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In operating theatres and other high pressure clinical environments, clear identification shouldn’t be a nice ‘extra’, it is a patient safety need. When staff cannot quickly recognise names and roles, communication becomes harder, escalation can be delayed and patients are left unsure who is caring for them. Reviews of patient safety repeatedly show that poor teamwork and unclear roles can contribute to avoidable harm. Danielle Checketts, Managing Director of Eco Ninjas, discusses why being able to identify staff by their names and roles is so important not only for the staff themselves but also patients. She explains how a simple idea, reusable hats with detachable name badges that can be removed before laundering, can support safety and teamwork. In theatre, everyone can look the same. Masks, gowns, visors and lead aprons often cover name badges, while lanyards are easily hidden or turned around. Theatre teams include surgeons, anaesthetists, students, agency staff and industry representatives, yet patients and colleagues are still expected to know who is who. When names, roles and seniority are unclear, questions may go to the wrong person, and valuable seconds can be lost. Even when introductions are made during the WHO surgical safety checklist,[1] names and roles can quickly be forgotten once a procedure is underway. In an emergency, it must be immediately clear who is who. This lack of clarity can lead to: Miscommunication at critical moments. Delays in escalation. Reduced patient confidence and psychological safety. Errors due to misunderstood roles or instructions. This isn’t just theoretical. Liz Fitzhugh, net zero lead and former theatre manager at University Hospitals Coventry & Warwickshire (UHCW), put it simply: “If a patient arrests and someone asks for the crash trolley, either everyone goes or no one goes.” In critical moments, teams need to be immediately identifiable so they can act without hesitation. Liz’s team at UHCW were among the first to introduce name and role theatre caps in 2019. It feels fitting that she was also the person who once asked me to write my name on my disposable cap with a marker pen, quietly sparking the idea that grew into this work. For years, poor identification in theatre has become accepted and been treated as normal. But it shouldn’t be. Patients want to know who is caring for them, and staff work more safely when names and roles are clearly visible. That is why the ‘theatre cap challenge’ gained momentum internationally, highlighting a simple idea: if the hat remains visible when wearing sterile attire, it can help make names and roles visible too. Patient perspectives: what matters most Patients consistently say they want to know who is in the room, who is leading their care and who they can turn to for reassurance. Feedback from surgical and maternity care journeys, including caesarean births, shows that visible names and roles help people feel safer, calmer and better able to engage in what is happening around them. Patients describe feeling more reassured when: Staff introduce themselves clearly. Visible names and roles help patients and colleagues remember who is who after introductions, rather than relying on memory alone. There is consistency in communication throughout their care. When identification is unclear, patients can feel anxious and excluded at the point they are most vulnerable. Visible names and roles do more than support courtesy, they strengthen communication, teamwork and reassurance for patients and families. Infection prevention, hygiene and practical constraints Efforts to improve identification must also align with infection prevention standards. Theatre attire cannot simply be adapted without considering contamination risk, laundering processes and the wider pressure to reduce reliance on single use items. The challenge with current approaches The current embroidered theatre caps improve visibility of names and roles, but they are difficult to manage at scale and fail to support consistent identification for all staff. Students, visitors and temporary staff are often excluded, and new starters can wait months before receiving one. They also create ongoing operational challenges, including time-consuming bespoke ordering, poor fit, loss and replacement costs, outdated roles, and complications with laundering. As Alan Dickens, Theatre Manager at MMUH Birmingham, explains: “Bespoke embroidered caps are hard to manage over time. When staff leave or change roles, the hats issued to them often leave with them or need replacing. This creates ongoing cost for the trust and delays in maintaining accurate identification.” Emerging responses across the NHS Several NHS organisations are now testing a more practical approach: reusable hats with detachable name badges that can be removed before laundering. This keeps identification visible while fitting more easily into real hospital systems. In Somerset, a pilot at Musgrove Park showed how a simple change can support safety and teamwork. Mr Andy Stevenson, orthopaedic consultant at Somerset NHS Foundation Trust, said: “In theatre, there can be a really high turnover of colleagues at times, with new people coming and going all the time. This can make it really difficult to know who is who, let alone what jobs they have. Some days, it will be the first time working with half the people in the room. The badge hats have helped to positively transform communication and safety.” A similar message has come from maternity services. Kathryn Harrison, delivery suite manager at Great Western Hospital, said: “Despite staff introducing themselves in the morning, remembering everyone’s name and role throughout the day is challenging, especially when more than 12 people can be in the room at any one time. The badge hats reinforce this critical stage in safe surgery, improve teamwork and communication, and help break down hierarchical barriers. They can be worn by all staff, students, birthing partners and even the patients wear them on our unit”. Building the evidence base There is growing research interest in identification in healthcare.