NHS Patient Safety Syllabus
NHS Patient Safety Syllabus
Safety Syllabus
Training for every member of staff across the NHS
3 Foreword
4 Introduction
19 Glossary
22 Acknowledgements
“
CQC welcomes the
development of the patient
safety syllabus and its
curriculum guidance which
represents an opportunity to
“Developing an NHS patient safety syllabus for the NHS is a core
part of the NHS Patient Safety Strategy. The initial training
material (Levels 1 and 2) are now available online and early
evaluations have been extremely positive.
The team at the Academy of Medical Royal Colleges has now
understand the factors that
transformed the remainder of the syllabus into a full set of
are essential foundations of
educational modules (levels 3,4 and 5). This will allow delivery
safety, and will help everyone
to begin in earnest which, alongside an accreditation process,
think differently about how to
will ensure consistent, high-quality patient safety education
provide the consistently safe
and training is provided to the NHS.
care that must underpin all
services in the NHS.” This material, which focusses on both proactive and reactive
approaches to patient safety, alongside key areas like systems-
Victoria Vallance, CQC’s
thinking and human factors, will provide staff with a common
Director of Secondary
set of concepts, helping to create a positive culture of patient
and Specialist Healthcare
safety, and ultimately lead to safer care.”
Dr Aidan Fowler, National Director of Patient Safety,
NHS England and NHS Improvement
Patient safety continues to be a significant These are industries where the use of a systems-
issue in healthcare and a focus of both based approach and the recognition of human
quality improvement and academic research. performance variability have brought safety to
high-risk areas. These industries have long been
The NHS published its first Patient Safety upheld as learning opportunities for healthcare.
Strategy in July 2019 with the development Secondly, and in line with best practices from
of the first NHS-wide Patient Safety Syllabus safer sectors, the syllabus adopts an approach
to support a transformation in patient safety that brings a systems perspective to reactive
education and training in the NHS. The safety methods and – perhaps most importantly
Patient Safety Strategy included ambitions – uses a systems approach to enhance patient
to develop training in the fundamentals of safety proactively. Thirdly, this is the first NHS-
patient safety that would be relevant to all wide patient safety syllabus. The syllabus
NHS staff – clinical and non-clinical – as well consists of five sequential domains, drawn from
as more detailed training and education that developing themes in patient safety, which are
could be incorporated into clinical and outlined in the next section.
non-clinical undergraduate and postgraduate
healthcare education and continuing
professional development.
Human
Systems
Learning factors, human Creating Being
approach
from performance safe sure about
to patient
incidents and safety systems safety
safety
management
The rationale used in developing the domains of the four key themes of the syllabus for those
embodies a spiral of learning, with each domain who choose to develop their expertise further.
building on and deepening the work carried
out in previous domains. The elements of The four key themes of underpinning
underpinning knowledge and expertise fall into knowledge and expertise are:
four key themes that run through each of the
• Systems thinking
domains and, through the unfolding of further
knowledge within each domain, will build to a • Human factors
comprehensive understanding in each area.
• Risk expertise
The syllabus has now been translated into
guidance for training providers to create discrete • Safety culture.
learning modules to form a curriculum. These
will be discrete for the purposes of educational
design, but inevitably the skills in different
domains will integrate in different ways in a
behavioural context depending on the demands
of each situation. From the curriculum, staff
will be able to select those modules of most
significance to their work – perhaps focusing
on systems-based incident review, or on human
factors. The design of the learning modules, and
the incorporation of an ‘Essentials for patient
safety’ module for all staff, will enable staff and
patients to benefit quickly from the clear focus
on patient safety, and inclusion of an ‘Access
to practice’ module provides essential elements
Although elements of each area will be used The following sections take the domains above
in each domain, some domains have a strong and specify the capabilities. Each domain
focus on two or three areas. For example, contains a number of subsections describing
Domain 2 (learning from incidents) draws most key elements and within each subsection are
deeply on expertise in risk and human factors; more detailed capabilities to be attained in
Domain 4 (creating safe systems) draws more building expertise in the area. In addition to the
from systems thinking and safety culture. detailed capabilities, examples are provided of
generic learning and development activities,
The overall structure of the syllabus also focuses themselves divided into those to be delivered
on knowledge, action, and consolidation. in the early part of training and those to be
Domain 1 provides the systems knowledge mastered at a higher level.
which is critical to carrying out the necessary
actions in reactive approaches in Domain 2.
Domain 3 provides the knowledge base for
actions in proactive approaches to patient safety
in Domain 4. Domain 5 draws on all previous
domains to provide the knowledge and tools
that consolidate and maintain patient safety.
