Patient Safety Resources

The aim of the NOTSS project was to develop and test an educational system for assessment and training of non-technical skills in the intra-operative phase of surgery. NOTSS is a behaviour rating system based on a skills taxonomy that allows valid and reliable observation and assessment of four categories of surgeons' non-technical skill: situation awareness, decision making, communication & teamwork, and leadership.

These are the essential non-technical skills surgeons need to perform safely in the operating room and NOTSS allows measurement of several ACGME (Accreditation Council for Graduate Medical Education) competencies, including professionalism, interpersonal and communication skills, and systems-based practice. The skills taxonomy can be used to structure training and assessment in this important area of surgical competence.

The Royal College of Surgeons of Edinburgh has been successfully running a NOTSS Masterclass in observing and rating behaviour for both consultant/attending and trainee surgeons since 2006. Faculty development has also occurred for groups in North America, East Africa, Japan, Australasia and Malaysia, all of whom now run their own NOTSS courses. NOTSS has been adopted by the Royal Australasian College of Surgeons as part of their competence assessment and recommended by the ACGME (Accreditation Council for General Medical Education) for workplace assessment in the UK. In order to support trainee assessment two online training resources have been developed: NOTSS in a Box (for senior trainees and consultants) and NOTSS for Trainees (for early stage trainees). Many regions in the UK now offer NOTSS courses to all their trainees and this is likely to increase in the next few years.

View all NOTSS resources below:

• RCSEd NOTSS
• NOTSS Courses
• NOTSS Handbook
• NOTSS Introductory Videos
• NOTSS in a Box e-learning Resource

The non-technical skills of perioperative care practitioners play a significant role in patient safety. This one-day course enables perioperative care practitioners (PCPs) and surgical first assistants (SFAs) to improve their intra-operative performance and help them observe and rate intra-operative non-technical skills.

Book the PINTS course here.

DeNTS is a new assessment tool for rating the non-technical skills of dentists and is the first of its kind. This course will teach delegates how good non-technical skills can improve clinical performance and patient management. Participants will be able to practice rating these skills using the new DeNTS taxonomy and will be calibrated to use DeNTS.

Book the DeNTS course here.

This is a new initiative aligned to the DeNTS taxonomy and is a framework for dental nurses to observe and appraise the non-technical skills of the clinicians with whom they are working.

Find out more about the DNOT tool here.

Surgical ward rounds are fast-paced, covering a large number of patients with varying conditions, over a short period of time. These factors combined have the potential to impact the quality of patient care and experience. It has been shown that our non-technical skills (NTS) contribute just as much as our technical skills, if not more, to the quality of care we provide. The Ward-round Non-technical Skills for Surgery (WANTSS) e-Learning module is designed to improve clinical performance and patient safety on surgical ward-rounds.

To access the module please click here, logging in with your College account. On successful completion of the module, you will be able to download a Certificate of Completion confirming that you have been awarded 1 hour of CPD.

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.

Book the ICONS course here.

Team Based Quality Reviews or TBQR is a generic term for traditional multi-professional team learning activities such as mortality and morbidity meetings (M&M) or significant event analysis reviews, which typically take place routinely across all surgical specialities and healthcare sectors. TBQR process refers to a wider activity that starts at the point of an 'event' through to the shared learning gained, action agreed and monitoring for the purpose of improvements where needed. This includes identifying and addressing unintended consequences of actions taken.

The TBQR programme seeks to embed evidence-based structure into such review processes through the provision of training, educational resources, tools and frameworks underpinned by Human Factors and Systems Thinking sciences. Support is provided into how to follow a system-based approach, capture multiple perspectives from the wider healthcare team as well as patients, maximize learning, and, very importantly, ensure a non-threatening atmosphere and blame-free culture.

Book the TBQR course here.

This workshop explores the impact of mistakes on all those involved; looking at how best to support and prepare each other; and how we might appropriately respond to patients and their families in the aftermath. Making and living with mistakes is a core part of what it means to be a surgeon, yet it is seldom discussed. Many trainees feel ill-prepared to cope with the burden this can bring; many senior surgeons are still troubled by the legacy of past mistakes in their practice.

