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On Wednesday 19 March 2025, over 280 healthcare staff in England attended the first ever Patient Safety Specialists event to celebrate completion of the National Patient Safety Syllabus training.  Claire Morgan, Patient Safety Specialist, Royal London Hospital, Barts Health NHS Trust, reflects on the day. Over 280 healthcare staff in England attended the first ever Patient Safety Specialists (PSSs) event to celebrate completion of the National Patient Safety Syllabus training. With a further 203 graduates across England, these were the first ever cohort of PSSs to have passed the NHS Patient Safety Syllabus Levels 3 and 4. This historical event was held at Hollywell Park Conference Centre on the impressive campus of Loughborough University in the heart of Leicestershire. The sun shone and, despite the Government’s announcement to dissolve NHS England (NHSE) the week before, many of the delegates saw true reason to celebrate with this first event driving patient safety in England. The Faculty at Loughborough, headed by Professor Mike Fray, celebrated with us our success and a welcome introduction was given by Professor Nick Jennings the Vice Chancellor of Loughborough University. Lessons shared To start the morning, Professor Sue Hignett shared the insights from almost 500 PSSs’ videos that had been submitted as our final coursework. Lessons shared included: Changing the safety approach in terms of Safety II and human factors and ergonomics (HFE) principles. Embedding the Just Restorative Culture. Using safety science tools. Developing and using common language. Engaging with Patient Safety Partners. Promoting the PSSs. Considering IT design and usability. Procuring and designing medical devices and buildings. Applying the 'hierarchy of controls' for actions. Reviewing policies, procedures, guidelines using safety science tools. In addition, pre-event survey results collected from the delegates included an impressive array of ideas on what support they need, including: Future continuing professional development (CPD). Formation of a support network. Governance and advocacy on roles of PSS for organisations. Their ideas for the next steps included: Application of learning in sharing knowledge. PSS role development and recognition. Culture and practice. System level collaboration impact. Reflections on the course Presenting next were six PSSs, chosen from different healthcare sectors, to reflect on the course in terms of take-aways, personal growth and organisational impact, including threats and opportunities. I was asked to present on behalf of an Acute Trust and my organisation the Royal London Hospital, Barts Health Trust. With similarities to the other presenters, I extolled the virtue of the practical nature of the Loughborough course, affording participants the opportunity to the test the tools and methods that we had been introduced to throughout the five courses. Personal growth was often focussed on with the unique PSS network and ‘specialist’ expertise now gained. The impact, including opportunities and challenges on the variety of organisations operating within the varied and complex socioeconomic healthcare system that we work in, became apparent. Professor Thomas Jun then gave the opportunity for section-specific smaller group discussions. Delegates agreed that undertaking the Levels 3 and 4 of the Patient Safety Syllabus was no mean feat for most participants. The course adopted a blended learning approach of 100 hours online and five in-person days delivered conveniently around the country. There were five courses, with a number of modules, and six assignments applied to ‘Wicked’ problems to submit, requiring application of tools and methods introduced. Appointment of at least one PSS is a requirement for NHS organisations in England. Once nominated by our Chief Executive Officers (CEOs), we started the course in November 2023 working towards a deadline of December 2024, with many of us admitting to spending much of our own time working towards the goal. Most of us will never forget the legendary hospitality and encouragement of the Loughborough Faculty and those at the Health Service Safety Investigations Body (HSSIB) on the five in-person days of the course. Looking forward After a welcome lunch at Hollywell House, we were invited to explore future opportunities in PSS training both from Ben Peachey, CEO at the Chartered Institute in Ergonomics and Human Factors, and Professor Mike Fray at Loughborough. Dr Robert Pralat who has been conducting research into the role of Patient Safety Partners and Specialists updated us on the NIHR research led by THIS institute at the University of Cambridge. Finally, a discussion panel facilitated by Thomas was convened between Professor Ramani Moonesinghe (the interim NHSE Patient Safety Director), Dr Helen Vosper (HSSIB education team), Helen Keynes (Head of Quality and Patient Safety at NHSE) and Professor Jay Banerjee (Emergency Physician and Quality Improvement Fellow Leicester). This allowed interesting and thought provoking discussion on the future of patient safety. Professor Mike Fray finished the day with a running display of the 483 PSSs' names to a positive music accompaniment bringing finale to a great day. Personal reflections I personally see PSSs as the golden thread of patient safety throughout England and these 483 PSSs should be encouraged to take this movement forward by whatever replaces NHSE. They must lead, challenge and champion patient safety in their organisations and beyond. The benefit of improving patient safety is supported by science, with patients at the forefront; Martha’s Rule empowers patients, their parents and carers to challenge where concerns are not listened to. The impact of compassionate engagement of the Patient Safety Incident Response Framework (PSIRF) for patients and staff involved in patient safety incidents from personal perspectives must be spearheaded. The value of organisational cultural benefits and reputations, along with the potential financial impact of improving patient safety in healthcare, cannot be underestimated. Finally, thank you Aidan Fowler, the previous Director of Patient Safety at NHSE, and all those at NHSE involved in writing the Patient Safety Strategy in 2019, which introduced the National Patient Safety Syllabus and the concept of a PSS. I also want to thank the authors of the National Patient Safety Syllabus at the Academy of Royal Colleges of Medicine, what was Health Education England, the Loughborough Faculty for delivering, NHSE for sponsoring and, of course, the healthcare organisations and their CEOs for supporting all 483 of us through our journey. Acknowledgement: Thank you Thomas for your input into this blog.

