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

In this blog, Clare Wade, Patient Safety Learning's Director, draws attention to the impact toxic cultures have on staff and how, sadly, most often nothing is done about it. Clare shares her own personal reflections from past experiences in her career. There is a clear link between toxic cultures and patient safety, and while there are no easy answers these behaviours must be acknowledged, challenged and cured if the NHS is to survive. I’ve personally experienced toxic culture and behaviour on many occasions, but I found two examples particularly tough to navigate. The first was more than 20 years ago when I worked clinically in a trust largely staffed by the local population where most colleagues were either related or friends; I lived some distance away and commuted in. I’d witnessed troubling behaviour from one senior time-served nurse several times, but one day I heard a blatant, serious breach of patient confidentiality between her and another patient. I was shocked and initially didn’t know what to do. I raised it with the nurse involved who laughed at me, and then the sister in charge who told me to just forget it. After much deliberation, I went to the matron in charge of the department. Conversations took place behind closed doors and eventually I was hauled into trust HQ for a formal meeting, alone—the nurse was nowhere in sight. I was accused of causing upset and the nurse had denied any wrongdoing. In no uncertain terms it was made clear that I should keep my head down and mouth closed if I wanted to remain in post. From that day on my time was made miserable, colleagues closed ranks, stopped talking to me and I was ostracised until the day I left the trust. Later in my career, at a different trust, a new director was recruited to lead my department. From the start something felt off as several senior leaders quickly left their roles. It became obvious that the director was a bully; we largely worked in open plan offices, and the director thought nothing of shouting at and belittling people in front of everyone, even other directors and the CEO. It was impossible for senior colleagues not to know what was happening, but no action was taken. The situation worsened with many people taking sick leave or leaving the trust completely. I came under fire as the director didn’t agree with how I led my team or how we worked, even though our performance was excellent. An external consultant was brought in to identify issues with my practice and help build a case against me. The consultant admitted this to me and said they couldn’t find anything wrong to report back. At the time I had a mentor relationship with a senior board member, and I chose to confide in them with the hope of gaining some insight into how I might be able to better deal with the situation. I didn’t know until sometime later, but my mentor was informing the director about our conversations. As time passed, the behaviour worsened and, although many colleagues were experiencing it too, it was obvious I was on my own in wanting to speak up. I was encouraged to go to a senior HR colleague who would be empathetic, so I did and eventually the director agreed to mediation. I was so nervous ahead of the meeting, but it went ahead and to my surprise the director admitted to some of the allegations and agreed some actions. If I thought my treatment had been bad to this point, I had no idea what was to come. It felt like open season with the director’s full toxicity focussed on me. Derogatory rude emails would be sent daily, raising my anxiety as they landed in my inbox. Meetings where we were both present made me feel sick; they would think nothing of singling me out in front of everyone for their derision and nastiness. The barrage was constant and debilitating, affecting every part of my life and breaking my confidence. One day I couldn’t take any more so left work early and crawled into bed at home where I felt safe. I decided to call the senior HR colleague who had facilitated the previous mediation to ask for an update about the agreed actions. I was absolutely shocked to my core at their reaction, they shouted down the phone that I’d had my opportunity to air my grievances, nothing more was going to happen, the director wasn’t going to be held accountable for the agreed actions and I just needed to forget it and get on with my job. Was I naive to expect a different response? I hit rock bottom, felt scared to go into work and knew I had to get out of there for my health and sanity. Even when I left, the impact followed me to my next role; my confidence and resilience were shot and took a long time to rebuild. The director stayed in post for another couple of years until there were so many grievances that the CEO had to act. The sickening part is that after a period of ‘gardening leave’ the director secured another senior role in another trust in the area so will be perpetrating the same toxic behaviour onto others. I know there are thousands of experiences throughout the NHS just like mine and, unfortunately, in many organisations culture and behaviours aren’t improving. This problem is endemic and has decades of history behind it. There is a clear and acknowledged link between toxic cultures and patient safety. Within the NHS Patient Safety Strategy, NHS England states that: "positive patient safety and healthy organisational culture are two sides of the same coin. A culture in which staff are valued, well supported and engaged in their work leads to safe, high-quality care." In order to improve the care delivered to our loved ones, friends and ourselves, the NHS must take action