Watch the webinar here.

This public engagement event aims to shed light on what happens when things go wrong in surgery. It is based around the performance of a play written by ENT Surgeon David Alderson, which brings the hidden world of the operating theatre onto the stage, facilitating discussion of the issues between surgeons and the general public.

Read more here.

The Addressing Conflict in Surgical Teams (ACT) Workshop explores the causes and impact of conflict within the surgical workplace and discusses different strategies to address this, including how to have difficult conversations, the art of negotiation and how to approach challenging situations. These skills will help foster closer working relationships leading to more productive teamwork.

Book the ACT course here.

The project to develop the Surgical Ward Round Toolkit was sponsored by a grant from SHINE (Health Foundation) and was carried out jointly between the Patient safety Board of The Royal College of Surgeons of Edinburgh and the Royal Infirmary of Edinburgh. Using an adapted NOTSS (Non-Technical Skills for Surgeons) system and a ward round based structured checklist, the aim of the Toolkit is to reduce errors and improve safety on surgical wards.

Read more about the SHINE toolkit here.

The College has developed this three-year part-time online MSc programme in Patient Safety and Clinical Human Factors alongside the University of Edinburgh, as part of the Edinburgh Surgery On-Line suite of courses. It aims to support any graduate health care professionals (ranging from nurses to surgeons and anaesthetists) in using evidence-based tools and techniques to improve the reliability and safety of everyday health care systems and processes.

Find out more about the course here.

This very popular 10 part series featured contributions from renowned world experts in the patient safety arena drawn from a wide range of disciplines.

Watch the Patient Safety webinar series here.

The College’s patient safety podcast series allows in-depth personal discussion with a range of patient safety experts on a variety of subjects. Recent episodes have covered topics such as Patient Safety Innovations with Maryanne Maryaselvam, the work of the Healthcare Safety Investigation Branch (HSIB) with Andrew Murphy-Pittock, and the highly popular 4-part series with David Alderson on Helping Surgeons When Things Go Wrong.

Watch the 2024 and 2023 RCSEd Patient Safety Day Podcast series below.

Past Patient Safety Podcasts can be found here.

The College’s Patient Safety Blog Series has been based around the themes of the WHO’s annual World Patient Safety Day. Since the launch of this initiative in 2019, we have published a series of blogs each year to mark the campaign. These have included: Speaking Up for Patient Safety, Keeping Healthcare Workers Safe to Keep Patients Safe, Safe Maternal and Newborn Care, Medication Safety, Engaging Patients for Patient Safety and Diagnostic Safety.

Read the 2024 and 2023 RCSEd World Patient Safety Day Blog series below.

Past Patient Safety Blogs can be found here.

The Patient Safety group contribute a regular feature in each edition of the College magazine, Surgeons News. These articles have covered a wide range of topics in the patient safety field, with particular features recently including a Helping Surgeons When Things Go Wrong series and a 10-page feature on the importance of timely and accurate diagnosis for helping to ensure patient safety.

Read the 2024 and 2023 RCSEd Patient Safety Surgeons' News articles below.

Past Patient Safety Surgeons' News articles can be found here.

The College has been running this symposium for the last 23 years. This popular event provides opportunity for surgical and dental trainees to present and receive feedback on their audit and quality improvement projects. There is a dedicated patient safety session, incorporating a keynote lecture from an expert in the patient safety field, along with the presentation of a patient safety medal to the trainee delivering the best patient safety presentation. Observations from the 2023 winner, Ronan Lee, can be found here.

Book the 23rd QI & Audit Symposium 2025 here.

The Royal College of Surgeons of Edinburgh is committed to eradicating bullying and undermining from the surgical and dental professions. It is reported that almost a quarter of all NHS staff have experienced harassment, bullying or abuse from colleagues. Not only does this have a devastating impact on individuals and the teams within which they work, but it can have dire consequences for patient care and impact negatively on patient safety. Bullying also drains limited NHS resources, resulting in increased sickness absence, employee turnover, productivity and employment relations.