[2][3][4] We have started to work with medical schools on exploring the impact on training environments, role visibility and communication. This is helping to strengthen the evidence base for scalable, system-wide approaches. Students can be included simply using a badge with their name and role alongside a standard fitted hat. Towards integrated, system-based solutions The challenges across current approaches show the need for solutions that fit existing NHS processes, including laundering and distribution, while also identifying temporary staff, visitors and students. The most effective solutions will improve safety without creating new inefficiencies. A call to action Clear identification in healthcare is not optional. It is a practical safety intervention. When people can immediately see names and roles, communication improves, hierarchy softens, patients feel more reassured and teams are better able to act quickly when it matters most. If the NHS is serious about reducing avoidable harm, improving teamwork and strengthening patient experience, visible identification should be part of the solution. Wearing a detachable badge on a reusable theatre cap sounds very simple but this is a small change that can make a very big difference to the safety of patients. References World Health Organization. WHO Surgical Safety Checklist. Kouba LP, Fabi A, Bayer S, et al. Labeled surgical caps improve perioperative patient safety and interprofessional communication in the operating room: a scoping reviewe. Patient Saf Surg, 2026; 20:(9). Liverpool University Hospitals NHS Foundation Trust (LUHFT) and Warwick Med. Case study – Switching to Reusable Theatre Caps. NHS England. Douglas N, Demeduik S, Conlan K. Surgical caps displaying team members' names and roles improve effective communication in the operating room: a pilot study. Patient Saf Surg 2021;15:27. doi: 10.1186/s13037-021-00301-w.

John Bradley Williamson was a spinal surgeon whose work later became the subject of investigations and reviews following concerns raised by former patients regarding surgical outcomes and complications. Many of his patients experienced long-term health problems, additional corrective surgeries, chronic pain, and lasting physical and psychological harm. The case has since received national media attention and prompted wider discussions around patient safety, oversight, follow-up care and how concerns are communicated to patients. Simon Wainwright, a former patient affected by the spinal surgery carried out by John Bradley Williamson, has lived with the long-term complications that have required multiple corrective operations across several hospitals. Simon reflects on the gap between the recommendations made in investigation reports and the realities patients face, and how patients like himself are often left to navigate the long-lasting complications largely on their own.  Over the years, there have been formal reviews and reports into what happened to patients operated on by consultant spinal surgeon John Bradley Williamson, and many recommendations made.[1][2][3] Although these processes are important, there remains a gap between the recommendations written in these reports and the reality patients continue to experience years later. Although there are processes described on paper that sound reassuring, many patients still feel they are left to navigate ongoing complications, uncertainty and fragmented care largely on their own. One example of this is the concept of a “patient-initiated review.” A patient-initiated review essentially means that patients themselves are expected to come forward if they have concerns about the care or surgery they received. In theory, this sounds positive—giving patients the opportunity to come forward if they have concerns, ask questions or seek reassessment. However, in practice, it raises an important question: how will patients even know this option exists? Many patients are not routinely followed up long-term, may have moved areas or may not realise that the symptoms they are living with could be connected to a previous surgery. By relying on patients to initiate this themselves, without proactive communication and outreach, there is a real risk that affected patients remain unaware that support or review pathways are available to them at all. There is often an assumption that primary care services will help identify and support these patients, but the reality is more complicated. GPs may not have access to a patient’s complete historical surgical information, particularly when treatment occurred many years ago or across multiple hospitals. This means some patients can easily fall through gaps in the system unless there is a coordinated and proactive approach. For patients like me, the impact is not limited to a single procedure. It is ongoing—affecting physical health, independence, mental wellbeing, family life, the ability to work and live normally, and confidence in the healthcare system itself. In my own experience, the consequences did not end after the original surgery. I have required multiple corrective operations across different hospitals and continue to live with the long-term physical and emotional effects. What has been difficult at times is feeling that patients are expected to coordinate much of this themselves; patients are often left chasing information rather than being actively supported through the process. I would like to see genuine commitment to patient safety and learning, with communication clear, proactive and accessible. Patients should not have to discover reviews through the media, search