to improve its culture. Forget the financial situation and the waiting lists, this is the most pressing and wicked problem facing our health service today; it permeates throughout everything and unless it is acknowledged, challenged and cured no other interventions will work. Money doesn’t solve toxic cultures, neither does restructuring the NHS for the umpteenth time. Sadly, some colleagues have taken their own lives because of the toxicity they have endured, this needs to stop now. There are no easy answers here but if we don’t put this right the NHS won’t survive. Share your story Have you worked in a toxic culture? Have you tried to speak up? Have you examples of a good team culture? Add your comment below (you will need to be a hub member and signed in) or contact us at [email protected] and we can share your story anonymously. Related reading on the hub Speaking up for patient safety: A new interview series about raising concerns and whistleblowing Speaking up as an agency nurse cost me my career My experience of speaking up as a healthcare assistant in a care home

*Trigger warning: content related to suicide Rachel Gibbons is the Vice Chair of the Psychotherapy Faculty at the Royal College of Psychiatrists. In this opinion piece she draws on personal and professional experience to explore the complex relationship between patient safety and inpatient suicide. Rachel argues that fantasy-driven ideas of control and simplistic blame narratives do profound harm—both to clinicians and those bereaved. I'm a consultant psychiatrist whose professional trajectory was profoundly shaped by a harrowing experience early in my career. In 2009, during my first 18 months as a consultant, four of my patients died by suicide. The intense aftermath—serious incident inquiries, coroner's court appearances, and the emotional fallout—fundamentally changed who I was, both personally and professionally. Before this, I was someone different; afterward, thoughts about suicide dominated my consciousness. Since then, I've dedicated my professional life to deeply understanding suicide, it’s devastating impact on those bereaved, and the complex interactions involved in patient safety. Central to my work is the question of truth in patient safety—how to engage honestly and realistically with this complex subject. Too often, safety is driven by fantasies of control rather than by realistic expectations and honest acknowledgment of uncertainty. When our expectations are unrealistic, it harms clinicians and bereaved families alike. The profound trauma of inpatient suicide When suicide occurs within inpatient settings, its impact can be especially devastating. These tragedies unfold in two distinct scenarios: deaths occurring off the ward, and those taking place directly on the ward itself. Deaths on the ward can be especially traumatic—sometimes violent and occurring in the immediate presence of staff and other patients. I have personally been involved in such cases, witnessing first-hand the traumatic ripple effect across an entire organisation. The sudden, shocking nature of an inpatient death reverberates, intensifying every response, from the serious incident inquiry to appearances at the coroner’s court. Unfortunately, we don’t often give sufficient attention to the profound trauma staff and patients experience when exposed to inpatient suicide. If not effectively addressed, this trauma can linger unresolved for years, manifesting repeatedly in patterns of care—a phenomenon Freud described as "repetition compulsion". Unprocessed trauma can harm staff and affect the safety and wellbeing of future patients. The double-edged sword of patient safety investigations It’s essential that every inpatient death prompts a thorough patient safety investigation. However, the issue isn’t the investigation itself; it’s how easily the concept of patient safety can become distorted following a traumatic death. When a suicide occurs, intense emotions and destructive forces are unleashed within an organisation. This often results in attempts to create a simplistic causal narrative for the tragedy—a narrative that can never truly capture the complexity of suicide. In the aftermath of suicide, people’s ability to mentalise—to think clearly and compassionately—is severely compromised. The intense emotional turmoil often triggers a search for blame. As the deceased patient’s agency is often discounted, blame shifts rapidly towards clinicians. I've seen distressing examples where clinicians become scapegoats, absorbing an organisation’s collective anxiety and guilt. Organisations can behave almost like sentient beings, attempting self-preservation by shifting blame onto individual staff, often with devastating personal and professional consequences. Improving support for bereaved families The anxiety surrounding inpatient suicides can make it challenging for organisations to engage compassionately and openly with bereaved relatives. Defensive postures, though understandable given potential repercussions, ultimately harm those grieving. One proven way to mitigate confrontation and provide genuine support is appointing Family Liaison Officers. These dedicated individuals advocate for bereaved families, offering emotional support, clarity, and careful communication, thus alleviating confrontational dynamics. Supporting staff in caring for the bereaved Staff must not be left unsupported in their interactions with grieving families. Effective engagement with bereaved relatives requires thoughtful, organisational leadership and strategic planning. I've witnessed harmful situations where clinicians, driven by guilt, rush prematurely to communicate with