The RCSEd has run the very successful Let'sRemoveIt campaign since 2017, to reduce bullying and undermining, and its resultant detrimental effect on patient safety, in the surgical and dental workplace. A large range of resources have been developed to help in this area. We have produced a series of Professional Standards we expect RCSEd Fellows and Members to uphold. We have also developed a series of comprehensive resources to help staff and organisations to develop good practice in this area. We work with partners from across healthcare professions to host events, offer advice and other initiatives  aimed at developing practical solutions to address bullying in the medical workplace. such as The College were instrumental in forming the anti-bullying Alliance with other national bodies.

View the Anti-Bullying & Undermining hub here.

All healthcare professionals have a duty to promote a culture that allows staff to raise concerns openly and to take prompt action where patient safety may be compromised. The RCSEd is committed to greater transparency in healthcare and encourages staff to speak up if they have concerns regarding practice that may be detrimental to patient safety. This guide provides advice and support for healthcare workers when speaking up, raising concerns and whistleblowing.

Read the Raising Concerns and Whistle Blowing guide here.

In July 2017, the RCSEd surveyed opinions from a cross-section of the UK surgical workforce which highlighted broad inefficiencies on the frontline which impacted the working environment and delivery of a safe service.

The report noted factors adversely affecting morale, including a lack of team structure, poor communication, high stress levels, and limited training opportunities. The report also recorded how staff, at times, felt diverted away from the patient-centred care they strive to deliver because of administrative and IT issues, and their believe that being more innovative and efficient with existing resources could make a positive difference.

On the basis of this survey, a number of critical recommendations to government were made to improve safety in the delivery of surgical care.

Read the report here.

In 2019, RCSEd carried out a survey which evidenced the extent of non-consultant hospital doctors’ concerns about different aspects of their ability to deliver out of hours care. The RCSEd Trainees' Committee have written a report which uses this survey data and examples of best practice to provide a proactive guideline to support trainee surgeons. The report considers the results of the survey to make recommendations on best practice that will support non-consultant hospital doctors' and protect patients out of hours.

Read the full document here.

The College also recognizes that staff resilience and wellbeing is a major factor in helping to ensure safe patient care and this has been a major recent focus for the College. The College Trainees’ Committee has taken the lead in this and the Patient Safety Group have been proud to support them in this endeavour.

The Committee have run very successful wellbeing weeks over the last five years. These have raised the awareness of the importance of wellbeing amongst all members of the surgical team and included various activities such as daily webinars, virtual workshops and sessions on cooking, mindfulness, yoga, art and how to make work fun. CPD points for the webinars in the series were provided, underlining the importance that the College places on this subject.

The College’s 'Moon and Back’ campaign, launched in 2021, encourages all members of the surgical team to take time out of their busy schedules to focus on their mental health.

Dealing with complications, adverse outcomes and mistakes is widely recognised as a major challenge for all members of the surgical team. Being involved in these events has a significant impact on surgical team wellbeing and mental health. The College provides support for staff through our Team Based Quality Review and Helping Surgeons When Things Go Wrong workshops.

The MacLeod McLaren Medal in Patient Safety is a prestigious new medal that strives to celebrate the efforts of multidisciplinary teams who focus on improving patient safety in either a clinical setting or through research. 

This medal has been made possible by Professor Stephen MacLeod (FRCSEd) who hopes the medal will celebrate the contributions of the lager surgical workforce in improvements of patient safety, and will personally also commemorate those who inspired him, including his Aunts, after whom this medal is named. Read the story behind the MacLeod McLaren Medal here.

The first MacLeod McLaren Medal in Patient Safety will be presented by Professor Rowan Parks, President, at the Triennial and ICOSET Conference in June 2025 and applications are currently open.

The George Gray Youngson Medal is awarded to the highest placed graduate in the Edinburgh Surgery Online MSc in Patient Safety and Clinical Factors. There is no need to apply for this medal as the selection is performance based.