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

We asked the Patient Safety Group (PSG) of The Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top 10 patient safety tips for surgical trainees. See also: Safety in surgery series Top 10 tips for surgical safety: ‘Think Safety, think SEIPS’ Top 10 priorities for patient safety in surgery Listen to the patient and what matters to them; share decisions with them. Encourage the patient to be in control of their care; they only have to consider their own care and will not be lost to follow up. Trust your instincts; always speak up if you think something is not right. Never be afraid to ask for help if you need it. Look after yourself and your team; there can be no patient safety without team safety. Foster good team working; recognise and respect the value of all team members; take account of everyone’s strengths and weaknesses. Take responsibility for the safety of your patients; patient safety is everyone’s responsibility, not just that of the quality improvement team. Help design systems that make it easier for you to do the right thing. Do not make assumptions. Work as imagined is not the same as work done; make sure you always test any process in practice and confirm that what you think is the case is actually happening. Regularly audit your practice. Celebrate good practice and share your experiences. Take on board feedback and learn from it; be willing to change practice. When outcomes are not as expected, openly discuss and learn, to enable you and your team to reduce the risk of the same thing happening again.

Moving away from home and starting university has been a transformative experience. As an 18-year-old studying law and international relations, I’ve enjoyed the new found independence and academic challenges. However, persistent health issues have complicated my transition, leading to a frustrating journey through the healthcare system. My health struggles Since starting university, I’ve dealt with multiple colds and flu-like symptoms, some may call it ‘freshers flu’. A productive cough that lingered for over a month concerned me, but the situation took a serious turn when I started feeling dizzy and breathless with minimal exertion. Realising the severity of my condition, I knew I needed medical help. Seeking help: a series of missteps 1. Pharmacy visit My first stop was the local pharmacy. After describing my symptoms, the pharmacist suspected iron deficiency and recommended iron tablets. While this seemed plausible, my condition continued to worsen, prompting a call to my parents. 2. Exploring options: walk-in GP and NHS 111 My parents suggested visiting a walk-in GP, but I discovered none were available in my area. I then called NHS 111, hoping for guidance. They advised going to Accident and Emergency (A&E) but also mentioned they would request a GP call-back. Given the NHS’s known pressures, I was hesitant to visit A&E for what I didn’t consider an emergency. 3. Urgent treatment centre attempt My mum then suggested my local hospital’s urgent treatment centre. I mustered my energy to go there, only to be informed that I needed a GP appointment. They again suggested A&E. 4. Finally, A&E Feeling increasingly unwell, I headed to A&E. Although it felt like I was going in circles, this decision was crucial. At A&E, I was redirected to the urgent treatment centre where I finally saw an excellent doctor. I was seen quickly, diagnosed and given medication that soon began to help. A few days later, I received a message from NHS 111 stating that my request for a GP call-back had dropped off the system due to the delay. This entire experience has been eye-opening and frustrating. As a young and intelligent individual, I found navigating the healthcare system challenging. I can only imagine how overwhelming it must be for older adults, those with additional needs or those less familiar with the process. Lessons learned Navigating healthcare while dealing with a serious condition can be daunting. Here are some key takeaways from my experience that may help other university students or young adults who have moved away from home for the first time: Register with a local GP early As soon as you arrive at university, register with a local GP. It’s crucial to have access to medical care, especially when living away from home for the first time. Understand your options Familiarise yourself with the local healthcare facilities, including urgent treatment centres, walk-in clinics and A&E. Knowing where to go in different situations can save valuable time and stress. Persist and advocate for yourself Don’t be afraid to seek second opinions or alternative solutions if your initial attempts to get help are unsuccessful. Be persistent in advocating for your health needs. Stay informed about healthcare systems Understanding how the healthcare system works, including the pressures it faces, can help you make informed decisions about when and where to seek care. Moving forward Despite the hurdles, my health is now improving thanks to the excellent care I eventually received. This experience has taught me the importance of being proactive about my health and understanding the healthcare system. As I continue my university journey, I’ll be better prepared to navigate any future health challenges. If you’re a student facing similar issues, remember that you’re not alone. Reach out to university health services, friends and family for support. And most importantly, take your health seriously—it’s the foundation upon which all other successes are built. Reflections from my mother My mother, who is a healthcare professional working in the NHS, has had her own set of frustrations and concerns for me throughout this ordeal. She shares her own reflections on my experience: Frustration and helplessness Despite my extensive knowledge of the healthcare system, I felt powerless to help my child navigate the healthcare system from miles away. It was frustrating to be unable to fix the situation quickly and efficiently. Worry and concern Being far from home, I was naturally worried about my son’s health. The distance amplified my anxiety, knowing that they were dealing with worsening symptoms without immediate access to care. Concern for others I am also deeply concerned for other students and individuals who might be in similar situations but are not as vocal or persistent. How do they cope and navigate the system, especially those without a strong support network? Emotional impact This experience left me feeling upset and distressed. As a healthcare professional, I am acutely aware of the pressures on the NHS and the potential for patients to fall through the cracks. Seeing my own son’s struggle highlighted these issues in a very personal way. Are you a student or a young adult who has moved away from home for the first time? How easy have you found it accessing healthcare. We would love to hear your stories. Please comment below (you will need to register with the hub, it's free and easy to sign up), share your story in our community forum, or email us at [email protected]. Related reading The challenges of navigating the healthcare system: David's story The challenges of navigating the healthcare system: Margaret's story The challenges of navigating the healthcare system: Sue's story Lost in the system? NHS referrals "I love the NHS, BUT..." Preventing needless harms caused by poor communication in the NHS (DEMOS, November 2023) Robust collaborative practice must become the bedrock of modern healthcare Robbie: A homeless patient’s struggles with the system Digital-only prescription requests: An elderly woman sent round the houses Lost in the system: the need for better admin Digital-only prescription requests: An elderly woman sent round the houses