bereaved families. Such impulsive actions, however well-intentioned, can cause unintended harm. Again, Family Liaison Officers are instrumental in mediating this delicate and emotionally charged communication, providing guidance and helping staff navigate difficult interactions more safely. Creating reflective spaces for staff Mental health work, particularly in inpatient environments, is intensely emotional and psychologically demanding. In the aftermath of a patient suicide, it becomes vital for organisations to provide reflective spaces—dedicated times and places where clinicians can safely process traumatic experiences. Without such spaces, unprocessed trauma can manifest as "acting out," leading to harmful patterns in care delivery and clinician burnout. Embedding regular reflective practice is essential, enabling staff to maintain their psychological wellbeing and enhancing patient safety through thoughtful, compassionate care. Final thoughts: seeking truth and compassion in patient safety Throughout my career, my core interest remains the truthful engagement with suicide and patient safety. We need honest, realistic frameworks that acknowledge limitations, complexity, and uncertainty. Fantasy-driven ideas of control and simplistic blame narratives do profound harm—both to clinicians and those bereaved. True safety comes from authentic, reflective practice, compassionate communication, and careful systemic support. Further reading on the hub: Rethinking suicide prevention: from prediction to understanding

This Hospital at Night Summit focuses on out of hours care in hospitals, delivering high quality safe care at night, and supporting the wellbeing of those working at night. Through national updates, networking opportunities and case studies this conference provides a practical guide to delivering a high-quality hospital at night service and transforming out of hours services and roles to improve patient safety. The 2024 conference will focus on developing an effective Hospital at Night service and focus on the practicalities of supporting staff at night, improving wellbeing, and fighting fatigue. For further information and to book your place visit: https://www.healthcareconferencesuk.co.uk/virtual-online-courses/hospital-at-night-summit or email [email protected] Follow on X @HCUK_Clare #HospitalAtNight hub members receive a 20%. Email [email protected] for discount code.

In this blog, Patient Safety Learning looks at the results of the NHS Staff Survey 2024, focusing on responses relating to reporting, speaking up and acting on safety concerns. We highlight that, alongside other evidence, the survey results point to a lack of progress in improving safety culture in the health service. In its major restructure of healthcare governance in England, Patient Safety Learning argues that the Government needs to prioritise decisive, practical action to create cultures in which staff feel safe to speak up. On 13 March 2024, the NHS published the results of its 2024 staff survey. 774,828 staff from 263 organisations took part and the results provide a snapshot of their experiences of working in the health service.[1] The survey included a range of questions specifically about reporting, speaking up and acting on patient safety concerns. Unfortunately, the responses show little positive progress on these areas from previous years, underlining the persistence of blame cultures and a fear of speaking up in significant parts of the NHS. Survey results Reporting of errors, near misses and incidents Two-fifths of survey respondents, over 300,000 NHS staff, were unable to say with confidence that their organisation treats them fairly if they are involved in an error, near miss or incident. This is set against a much higher number of respondents, 86.43%, who said their organisation encourages staff to report errors, near misses or incidents. Responses to both these survey questions have not significantly changed in the past three years. This demonstrates that staff see a significant disconnect between what their organisation tells them about reporting patient safety issues and how they feel they will be treated if they actually raise concerns. There is also a significant problem when it comes to what staff think about how their organisations respond to patient safety issues. 68.21% of staff said that when errors, near misses or incidents are reported, their organisation takes action to ensure that they do not happen again. It is a major concern that over 240,000 NHS staff feel unable to agree with this statement. Connected to this, nearly two-fifths of respondents, 38.71%, did not agree that they are given feedback about changes made in response to reported errors, near misses and incidents. When staff are unable to clearly see their organisation’s approach to learning and acting on safety concerns, it is understandable that they might not have confidence these are being acted on. This issue is likely to be amplified further for patients and the public who do not have an inside view of the NHS. We need to see action for improvement being shared transparently within organisations and with the wider public. Concerns about clinical safety and speaking up The percentage of staff who say they would feel secure raising concerns about unsafe clinical practice has changed very little in the past five years, hovering at just above 70%. The response rate in 2024 means that over 200,000 NHS employees, 28.47% of survey respondents, could not say that they would feel secure raising concerns about unsafe clinical practice. When asked if they were confident that their organisation would address these concerns, only 56.83% of staff responded positively, a figure very similar to last year’s results and down nearly 4% from 2020 (56.87% in 2023, 60.57% in 2020). When it comes to speaking up about broader issues, 38.18% of respondents, nearly 300,000 NHS staff, could not say that they felt safe to speak up about anything that concerns them in their organisation. When asked about their confidence in their organisation acting on any concerns, the picture looks worse, with half of all respondents not having confidence that their concerns would be addressed (50.48%). Published in July 2019, the NHS Patient Safety Strategy identifies a patient safety culture as one of the two foundations required in working towards its safety vision “to continuously improve patient safety”.