online for information themselves, or rely on chance conversations to understand what support may be available to them. Affected patients should be directly contacted wherever possible, given clear information in accessible language, and offered appropriate long-term clinical and psychological support. This is not just about past events – it is about ensuring that patients are not left behind in the process of reviewing and learning from them. Real accountability is not just about producing reports. It is about ensuring patients feel informed, listened to and supported long after the headlines disappear. References tps://www.northerncarealliance.nhs.uk/about-us/nca-independent-report-previous-management-concerns-regarding-consultant-spinal-surgeon?q=%2Fabout-us%2Fnca-independent-report-previous-management-concerns-regarding-consultant-spinal-surgeon https://www.northerncarealliance.nhs.uk/application/files/5516/8985/5202/SPSLBR_Report_Final_060623_redacted.pdf Spinal-diagnostic-Final-report.pdf

Promoting Learning, Safety, and Improvement in Surgical Teams Team Based Quality Reviews (TBQR) provide a structured, evidence-based approach to team learning in clinical practice. Building on existing processes such as morbidity and mortality (M&M) meetings and significant event analyses, TBQR supports whole-team reflection from the point of an event through to shared learning, meaningful actions, addressing unintended consequences and follow-up for improvement. This one-day course, developed in partnership with NHS Education Scotland, RCSEd and the GMC, equips healthcare professionals with the tools, frameworks, and strategies needed to embed TBQR into clinical practice. Participants will gain practical skills in implementation strategies, analysing events, identifying meaningful actions, and overcoming barriers—such as time, resources, and system alignment. Designed for colleagues leading or interested in safety reviews, or seeking to improve daily work practices, this course provides an opportunity to enhance the understanding, and application of Human Factors and Systems Thinking into practice. It explores how TBQR can be used not only to learn from harm, but also from success, innovation, and complexity in care delivery. This course provides delegates with an opportunity to join a wider network of professionals and learn from areas of good practice across the globe. By supporting collective learning and psychological safety, TBQR strengthens team performance, staff wellbeing, and organisational resilience, ultimately advancing safe, effective, and sustainable healthcare. Target audience: Surgeons and health care professionals leading safety reviews or team based review meetings, including mortality and morbidity meetings. Currently aimed at ST3 onwards but applications are encouraged from interested individuals. Register

Promoting Learning, Safety, and Improvement in Surgical Teams Team Based Quality Reviews (TBQR) provide a structured, evidence-based approach to team learning in clinical practice. Building on existing processes such as morbidity and mortality (M&M) meetings and significant event analyses, TBQR supports whole-team reflection from the point of an event through to shared learning, meaningful actions, addressing unintended consequences and follow-up for improvement. This one-day course, developed in partnership with NHS Education Scotland, RCSEd and the GMC, equips healthcare professionals with the tools, frameworks, and strategies needed to embed TBQR into clinical practice. Participants will gain practical skills in implementation strategies, analysing events, identifying meaningful actions, and overcoming barriers—such as time, resources, and system alignment. Designed for colleagues leading or interested in safety reviews, or seeking to improve daily work practices, this course provides an opportunity to enhance the understanding, and application of Human Factors and Systems Thinking into practice. It explores how TBQR can be used not only to learn from harm, but also from success, innovation, and complexity in care delivery. This course provides delegates with an opportunity to join a wider network of professionals and learn from areas of good practice across the globe. By supporting collective learning and psychological safety, TBQR strengthens team performance, staff wellbeing, and organisational resilience, ultimately advancing safe, effective, and sustainable healthcare. Target audience: Surgeons and health care professionals leading safety reviews or team based review meetings, including mortality and morbidity meetings. Currently aimed at ST3 onwards but applications are encouraged from interested individuals. Register

When repeated harm occurs in healthcare, public debate often centres on identifying an individual responsible. Although accountability is essential, patient safety may be better served by asking another question first: Were there earlier signals that something was going wrong? This blog reflects the perspective of Aditi Desai, a surgeon with nearly three decades of clinical experience and an interest in patient safety systems, surgical quality monitoring and organisational learning. Recent high‑profile cases, such as the case of surgeon Yasser Jabbar at Great Ormond Street Hospital,[1] have prompted difficult reflection across the profession about how systems detect repeated patient harm. These situations understandably lead to questions about individual responsibility, but they also highlight the importance of recognising warning signals earlier. After nearly three decades in surgical practice, I have seen how outcomes can fluctuate. A surgeon may perform many procedures safely, then experience several complications in close succession. Some of this represents natural variation. But sometimes patterns emerge that should prompt earlier concern. Modern healthcare systems collect large amounts of clinical data, yet we rarely use it systematically to detect deteriorating performance early.