The Fellowship Ad Hominem is awarded by the College Council to Fellows of sister organisations or to current or former practitioners whose professional status is of a high order and who are deemed worthy of the honour. The College Council has awarded this honour to several patient safety advocates in recognition of their highly significant contributions in this field.

CIEHF, the professional body for Human Factors specialists in the UK, has produced a number of resources on human factors in healthcare. Human Factors for Health & Social Care (white paper) sets out three broad principles for developing and delivering sustainable system-level improvements. Healthcare provision should be systems focussed, design led and emphasize improving wellbeing of patients and staff. Developing systems which can support people to have happy working lives can help to deliver a motivated and well-trained workforce. Having these same people working within robust systems; delivering consistently and striving to improve, is the best way to improve performance.

This white paper provides a roadmap for improving fatigue risk management in health and social care to improve patient safety and individual healthcare worker health and wellbeing.

This guidance document outlines eight key human factor principles and methods about use of Artificial Intelligence in healthcare.

The Clinical Human Factors Group is a charitable foundation founded by Captain Martin Bromiley, an Ad Hominem Fellow of the RCSEd, after his late wife died needlessly after a routine operation in 2005. The group works with healthcare professionals, managers and service-users partnering with experts in human factors from healthcare and other industries to campaign for changes in the NHS and healthcare. The group’s vision is of a healthcare system that places an understanding of human factors at the very heart of improving clinical, managerial and organisational practice leading to significant improvements in safety, efficiency and effectiveness.

This important work is being undertaken by the Bournemouth Adverse Events Research Team. This research group was co-founded in 2015 by Mr. Kevin Turner, a Consultant Urologist in Bournemouth and Visiting Professor at Bournemouth University with colleagues in the Psychology Department at Bournemouth University. The group studies the impact of adverse events on surgeons and is developing interventions to lessen that impact.

Find out more here.

CORESS is an independent confidential educational service established in 2005 to promote safety in surgical practice, both within the NHS and in the independent sector. Any surgeon, surgical trainee or member of the theatre staff from any specialty can voluntarily submit reports in confidence via the CORESS website. The case is then reviewed by experts in the appropriate specialty and if useful lessons can be learned an unidentifiable version is published in the surgical literature together with comments from the Expert Advisory Committee. Aiming to educate and avoid blame, CORESS calls on all members of the surgical team to recognise a near miss or adverse event, react by taking action to stop it happening and then report the incident to CORESS so others can learn.

The World Health Organization (WHO), through the World Alliance for Patient Safety and subsequently the Global Patient Safety Collaborative, has ensured that the drive for safer health care is a worldwide endeavour, securing commitment at the highest level from global health leaders. It has provided standards, evidence-based guidance and practical tools to support those involved in the design of national patient safety programmes.

WHO has undertaken a number of key international initiatives in this area. These include Global Patient Safety Challenges, Global Patient Safety Summit series, World Patient Safety Day, Global Initiative for Emergency & Essential Surgical Care and Guidelines for Essential Trauma Care.

Patient Safety: Safe Surgery

WHO World Patient Safety Rights Charter 2024

The Patient Safety Rights Charter was first published by the WHO in April 2024 to promote patient safety rights that are applicable globally. Ten fundamental patient safety rights are outlined. These address healthcare services, including patient access to appropriately trained healthcare workers in appropriate healthcare settings using safe medical products. They also focus on the rights of individual patients, calling for every patient to be treated with dignity, to have access to information supporting shared decision making, and to be engaged with and listened to.

WHO Global Patient Safety Report 2024

The Global Patient Safety Report published in April 2024 was the first-ever report offering a comprehensive overview of patient safety implementation worldwide. It presents the overall burden of unsafe health care practices including the impact on population groups and across different clinical domains. It reviews the progress countries are making worldwide to shape safety in health care through the implementation of policies, strategies, legal frameworks, patient engagement, educational initiatives, and reporting and learning systems.

WHO Second Global Patient Safety Challenge: Safe Surgery Saves Lives 2008

The goal of this initiative was to improve the safety of surgical care around the world by defining a core set of minimum surgical safety standards that could be universally applied across countries, regardless of circumstance or environment.