[2] This ambition clearly remains a long way out of reach when, for four consecutive years, nearly two-fifths of NHS staff surveyed have said they do not feel safe to speak up about concerns. No signs of culture change The 2024 staff survey results show no significant change from recent years in responses to questions on reporting incidents, clinical safety and speaking up about patient safety issues. While the survey only provides an annual snapshot of what it is like to work in the NHS, its findings are reinforced by evidence elsewhere. Blame cultures are a recurring theme echoed across many different inquiries into major patient safety scandals.[3] [4] [5] By creating an environment in which staff fear retribution if they are involved in a patient safety incident, blame cultures encourage staff to cover up the causes of avoidable harm rather than reporting them. The shocking experiences and testimonies of whistleblowers in healthcare are further evidence of staff not feeling safe to speak up and suffering severe repercussions when they do. Too often, staff raising patient safety concerns to their organisation are met with a hostile and aggressive response, rather than one that welcomes challenge and scrutiny. Staff who speak up for patient safety often receive personal threats, vexatious referrals to regulatory bodies, pay cuts and demotions, disciplinary action and contractual changes. We are highlighting these issues as part of a new interview series, Speaking up for patient safety, in partnership with Peter Duffy, an NHS whistleblower and Chair of the Healthcare Working Group at WhistleblowersUK.[6] The series looks at how people who speak up in healthcare are treated by organisations, leaders and regulators, and how this acts as a barrier to staff raising patient safety concerns. In each interview, Peter and Patient Safety Learning’s Chief Executive Helen Hughes, talk to with someone who has spoken up about patient safety in healthcare or who works to help staff raise concerns. We need to move from ambition to action At Patient Safety Learning, we believe it is vital that we create a culture in healthcare that supports raising, discussing and addressing the risks of unsafe care. It is difficult to imagine that this type of evidence of an unsafe culture in other safety-critical industries—where the consequences of incidents may also be serious injury or loss of life—would be considered acceptable. Responses to patient safety questions in this year’s NHS Staff Survey were very similar to the 2023 results, which we analysed in our report, We are not getting safer: Patient safety and the NHS staff survey results.[7] This year’s survey results indicate that in too many parts of the health service, staff don’t feel safe to speak up and don’t have confidence that their concerns are being listened to and acted upon. These results support our view that the health service needs a more transformative effort and greater commitment to creating a safety culture. As detailed in ‘We are not getting safer’, NHS England has made some positive progress by introducing new guidance and information that aims to help develop a safety culture in the NHS.[7] However, there is little detail about how to effectively implement safety culture guidance and best practice across NHS-commissioned health and social care providers. There is also a lack of clarity about how improvements in culture will be monitored, evaluated and shared for wider adoption. The way that the NHS will operate in future years is currently subject to significant change. The forthcoming 10-Year Health Plan and the recent announcement that NHS England will be incorporated back into the Department of Health and Social Care are signs of significant structural change.[8] Patient safety must be at the centre of this new operating model, with organisations supported and held to account in creating a culture where staff feel safe to speak up. We need to move beyond rhetoric and into practical action. References NHS Staff Survey. Results, Last Accessed 13 March 2025. NHS England. The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019. Department of Health and Social Care. 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. Department of Health and Social Care. Independent Investigation into East Kent Maternity Services. Maternity and neonatal services in East Kent – the Report of the Independent Investigation, 19 October 2022. The Mid Staffordshire NHS Foundation Trust Public Inquiry. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, 6 February 2013. Patient Safety Learning. Speaking up for patient safety: An interview series with Peter Duffy & Helen Hughes, 15 January 2025. Patient Safety Learning. We are not getting safer: Patient safety and the NHS staff survey results, 26 March 2024. Department of Health and Social Care. World’s largest quango scrapped under reforms to put patients first, 13 March 2025