[2] Risk‑adjusted monitoring of outcomes over time, combined with supportive mentoring and fair accountability, could help organisations intervene sooner, protecting both patients and clinicians. Improving patient safety requires moving beyond a simple choice between blaming individuals or fixing systems. Safer care depends on recognising both the human realities of clinical practice and the need for strong organisational oversight. Recognising the early warning signs of unsafe surgical practice Having practised surgery for more than 28 years, I have learned that clinical outcomes are rarely perfectly predictable. A surgeon may perform a hundred operations without complication. Then, within a short period, several adverse outcomes may occur—like unexpected bleeding, infection or an unintended injury during surgery. When this happens, patients suffer first and most. For clinicians, complications also carry a heavy emotional weight. Many doctors recognise the sleepless nights and intense self‑reflection that follow when a patient is harmed. In recent years, public discussions around cases of repeated patient harm have raised difficult questions about how healthcare systems detect unsafe practice. The case of Yasser Jabbar at Great Ormond Street Hospital, widely reported in the UK, has prompted reflection not only about accountability but also about whether earlier signals of unsafe care might have been detectable. The instinctive response is often to ask: “Who is the rogue clinician?” But from a patient safety perspective, an equally important question may be: “Where was the signal that care was becoming unsafe?” Distinguishing variation from unsafe care All clinical practice carries risk. Even highly skilled surgeons experience complications. Medicine is complex, and outcomes vary according to patient condition, procedural difficulty and chance. The real challenge is distinguishing between: Expected complication rates and natural variation, and Patterns that may indicate deteriorating performance or unsafe practice. This distinction is rarely straightforward. It requires careful interpretation of clinical outcomes and trends over time. The human side of surgical practice Medicine often expects clinicians to perform at a consistently high level throughout long careers. Yet surgeons, like everyone else, experience illness, fatigue, personal stress and periods of reduced resilience. Most clinicians continue working through these pressures because the culture of medicine places great value on strength, reliability and professionalism. Recognising this human reality does not diminish professional responsibility. Instead, it highlights the importance of systems that can identify when a clinician may be struggling and offer support or review before patient harm accumulates. The missing safety infrastructure Healthcare organisations collect vast amounts of data about procedures and outcomes. Yet in many systems, we still lack robust mechanisms that can: Risk‑adjust outcomes for patient complexity. Monitor outcome trends over time. Identify negative outliers early. Trigger timely peer review or mentoring. Such systems are not primarily about punishment. Their purpose is to protect patients while supporting clinicians to maintain safe practice. Moving beyond 'individual versus system' Patient safety discussions often frame harm as either the fault of an individual clinician or the result of system failure. In reality, safety depends on both. Strong systems should be able to detect emerging risks early, while still ensuring fair accountability when unsafe practice becomes clear. This approach aligns with the principles of a just culture, where organisations seek to understand and respond to risks rather than relying solely on retrospective blame.[3] A role for data, mentorship and oversight In other high‑performance fields, such as aviation and elite sport, continuous monitoring and coaching are routine. Medicine has traditionally been slower to adopt this approach. Yet supportive oversight and mentoring could help clinicians identify and address problems earlier in their careers or during periods of difficulty. Clinicians may benefit from ongoing coaching and feedback, not only during training but throughout their professional lives.[4] Surgeon and writer Atul Gawande, the WHO checklist pioneer, highlighted this idea in his TED Talk “Want to get great at something? Get a coach”, where he describes how even experienced surgeons can improve performance and safety through structured coaching and peer observation.[5] Looking forward Cases where repeated harm occurs inevitably raise questions about accountability. Where clear incompetence or unsafe practice exists, fair accountability is essential. But patient safety improves most when healthcare systems are able to recognise warning signs early, before serious harm accumulates. By combining risk‑adjusted data, supportive oversight and a culture of learning, healthcare organisations can better protect patients while supporting clinicians to maintain safe practice. Ultimately, safer care depends not only on responding to failure, but on building systems capable of recognising risk sooner. References Triggle N. Great Ormond Street doctor who botched surgery harmed nearly 100 children. BBC News, 29 January 2026. Royal College of Surgeons of England. Surgical outcomes data and transparency. Outcomes FAQ. NHS England. Being fair tool: supporting staff following a patient safety incident. 9 May 2025. Pradarelli JC, Yule S, Panda N, et al. Optimising the implementation of surgical coaching through feedback from practicing surgeons. JAMA Surgery, 2021; 56;(1): 42-49. doi:10.1001/jamasurg.2020.4581. Gawande A. Want to get great at something? Get a coach. TED Talk, April 2017.