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

This event gives trainees at all levels the opportunity to attend, present and gain feedback on their Audit and QI work. Further lectures will include the McKeown Medal Lecture, a keynote on patient safety and discussion from a Trainee Committee member. Trainees are invited to submit their abstracts for consideration for presentation at this event. Topics for submission: General Surgery, Trauma & Orthopaedic Surgery, Specialties & Common Interest and Patient Safety. Register

In this blog, Professor of Medical Education Kate Owen explains how her team has embedded a session on patient safety in the final year curriculum at Warwick Medical School. Using a real-life story posted on the Care Opinion website, the session gives medical students an opportunity to use investigation tools, understand NHS reporting systems and consider the importance of compassionate communication with harmed patients and their families. Patient safety is a fundamental part of a large proportion of teaching in a medical degree. We found, however, that students were reaching the end of their studies and telling us that they had not been “taught patient safety”. We also realised that students had not had any opportunity to rehearse clinical reporting systems and discuss with their peers some of the challenges around reporting errors and near misses. So we decided to develop a workshop for final year students in their assistantship block, to pull together their learning and discuss how this would apply to their FY1 posts. This has now run for two years and is embedded in our curriculum. I am a patient as well as an educator and am aware that discussing one’s own traumatic experiences can have negative impacts on mental health and wellbeing. I believed it was vitally important to centre the session on patient stories, but without causing additional burden, which is why I decided to work with Care Opinion. I read very many Care Opinion stories before deciding to use this one about an elderly woman who went through a series of near misses because of an initial poor clinical decision. I felt it was important to focus on skills and active learning in preparation for becoming a junior doctor so the session has a series of small group activities. During the session, we split the students into groups and give each group a different tool with which to 'investigate' the episode—Fishbone, Root Cause Analysis, Human Factors, the Patient Safety Incident Response Framework and a SEIPS worksheet. We then come back together and discuss the findings, which are usually very similar between groups. We then discuss saying sorry (using this excellent patient video) and get the students to write a letter to the woman's daughter. Next, we look at reporting including using the Yellow Card system and Datix—we get the students to actually complete a form for the patient we have just investigated so that they have done it once before they may need to do it for real. We finish the session by discussing student concerns about patient safety when they start work, and this has resulted in many useful conversations. Students have fed back that the session really highlighted relevant issues: “I think the patient safety session was interesting to put so close to F1, as it highlighted a lot of the system issues with the NHS and how tough it will be.” Related reading Patient Safety Spotlight interview with James Munro, Chief Executive of Care Opinion