Four areas were identified in which dramatic improvements could be made in the safety of surgical care: 1) prevention of surgical site infection, through antisepsis and control of contamination; 2) safe anaesthesia, by appropriate patient monitoring and advance preparation; 3) safe surgical teams, by promoting communication and teamwork; and 4) measurement of surgical services, by creating public health metrics to measure basic outcomes of surgical care.

Ten essential objectives for safe delivery of surgical care were identified which formed the basis of a one-page Surgical Safety Checklist to be carried out during surgery, to make care safer worldwide. In addition, a set of five standardized surgical ‘vital statistics’ were developed to facilitate comparison of surgical results across countries. The checklist and surveillance tools were tested at pilot sites in all WHO regions and then disseminated to hospitals worldwide.

WHO Surgical Safety Checklist

The Surgical Safety Checklist was introduced by the WHO in 2008 as part of their Safe Surgery Saves Lives Campaign. It contains 19 items to be read aloud to the whole operating team at three key defined time points during an operation: sign in - when the patient arrives in the theatre complex, time out or surgical pause - immediately before the planned procedure starts and sign out - at the end of the procedure before the patient leaves the operating theatre.

The items are aimed at preventing uncommon but serious errors by reminding the team to confirm patient identity, surgical site, and other important characteristics such as critical stages of the procedure, co-morbid conditions or anticipated complications. They act as a final check of everyone’s understanding of what the team is about to do and help to resolve concerns.

It is important to recognize that the checklist should not simply be a tick-box exercise, but should serve to change the culture in the operating theatre, building greater teamwork and communication, both key to reducing harm.

WHO World Patient Safety Day 

World Patient Safety Day (WPSD) has been celebrated globally each year since 2019 on 17 September. The 2024 theme is "Improving Diagnosis for Patient Safety" with the slogan "Get it Right, Make it safe!". Previous themes include: Engaging Patients in Safety, Medication Safety, Safe Maternal and Newborn Care, and Safe Staff Safe Patients.

Founded in the USA in 1991 and experts in the field of improvement science, IHI works closely with local partners to advance and sustain a total systems approach to safety across entire organizations. Initial focus was on the identification and spread of best practices in healthcare, reducing defects and errors in hospital microsystems. Their highly successful 100,000 Lives Campaign (an 18-month national initiative to drive adoption of six patient safety practices in US hospitals) and 5 Million Lives Campaign (a two-year endeavour that engaged more than 4,000 US hospitals to prevent five million incidents of medical harm), spread best practice changes nationally and helped create an engaged global improvement community. More recently, through their Triple Aim framework, they are working to optimize whole health system performance at a national level.

Patient Safety Champions at every level of healthcare can access an online educational curriculum, community and range of courses through their Open School Programme. A range of training programme are available which are designed to foster collaborative learning and hands on experience to provide practical skills.

The Model for Improvement used in in all IHI’s improvement efforts asks three questions: What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Plan-Do-Study-Act (PDSA) cycles are employed for small, rapid tests of change to assess whether a change leads to improvement. As these small tests are refined and successfully implemented in a particular context, testing is spread and changes scaled up to produce sustainable improvement. Run Charts and Control Charts monitor performance over time. Change bundles - small, straightforward sets of 3-5 evidence-based practices - are developed which, when performed reliably together , improve patient outcomes.

The SMMP, which ran from 2015-2018, functioned to improve, standardize and co-ordinate M&M processes throughout NHS Scotland. This programme developed a Practice Guide and National Training Workshop embedding a basic understanding of clinical human factors to provide skills and support to healthcare staff in the running of effective local M&M reviews. It provided a platform for healthcare teams to share evidence of good practice nationally and advises on IT systems to support the process.

The Scottish Patient Safety Programme, established in 2008, was the first national approach to patient safety improvement in the world. It aimed to fundamentally change healthcare culture to put patient safety at its forefront. The programme was coordinated by Healthcare Improvement Scotland with support from the Institute for Healthcare Improvement and offered a national co-ordinated approach to improve patient safety across all Scottish hospitals, regardless of location, clinician experience, or underlying knowledge.

