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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

Webinar overview: Understanding ISO 7101: Gain insights into the development and core principles of the standard. Benefits for the NHS: Learn the benefits of implementing the standard which can lead to improved patient outcomes, enhanced workforce wellbeing, and greater health equity. Implementation and certification: Discover practical steps for integrating the standard into existing NHS frameworks and quality improvement initiatives, as well as how to achieve certification. Q&A: Time to ask questions and hear from our expert(s)

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.

This webinar will give the nursing team in all fields a better understanding of autism. It will offer practical strategies on reducing health inequalities and making reasonable adjustments in health and social care settings. Nurse experts will highlight common challenges autistic people may face in health and social care settings, and the approaches nurses can use to overcome barriers to effective care including person centred approaches, environmental approaches and communication skills. Nurses can learn from real practical examples of successfully supporting autistic people in a range of settings. And we will be showcasing the RCN’s recent position statement on autism and reducing health inequalities and the need for evidence based practice. Plus your questions answered by our panel of experts. Register

Any older person in your care may be at risk of delirium. Nearly 100% of cases are experienced by older people. This common and sudden change in mental function involving confusion, anxiety, hallucinations or severe lethargy can have severe consequences, including an increased risk of dementia and death. Up to 1 in 3 people admitted to hospital become delirious at some time during their stay. In nursing homes and post acute care this rises to 60%. In residential care homes the incidence of delirium can be up to 40%. In all settings, it is often not diagnosed. Thankfully, delirium is preventable and effective management can make a significant difference to a patient’s outcomes. As nurses, you have a vital role to play to make sure people get the care and support they need to prevent complications. This webinar will give you the information and practical strategies you need to prevent, detect, assess and manage this distressing condition. Register

Facere Melius are the only NHS Framework Provider approved training supplier that worked closely with NHS England in developing tools and guidance to support PSIRF. This training will support the development of expert understanding and oversight of systems based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: PSIRF and associated documents (PSIRP, PSII standards) oversight framework effective oversight and supporting processes related to incident response maintaining an open, transparent, and improvement focused culture importance of communication and involvement of those affected (preventing further harm) commissioning and planning of patient safety incident investigations complex investigations spanning different organisational, care setting, and stakeholder boundaries Register hub members receive a 20% discount. Email [email protected] for discount code.

Facere Melius are the only NHS Framework Provider approved training supplier that worked closely with NHS England in developing tools and guidance to support PSIRF. This training will support the development of expert understanding and oversight of systems based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: PSIRF and associated documents (PSIRP, PSII standards) oversight framework effective oversight and supporting processes related to incident response maintaining an open, transparent, and improvement focused culture importance of communication and involvement of those affected (preventing further harm) commissioning and planning of patient safety incident investigations complex investigations spanning different organisational, care setting, and stakeholder boundaries Register hub members receive a 20% discount. Email [email protected] for discount code.

Facere Melius are the only NHS Framework Provider approved training supplier that worked closely with NHS England in developing tools and guidance to support PSIRF. This training will support the development of expert understanding and oversight of systems based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: PSIRF and associated documents (PSIRP, PSII standards) oversight framework effective oversight and supporting processes related to incident response maintaining an open, transparent, and improvement focused culture importance of communication and involvement of those affected (preventing further harm) commissioning and planning of patient safety incident investigations complex investigations spanning different organisational, care setting, and stakeholder boundaries Register hub members receive a 20% discount. Email [email protected] for discount code.

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.

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Facere Melius are the only NHS Framework Provider approved training supplier that worked closely with NHS England in developing tools and guidance to support PSIRF. Training to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations Being open and apologising when things go wrong Challenges/complexities associated with cases where there is more than one investigation Effective communication, including dealing with conflict and difficult conversations Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation Sharing findings Signposting and support: including loss, trauma and stress Who should attend Lead investigators conducting patient safety incident investigations Executive and service lead for duty of candour Executive and service lead for patient safety Executive and service lead for the supporting response to patient safety incidents Investigators supporting patient safety incident investigations Register hub members receive a 20% discount. Email [email protected] for discount code.

Facere Melius are the only NHS Framework Provider approved training supplier that worked closely with NHS England in developing tools and guidance to support PSIRF. Training to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations Being open and apologising when things go wrong Challenges/complexities associated with cases where there is more than one investigation Effective communication, including dealing with conflict and difficult conversations Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation Sharing findings Signposting and support: including loss, trauma and stress Who should attend Lead investigators conducting patient safety incident investigations Executive and service lead for duty of candour Executive and service lead for patient safety Executive and service lead for the supporting response to patient safety incidents Investigators supporting patient safety incident investigations Register hub members receive a 20% discount. Email [email protected] for discount code.

Facere Melius are the only NHS Framework Provider approved training supplier that worked closely with NHS England in developing tools and guidance to support PSIRF. Training to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations Being open and apologising when things go wrong Challenges/complexities associated with cases where there is more than one investigation Effective communication, including dealing with conflict and difficult conversations Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation Sharing findings Signposting and support: including loss, trauma and stress Who should attend Lead investigators conducting patient safety incident investigations Executive and service lead for duty of candour Executive and service lead for patient safety Executive and service lead for the supporting response to patient safety incidents Investigators supporting patient safety incident investigations Register hub members receive a 20% discount. Email [email protected] for discount code.

Training to support the development of core understanding and application of systems-based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: purpose of patient safety incident response framework introduction to complex systems, system thinking and human factors restorative just and learning culture duty of candour involving staff in incident response involving patients, families and carers in incident response improvement science and developing system improvement plans general response techniques interviewing and asking questions conducting observations, understanding work as done systems frameworks response types patient safety investigation planning, analysis and report writing commissioning and oversight of an internal investigation a high-level overview of system-based response tools Who should attend: Lead investigators; Executives, commissioning, and service leads for investigations; Investigators supporting or overseeing patient safety incident investigations Facilitator: Jo Perruzza is a former mental health nurse and has been a clinician, a clinical leader and a senior manager in mental health provider organisations. With a passion for patient safety and an expert in psychological safety she brings experience of leading internal and external investigations. Register hub members receive a 20% discount. Email [email protected] for discount code.

The course will provide participants with an in-depth knowledge and understanding of how to not only comply with the duty of candour and the Patient Safety Incident Response Framework (PSIRF), but to do so in an emotionally intelligent way, with empathy and compassion for all involved. Practical guidance on complying with the regulations and guidance The “grey areas” and what people most often get wrong Using emotional intelligence to understand the difficult emotions experienced by patients/those closest to them and staff following patient safety incidents What empathy and compassion mean in practice Handling difficult and emotive conversations well Making a meaningful apology How Duty of Candour and PSIRF work alongside other policies and procedures including complaints; litigation; Martha’s Rule and the soon to be introduced “Hillsborough Law” How the new “Harmed Patient Pathway” can help you get it right 7 How to ensure communication moves beyond compliance and frameworks but remains emotionally intelligent and personal Register hub members receive a 20% discount. Email [email protected] for discount code.