Human
Systems
Learning factors, human Creating Being
approach
from performance safe sure about
to patient
incidents and safety systems safety
safety
management
The systems approach to safety Patient safety and its public context
1.1 Has knowledge of national learning reports and can describe key findings
1.2 Has knowledge of essential safety procedures, including reporting, safety alerts and regulatory requirements
1.4 Analyses patient harm levels to evaluate the safety of the area
2.1 Recognises and describes the effect of systems design on risk and safety
2.2 Outlines the principles of direct and latent failures and of performance-influencing factors
2.5 Acts to break the link between error and blame by describing system-induced error in all incident
responses and reports
3.1 Recognises the key principles of Safety-II theory and how they may complement Safety-I
3.2 Encourages anticipation, adaptation, monitoring, and responding, to address existing and developing risks
3.3 Has detailed knowledge of evidence-based interventions in Safety-II and how they apply to
improving patient safety
3.4 Is able to integrate and apply the principles and practices of Safety-II in making direct improvements
in patient safety
4.4 Contributes to sharing lessons learned in patient safety and promotes a learning culture
5.1 Recognises and adopts the 2021 NHS Framework for involving patients in patient safety
5.2 Supports organisation-wide protocols for listening, responding to, and sharing patient-centred information
including those regarding current priorities in patient safety
5.3 W
orks in partnership with patients and carers in key areas of safety where public and patient involvement
improve patient safety, including medication safety, service design, incident reporting and investigations,
and communication
5.4 S upports a culture of patient safety through identifying and sharing examples and evidence of patient safety
improvement through public, patient, and carer involvement
6.1 Aware of, and understands, key concepts and definitions in medical ethics and law and the provisions of
significant legislation including the Health and Social Care Act (2012) and further instruments, Deprivation
of Liberty Safeguards (DOLS), Mental Capacity Act (2005), the Mental Health Act (2007), and equivalent
provisions from devolved legislations
6.2 Explains the ethical and clinical issues involved with patient care, including
the withholding or withdrawal of care, and with the rights of the patient to refuse care
6.3 Complies with legal requirements in patient confidentiality and information governance
6.4 Recognises the legal issues surrounding clinical negligence, compensation, and the accountability of
individual practitioners
6.5 U
nderstands the legal basis of, and requirements relating to, the activities of Coroners, Coroners’ inquests,
medical examiners and related law
7.1 O
utlines and explains key safety recommendations from professional bodies and regulators, including
mandated safety practices
7.2 Ensures that recommendations such as national patient safety alerts are complied with
7.3 Is aware of all indications of patient harm and risk, including incident reporting, complaints and
mortality reviews
7.4 Has full knowledge of the Duty of Candour regulations and how they are to be applied
Human
Systems
Learning factors, human Creating Being
approach
from performance safe sure about
to patient
incidents and safety systems safety
safety
management
Investigating patient
safety incidents
Designing system-based
interventions
1.1 Ensures that a multidisciplinary team with a qualified leader manages the incident investigation
1.3 Creates an evidenced timeline for the patient journey through document review and unbiased data collection
1.4 Uses a systematic approach to identifying causal and contributory factors in analysing incidents
1.5 Where appropriate, uses an understanding of human performance and its variability to describe discrete
care and service delivery problems
2.1 Uses the wider system and context to respond to incident investigations
2.2 U
ses an understanding of each separate care delivery problem to bring about changes in the system which
will prevent future harm
2.3 Uses an awareness of stronger and weaker interventions when developing safety interventions
2.4 Checks the robustness of interventions for the impact on future risk and safety
3.1 E nsures that incident investigations recognise and highlight human contributions to risk and
patient safety incidents
3.2 Applies an understanding of human performance variability as a consequence of systems rather than an
explanation of safety failures
3.4 Builds human performance management explicitly into incident investigation reports
4. Avoiding blame and creating a learning culture through a just culture approach
4.1 Explains how to distinguish between systems-based failures in safety and the contribution of individual staff
4.2 Uses the ‘Just Culture Guide’ (JCG) with each individual failure in a systematic way to challenge and validate
individual behaviours
4.3 Documents and shares the outputs from the JCG with those involved in the incident and the investigation to
ensure complete transparency
4.4 Demonstrates that systems failures identified by the JCG are addressed in the response to the incident
or near-miss
4.5 Uses a knowledge of systems and systems-induced failures to prevent inappropriate blame of staff following
a patient safety incident
Human
Systems
Learning factors, human Creating Being
approach
from performance safe sure about
to patient
incidents and safety systems safety
safety
management
Non-technical skills in
clinical practice
1.1 Outlines and explains the role and effect of humans in complex systems and the fundamentals
of human factors
1.3 Evaluates the key factors that affect human performance and relate them to local work systems