Engagement from all staff was actively encouraged, with principles of quality improvement being embedded in everyday working to create a culture where patient safety was the responsibility of all frontline staff and not just those with a particular interest. Staff education and training was provided and sharing of knowledge facilitated using biannual nationwide meetings. Resources were provided to all frontline teams in quality improvement methodology. Senior leadership support was ensured by having executive sponsors in each health board to raise the profile of patient safety in organisational culture.

At the time of launch, improving patient safety during surgery was one of the four key workstreams of the programme The five peri-operative drivers for change included: surgical site infection, VTE prophylaxis, antibiotic administration, maintenance of normothermia, blood glucose control, and implementation of the WHO surgical brief, checklist and debrief. The programme has many other key workstreams including leadership walkrounds, ICU daily goals, general ward safety brief, national early warning score, acute kidney injury, and healthcare-associated infections.

This ground-breaking national initiative has delivered clear improvements in healthcare quality across many settings. There has been a change in culture to a patient safety focused system of healthcare.

The GIRFT programme is a national NHS England initiative designed to improve the care of patients through in-depth review of services, benchmarking and presenting a data driven evidence base to support improvement. Clinically led reviews of specialties are undertaken, which combine wide ranging data analysis with input from senior clinicians to evaluate current practice and identify areas for improvement.

HSSIB is a fully independent arm’s length body of the Department of Health and Social Care which investigates patient safety concerns across England to improve care at a national level. They also provide an education programme to NHS England staff to support development and to help embed professional safety investigations across the NHS.

The first NHS Patient Safety Strategy for England was written in 2019 with the three aims: Insight, Involvement and Improvement. It was based on the two strategic foundations of patient safety culture and safety systems. It was updated in 2021 and a strategy is currently being written for primary care.

A number of initiatives have been developed. The Patient Safety Incident Management System (PSIMS), the world’s largest and most comprehensive patient safety incident reporting system, provides valuable insight into the patient safety climate nationally. The Patient Safety Incident Response Framework provides central standardized guidance on how NHS organizations should investigate patient safety incidents. A National Patient Safety Alerts System helps to streamline response to emerging risks, coordinating the outputs of all relevant bodies to ensure clear advice is provided regarding action providers need to take on safety critical issues. A range of Safety Improvement Programmes (SiPs) (e.g. emergency laparotomy collaborative programme) have been developed, delivered by local healthcare providers working within 15 regionally-based Patient Safety Collaboratives and linked to the national team.

A new digital safety learning system has been developed to support learning from what does and does not go well. A new medical examiner system to scrutinize deaths has also been implemented. A process has been created to share insight from litigation and to increase involvement of patients & carers in patient safety improvement. Patient safety specialists have been introduced into every hospital, and a patient safety syllabus for all staff has been established.

PSIRF replaced the Serious Incident Framework (SIF) of 2015 with a contractual requirement for all NHS Trusts in England to transition to the new system by Autumn 2023. This new approach to management of patient safety incidents is based on four principles:

1. Compassionate engagement and involvement of those affected by patient safety incidents.
2. Application of a range of system-based approaches to learning from patient safety incidents.
3. Considered and proportionate responses to patient safety incidents.
4. Supportive oversight focused on strengthening response system functioning and improvement.

The Learn from Patient Safety Events (LFPSE) service is a national NHS system for the recording and analysis of patient safety events that occur in healthcare. By 2023/24 most trusts in England/Wales and NI had this linked to their incident reporting systems such as Datix or Ulysses. LFPSE replaces the National Reporting and Learning System (NRLS) and Strategic transfer of Executive Information System (StEIS). NRLS is still present but no longer receives reports. There is a LFPSE portal for incident reporting allowing external reporting from any source including primary care and patients. The system should allow for big data learning and incorporate AI to theme and share concerns raised at an early date.

Involving patients in their own safety focuses on both empowering patients to speak up and also encouraging them to take control in their own investigations. The IPIPS framework was published in 2021.