Overview Technical skills alone are insufficient to ensure optimal outcomes following surgery. The Non-Technical Skills for Surgeons (NOTSS) Masterclass provides participants with a broad knowledge and practical experience of the non-technical skills that have been demonstrated to be essential for safe patient care. These include the cognitive and interpersonal aspects of operative surgery that are critical for optimising individual and team performance in surgery. Target audience Consultants and Senior Trainees in all surgical specialties. Learning style Participants are sent reading material prior to attending the course. The course gives participants practical experience of observing and rating non-technical behaviours. The format is centred on small group work and the use of simulated scenarios from the operating theatre and other industries. Learning outcomes By the end of this masterclass, participants should be able to: Discuss the underlying principles of non-technical skills which contribute to safe surgical care. Differentiate between four major categories of non-technical skills: Situation Awareness, Decision Making, Team Communication, and Leadership. Identify and assess surgical non-technical skills in a series of operative video simulations using the NOTSS taxonomy. Register

Overview Technical skills alone are insufficient to ensure optimal outcomes following surgery. The Non-Technical Skills for Surgeons (NOTSS) Masterclass provides participants with a broad knowledge and practical experience of the non-technical skills that have been demonstrated to be essential for safe patient care. These include the cognitive and interpersonal aspects of operative surgery that are critical for optimising individual and team performance in surgery. Target audience Consultants and Senior Trainees in all surgical specialties. Learning style Participants are sent reading material prior to attending the course. The course gives participants practical experience of observing and rating non-technical behaviours. The format is centered on small group work and the use of simulated scenarios from the operating theatre and other industries. Learning outcomes By the end of this masterclass, participants should be able to: Discuss the underlying principles of non-technical skills which contribute to safe surgical care. Differentiate between four major categories of non-technical skills: Situation Awareness, Decision Making, Team Communication, and Leadership. Identify and assess surgical non-technical skills in a series of operative video simulations using the NOTSS taxonomy. Register

This innovative educational initiative was developed as a direct and constructive response to the communication inadequacies exposed by the Montgomery case, and subsequent legislation. While it is not difficult to give "more information" it is harder for surgeons and patients to achieve a decision partnership. The ICONS workshop content has been informed by internationally recognised experts in Shared Decision Making, by consensus among senior practising surgeons, by patients and by professional experts in risk management and risk communication. Delegates on the ICONS workshops will acquire skills and knowledge to implement best practice in sharing the complex decisions surrounding informed consent. By participating in a workshop, they will also contribute to the development of resources for future training in the important area of informed consent. Target audience All grades of trainees; SAS / LED / Trust Doctors; Consultants. Non FRCS surgeons – Ophthalmologists; Obstetricians and Gynaecologists. Learning style Focussed topic introductory talks. Small group facilitated discussion tutorials based on review of exemplar videos of consent and other patient doctor communication scenarios. Aims & objectives The objectives of the course include: Learn the potential catastrophic and costly consequences of failure adequately to share important surgical decisions. Recognise the importance of discussion treatment options rather than risks. Understand key features of the case Montgomery v LHB 2015. Appreciate the legal view of Shared Decision Making. Identify key elements of a Shared Decision Making consultation. Understand how to deliver treatment recommendations. Gain new consultation skills. Identify and apply effective ways of risk communication. Appreciate the role of decision support tools before, during and after the clinical encounter. Understand the added value of writing letters directly to patients. Learning outcomes Having attended the ICONS workshop you will be able to: Understand the practical importance of the Montgomery decision. Identify the key elements of a Shared Decision Making consultation. Discuss options including surgery – elective and emergency. Employ efficient methods of eliciting patient needs, preferences and values in a busy clinic. Understand the added value of patient activation before options are discussed, and decision distribution thereafter. Develop skills for well-balanced, meaningful surgeon patient interactions. Communicate risk to patients in a more realistic way. Appreciate the role of recommendation. Review the limitations of and variation in current consent forms. Register