1.4 Demonstrates knowledge of the effect of human factors management in safety-critical industries
2.1 Outlines and explains the psychology of human performance variability and error modes
2.2 Analyses the range of tasks in the work area and evaluates task types as skill, rule, and knowledge-based or
applies other cognitive framework
2.3 Applies a knowledge of performance influencing factors and their effect on human performance
2.4 Evaluates safety-critical tasks where support is required to minimise error and improve quality of patient safety
3.1 Uses case studies to understand the effect of non-technical skills on working practice
3.2 C
arries out evaluation of personal non-technical skills (communication, situational awareness, stress
management teamwork and leadership)
3.3 Outlines and explains the hierarchy gradient and its effects
4.1 Has knowledge of the key principles and methodologies of quality improvement as they relate to healthcare
and evaluates their effect on patient safety
4.2 Can access and apply the evidence-base for quality improvement as it relates to patient safety in healthcare
4.3 Explains the relationship between clinical outcomes and process reliability
4.4 Identifies, maps and monitors safety-critical processes against clinical goals
Human
Systems
Learning factors, human Creating Being
approach
from performance safe sure about
to patient
incidents and safety systems safety
safety
management
Risk evaluation in
clinical practice
1.2 Has knowledge of hazards and risks and uses standard methodology to assess risks to patients
1.3 Applies formal risk analysis using Failure Mode and Effect Analysis (FMEA)
1.4 Identifies proximal and systemic causes of potential failures and develops strategies to address
immediate risks
2.1 Understands and applies process mapping to understand systems and to identify high-level risks to patients
2.2 Applies Hierarchical Task Analysis (HTA) to decompose safety-critical tasks and identify specific task risks
2.3 Takes outputs from mapping techniques to structure improvement programmes in safety and quality
2.4 Uses Hierarchical Task Analysis as a tool to design goal-oriented safe clinical systems
3.2 Outlines and explains checklist design and uses safety checklists appropriately
3.3 Outlines and explains weak and strong interventions in building safety
3.4 Applies the Hierarchy of Control to design and implement effective barriers to patient harm
4.1 Explains the key dimensions of reporting culture, just culture, flexible culture and learning culture
4.2 Applies a safety culture discussion instrument to create dialogue about risk, safety, reporting and learning
Human
Systems
Learning factors, human Creating Being
approach
from performance safe sure about
to patient
incidents and safety systems safety
safety
management
Creating a culture of
patient safety
1.1 Evaluates human factors integration through regular assessment against a formal system review checklist
1.2 Checks safety-critical tasks and provides task support and usable, effective procedures for all staff
1.3 Identifies, supports, and contributes to the design and implementation of safety-critical handovers
and communications
2.1 Understands and uses clinical governance meetings to review risks and identify residual (uncontrolled) risks
2.2 Justifies and applies the risk management strategies of eliminate, avoid, transfer, mitigate, contain, or accept
2.3 Populates the risk register with current and residual risks
2.4 Escalates uncontrolled risks to the next level of the risk hierarchy and monitors response
3.1 Fosters an open, multi-professional approach to patient safety using both reactive and proactive methods
3.2 Develops or adopts techniques such as Proactive Risk Management in Healthcare (PRIMO), sharing lessons
learned or the use of huddles as cultural interventions
3.3 Uses case studies from healthcare and other industries to ensure a continuing focus on safety management
3.4 Promotes the principle of measuring and monitoring patient safety, such as the Health Foundation’s
Measurement and Monitoring of Safety
4.1 B
uilds a safety case with defined scope, an evaluation of safety level, description of risks, risk control
measures and residual risks
4.2 Applies the safety case as a tool to measure and monitor safety
4.3 Uses the safety case to address residual risks through improvement activities
4.4 Develops the use of safety case as a tool in governance and regulatory compliance
Glossary
Capability Hierarchy gradient
The ability and confidence to use and Perceived difference in authority between
develop skills and attributes in complex junior and senior staff; often responsible for
and changing circumstances lack of communication in safety
Situational awareness
The perception of environmental elements and
events, the comprehension of their meaning,
and the projection of their future status.
Or, ‘knowing what is going on around you’
Systems approach
Recognition that the performance of an
enterprise depends on a dynamic and inter-
related set of parts; the focus on systems as
a route to safety and productivity
Systems expertise
An understanding and application of systems
thinking when applied to improvement in an
organisation
Task analysis
Analysis of how a task is accomplished,
including any sub-tasks, preconditions and the
range of factors affecting each step or element
in the system
Task support
Provision of systematic help for the user in
carrying out tasks, often taking the form of
visual guides, flowcharts etc
We would like to acknowledge the support and guidance offered by members of the
following organisations represented on our Advisory Group.
Telephone: +44 (0)20 7490 6810 Authors: Professor Peter Spurgeon and
Dr Stephen Cross on behalf of the Academy
Website: aomrc.org.uk of Medical Royal Colleges