Part A: ‘Involving patients in their own safety’.

Part B: ‘Patient safety partner (PSP) involvement in organizational safety’. PSPs will be appointed to various positions and some may be experts in their field. Roles will include:

• membership of safety and quality committees
• involvement in patient safety improvement projects
• working with organization boards to consider how to improve safety
• involvement in staff patient safety training

Read more here.

Martha Mills died in 2021 after developing sepsis in hospital, where she had been admitted with a pancreatic injury after falling off her bike. Martha’s family’s concerns about her deteriorating condition were not responded to, and in 2023 a coroner ruled that Martha would probably have survived had she been moved to intensive care earlier. The implementation of Martha’s Rule in the NHS is taking a phased approach, starting with 143 adult and paediatric acute provider sites who already offer a 24/7 critical care outreach capability. This builds on NHSEs Worry and Concern improvement work and is being implemented alongside the ‘PIER’ resources, introduced to improve the management of deterioration.

The 3 proposed components of Martha’s Rule are:

• All staff in NHS trusts must have 24/7 access to a rapid review from a critical care outreach team, who they can contact should they have concerns about a patient.
• All patients, their families, carers, and advocates must also have access to the same 24/7 rapid review from a critical care outreach team, which they can contact via mechanisms advertised around the hospital, and more widely if they are worried about the patient’s condition.
• The NHS must implement a structured approach to obtain information relating to a patient’s condition directly from patients and their families at least daily. In the first instance, this will cover all inpatients in acute and specialist trusts.

Future NHS is a collaboration web-based platform providing a network of workspaces for those who work in health and care. The platform houses 100s of specialist and sub-specialty areas within health and care, facilitating secure collaboration of people across organizations. It includes one dedicated to patient safety. The platform promotes learning through webinars, sharing of best practice and innovation through fora and shared documents such as policy, guidance and research.

For information on the Syllabus and Curricula, click here.

To Access Training Levels 1 and 2, click here.

The National Patient Safety Syllabus was written by the Association of Medical Royal Colleges (AoMRC) for Health Education England (HEE) in 2021. It was revised the following year, with 5 levels aimed at different health and care staff. It has subsequently been developed into curricula.

At Level 1 and 2 it is delivered through the online platform E-learning for healthcare. Level 1: Essentials is in two parts; the first has been developed for all staff who work in the NHS, the second is aimed at NHS Boards and senior leaders. Level 2: Access to Practice is aimed at clinical staff and those with an interest in patient safety. These can be completed online on demand and take up to an hour each. In addition, further complimentary modules have been developed in specialised areas, for example primary care, maternity or acute care.

Levels 3 and 4 are currently being delivered by Loughborough University. NHSE is funding this for the first cohort of appointed patient safety specialists across England in trusts, independent providers and for those in ICBs. This is blended learning and takes approximately 125 hours plus 6 assignments. Level 5 is yet to be launched.

NELA, commissioned in 2012 by the Healthcare Quality Improvement Partnership, is run by the Royal College of Anaesthetists with input from the Royal College of Surgeons of England. High-quality data from all NHS hospitals in England and Wales that undertake emergency laparotomy is collated and published in order to drive local quality improvement and to provide comparative data at individual hospital level to identify high performing sites and facilitate learning. Information reviewed includes organizational process (e.g. availability of appropriate protocols, resources, personnel and equipment) and key standards of patient care (e.g. early consultant review, documented assessment of operative risk, presence of consultant surgeon and anaesthetist in theatre, post-operative ICU admission for high-risk patients).

NCEPOD is an independent body whose remit is to assist in maintaining and improving the quality of patient care by undertaking confidential surveys and research. The first major NCEPOD report - Who Operates When published in 1996, led to major changes in how and when emergency surgery is provided in the UK, including the establishment of now familiar ‘CEPOD theatres’ to ensure 24-hour theatre availability for emergency care. Examples of other influential surgical NCEPOD audits include Emergency Admissions: A Journey in the Right Direction in 2007 which looked into organizational and clinical aspects of surgical emergency admissions, Knowing the Risk in 2011 which reviewed the peri-operative care of adult patients undergoing in-patient surgery, Treat the Cause in 2016 which looked into acute pancreatitis, Delay in Transit in 2020 looking into Acute Bowel Obstruction, Making The Cut in 2023 which audited Crohn’s Disease management, and Twist and Shout in 2024 on the management of testicular torsion.

