure that healthcare providers are open and transparent with the public. In legislative terms, it sets specific requirements for organisations to follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology when things go wrong.[4] PHSO state that from evidence gathered through their casework that they find that this duty is not always implemented as it should be and state they think this requires more attention and monitoring. The report recommends that: “The Department of Health and Social Care and NHS England should further scrutinise the lack of compliance with duty of candour. They should review the operation of duty of candour to assess its effectiveness and make recommendations for improvement.”[1] We agree with this recommendation. As part of this reviewing problems with compliance, we believe that there are also broader questions that also need to be addressed concerning how the implementation of this is monitored and what remediation and redress is available to patients and the families when these obligations are not met. The report also notes that despite a statutory duty for local authorities to commission NHS complaints advocacy, these services can be limited and are often restricted to helping people navigate the NHS complaints process. It recommends that: “The Department of Health and Social Care should commit to funding further independent advocacy to support harmed patients, families and carers when they raise concerns or seek answers after an incident.”[1] At Patient Safety Learning, we believe that patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account. Access to advocacy services is an essential part of this, helping address the power imbalance between patients and the healthcare system when things go wrong. We fully support this recommendation. Complex and fragmented patient safety landscape Discussing the national patient safety picture, the report points to the confusing landscape of patient safety roles and responsibilities that currently exist. It highlights how organisational functions can often overlap, creating confusion over who does what and undermining patient safety leadership. It recommends that: “The Department of Health and Social Care should commission an independent review of what an effective set of patient safety oversight bodies would look like. The review must include meaningful engagement with NHS leaders, staff, patients and families”[1] This is not a new concern. Five years ago, in its report Opening the door to change, the Care Quality Commission (CQC) raised similar issues, noting the lack of clear understanding of how patient safety is organised nationally and who is responsible for what tasks.[5] The Professional Standards Authority for Health and Social Care also pointed this out in their report last year, Safer care for all, stating: “For too long, individual organisations with different and specific remits have been expected to work together to address workforce and patient and service user safety issues. This approach is structurally flawed as there is generally no accountability for joint working and collaboration; bystander apathy and differing organisational priorities also present significant barriers. Everyone understandably looks at the problem through the lens of their own remit, but no one has the overview.”[6] Patient Safety Learning agrees with the PHSO’s assessment of this problem. We also highlighted this issue in our report last year, Mind the implementation gap. As stated then, we believe that with the current fragmented approach to patient safety leadership, the Secretary of State for Health and Social Care lacks the levers and means to fundamentally improve our national approach to patient safety.[7] Workforce strategy The report also makes a recommendation around the Government producing its long-term workforce strategy and sets out what the PHSO think this document must include, which was subsequently published the day after the report. Workforce shortages and pressures in the NHS and social care have serious implications for patient safety. We will be looking closely detail of the new NHS Long Term Workforce Plan, in the coming days and weeks from this perspective.[8] Patient safety as a core purpose of health and social care In this report, PHSO make the case that patient safety must be a consistent priority over the long term. It recommends that the Government should seek cross-party support for embedding patient safety and the culture and leadership needed to support it as a long-term priority. We agree with this recommendation. Patient Safety Learning believes that the persistence of avoidable harm is the result of our failure to address the complex systemic causes that underpin it. In our report A Blueprint for Action we set out the need for a transformation in approach to patient safety. This sets out how too often patient safety is typically seen a strategic priority, which in practice will be weighed (and inevitably traded-off) against other priorities.[9] To transform our approach to this it is important patient safety is not just seen as another priority, but as a core purpose of health and care. This applies to all parts of the system. We need everyone politicians, policymakers, patients, families and communities, clinicians, managers, system and professional regulators, researchers and academics, and health and social care system leaders involved in this effort. References PHSO, Broken trust: making patient safety more than just a promise, 29 June 2023. Independent Investigation into East Kent Maternity Services, Maternity and neonatal services in East Kent – the Report of the Independent Investigation, 19 October 2022. Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Findings, conclusions and essential actions from the independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust, 30 March 2022. Public Health England, Duty of candour, Last updated 5 October 2020. CQC, Opening the door to change: NHS safety culture and the need for transformation, December 2018. Professional Standards Authority for Health and Social Care, Safer Care for All: Solutions from professional regulation and beyond, 6 September 2022. Patient Safety Learning, Mind the implementation gap: the persistence of avoidable harm in the NHS, 7 April 2022. NHS England, NHS Long Term Workforce Plan, 30 June 2023. Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019