The charity Patient Safety Learning (PSL) is an independent voice for improving patient safety. It harnesses the knowledge, enthusiasm and commitment of healthcare organizations, professionals and patients for system-wide improvements and reduction in harm. PSL have developed ‘the Hub’, an award-winning free platform for all with a patient safety interest to share learning, and published a range of influential patient safety standards and support tools. These include A Blueprint for Action which describes the actions needed to make a patient safety future a reality, Mind The Implementation Gap which highlights and offers solutions to the persistence of avoidable harm in the NHS, and a Staff Support Guide describing good practice principles to be followed after serious patient harm.

CPOC is a cross-specialty, multidisciplinary initiative led by the Royal College of Anaesthetists dedicated to the promotion, advancement and development of peri-operative care for the benefit of patients at all stages of their surgical journey. CPOC is a partnership between patients and the public, other professional stakeholders including the Medical and Surgical Royal Colleges and bodies responsible for healthcare in all four devolved UK nations. The RCSEd is proud to be a CPOC Partner and to be represented by our Patient Safety Group Chair on the Board.

CPOC have published a range of valuable guidelines, including the peri-operative management of patients with anaemia, obstructive sleep apnoea, diabetes and frailty, alongside a range of patient education resources covering exercise, nutrition, stopping smoking and reducing alcohol intake. A battery of excellent resources has also been provided on the important area of Shared Decision Making for Clinicians.

Learn more about CPOC here.

CPOC Workforce Position Paper

There is irrefutable clinical, financial and patient associated benefit, for establishing a seamless, joined up perioperative care pathway.

To enable this transformational change in our patient’s surgical journey requires a skilled, motivated and high performing perioperative care team.

CPOC’s new workforce position paper describes strategic detail in 10 themes:

1. Efficiency
2. Working together
3. Activities to assist team-working
4. Culture and behaviours
5. Different staff groups
6. Education - levels of knowledge, skills and experience
7. Commitment to holistic health
8. I.T. systems set up to reduce workload
9. Patient-centred care
10. Leadership and workforce planning

This paper acknowledges the importance of patient-centred care and recognises that health is different from healthcare services. It describes the importance of valuing, educating and supporting every member of staff and of fostering excellent team-working to enable streamlined services. This new approach to the perioperative workforce has elements that may be transferable to other healthcare settings. Read more here.

The original National Safety Standards for Invasive Procedures were published by CPOC in 2015. The standards were revised in 2023 (NatSIPPs2) and are intended to share best practice to support multidisciplinary teams and organisations to deliver safe surgical care. These standards fall into two groups: Organisational Standards provide clear expectations of what health boards and external bodies should dop to support teams to deliver safe invasive care; Sequential Standards focus on the procedural steps that should be taken by individuals and teams for every patient undergoing an invasive procedure.

A free online journal for all interested in surgical safety. 

Access here.

The Academy of Medical Royal Colleges published guidance in 2019 highlighting the benefits of writing outpatient clinical letters directly to patients.

Read the guidance here.

In this video, IHIs Former CEO Don Berwick describes a 2001 report by the Institute of Medicine 'Crossing the Quality Chasm', which laid the foundation for health care reform all over the world.

It was announced in April 2024 that MEs would be introduced as a statutory requirement in England from 9 September 2024. All deaths in healthcare settings not reviewed by the coroner are to be reviewed by a ME. The MEs role is to:

• provide greater safeguards for the public by ensuring independent scrutiny of all non-coronial deaths
• ensure the appropriate direction of deaths to the coroner
• provide a better service for the bereaved and an opportunity for them to raise any concerns to a doctor not involved in the care of the deceased
• improve the quality of death certification
• improve the quality of mortality data