Frequently asked questions

What is Sign up to Safety?

Sign up to Safety is here to help NHS staff and organisations achieve their patient safety aspirations and care for their patients in the safest way possible.

Ours is a joyful, trusting, open and optimistic approach to patient safety improvement; empowering and enabling our members to make the changes they want to see in their work. We see each day and every action as an opportunity to learn and improve and we welcome everyone who wishes to get involved.

We want our members to feel that they have the power to make a difference; acknowledging that those who work closest to patients know best what needs to happen to reduce avoidable harm and save lives.

Our role is to help them create a positive and strong safety culture that will stand the test of time. We do this by celebrating progress and providing practical support and guidance through digital channels and social media, making it quicker and easier for our members to find what they need to know, to be inspired and motivated to keep going.

Each organisation or person signed up commits to make five safety pledges:

  1. Put safety first – Committing to reduce avoidable harm in the NHS by half through taking a systematic approach to safety and making public your locally developed goals, plans and progress. Instilling a preoccupation with failure so that systems are designed to prevent error and avoidable harm.
  2. Continually learn – Review your incident reporting and investigation processes to make sure that you are truly learning from them and using these lessons to make your organisation more resilient to risks. Listen, learn and act on the feedback from patients and staff and by constantly measuring and monitoring how safe your services are.
  3. Be honest – Being open and transparent with people about your progress to tackle patient safety issues and supporting staff to be candid with patients and their families if something goes wrong
  4. Collaborate – Stepping up and actively collaborating with other organisations and teams; sharing your work, your ideas and your learning to create a truly national approach to safety. Working together with others, joining forces and creating partnerships that ensure a sustained approach to sharing and learning across the system.
  5. Be supportive – Being kind to your staff, helping them bring joy and pride to their work. Being thoughtful when things go wrong; helping staff cope and creating a positive just culture that asks why things go wrong in order to put them right. Giving staff the time, resources and support to work safely and to work on improvements. Thanking your staff, rewarding and recognizing their efforts and celebrating your progress towards safer care.

What does Sign up to Safety mean?

Sign up to Safety and its mission are bigger and much more important than any individual’s or organisations’ programmes or activities. We are establishing and delivering a single vision for the whole NHS in England to become the safest healthcare system in the world. This means taking all the patient safety activities and programmes that organisations currently own and aligning them with this single common purpose.

Who can sign up to the campaign?

Sign up to Safety is for everyone, everywhere. Whether you work in primary, secondary, or tertiary care; whether you work in acute, mental health, learning disabilities, ambulance, or community care settings; whether you work in a national body or a general practice, Sign up to Safety applies to you.

Since launching in June 2014 organisations representing CCGs, acute trusts, mental health trusts, ambulance trusts, Royal Colleges and academic institutions are signed up and working proactively on prioritising safe care every day.

What do we ask ourselves at Sign up to Safety?

We shape our work around the following key questions, which help us remain open to learning;

  1. How can we create lasting change and a future where patients and those who care for them are free from avoidable harm? Could we create the conditions necessary for safer patient care together?
  2. How can we create a safety culture that leads to lasting change? If we create a culture where staff and patients are treated with empathy and kindness when things go wrong could we learn more about what we can do differently to make care safer?
  3. What if the solutions and proven interventions exist already? If we can help people with implementation of evidence based interventions and tools will we inspire and motivate people to keep going?
  4. Can we shift improvers from uni-disciplinary approaches focussing on individual safety topics to working inter-professionally and on increasing the reliability of the fundamentals e.g. communication, deterioration? Would tackling these make more of an impact?
  5. Could we approach capturing data, learning from incidents and investigations differently? If we do this will we move away from the culture of blame and fear and actually prevent things from going wrong in the future?
  6. Could we make a positive impact on the safety culture by focusing on helping people speak out, listen and observe what is going on beneath the surface? By placing importance on developing the right conditions to speak and listen, can more be uncovered and understood about what leads to unsafe care?

Why is Sign up to Safety necessary?

Staff in the NHS care deeply about the care they provide and they all want to provide safe and effective care.

However, we know that human error occurs in healthcare, as it does in all walks of life.  Therefore people make mistakes.  We are working with hundreds of organisations from across every healthcare setting in England helping galvanise the patient safety field to move forward over the next fifteen years with a unified view of the future of patient safety to create a world where patients and those who care for them are free from avoidable harm

Healthcare is high risk and mistakes can happen. Only safe healthcare services are truly efficient, effective and able to offer the best experience – patient safety is the organising principle of the high quality healthcare we all want to provide. Sign up to Safety is helping the NHS to make improvements and create a supportive, open and transparent environment for their patients and staff.

What can we do to make care safer?

There are numerous interventions that make care safer.  Safe care is reliant on successful adoption and implementation of these interventions.

What is the current problem with implementation?

Implementation is complex.  When we normally talk about implementation, we often use phrases such as carry out, realise, bring about, launch, etc. Implementation is a specified set of activities designed to put into practice an activity or program or solution.  In the NHS we introduce and put new ideas into use and practice all the time.

Implementation is not a one-off event.  The implementation process starts with someone having an idea about a new method that can be used to meet a need or solve a problem. The idea may originate in the organisation where the need arose or outside of the organisation where external view has identified a need and a solution.

The idea is presented and a decision is taken, normally on a high level within the relevant organisation. Once decided the next stage is dissemination and adoption which includes the key steps of planning, preparation and application of the solution or activities needed to achieve the sought–after change.

Once the new method has been adopted from both a practical and organisational point of view, it is then evaluated and any necessary local adjustments are made, it is then integrated or assimilated to the local context.

Finally, the method is considered institutionalised, embedded or sustained, if it is taken for granted or is the ‘way we do things’ regardless of reorganisations, personnel turnover and political changes.

Although there have been huge strides in patient safety made over the last fifteen years, there is still a gap between how safe we all want care to be, and what is achieved in practice each and every time in a highly complex and evolving system.

The issues include:

  • Failing to appreciate the complexity of a problem
  • Strategies that sound like solutions but still haven’t been worked out, so are really unsolved problems e.g. change the culture, sort out team work
  • The intervention may commonly be implemented inadequately
  • The intervention requires much more effort or expertise than generally recognised
  • There are competing priorities

Implementation research has identified the common factors or components that have significant bearing on the success or failure of implementation.  These include:

  • The recognition that there is an explicit need for change and the solution and that the proposed method is the right one in the context
  • There are visible benefits
  • The solution is in line with the norms, values and working methods of the individuals, teams or organisation implementing it
  • The solution is easy to use and it can be tested on a small scale
  • It can be adapted to the needs of the recipient and the context
  • Finally, it gives rise to knowledge that can be generalised to other contexts

A dilemma in the patient safety field is that it often takes a long time to see the benefits of a new method.  To achieve widespread dissemination, a method for improving the safety of patient care must therefore be better, preferably much better, than any competing methods and liked by the end users / practitioners so that they influence their colleagues to change.

What is Sign up to Safety actually doing?

Sign up to safety is building capability and enthusiasm for patient safety. Sign up to Safety is harnessing the commitment of staff to make care safer. The campaign is bringing to life the recommendations of the Berwick Advisory Group report and, alongside several other initiatives, aims to make the NHS in England the safest healthcare system in the world.

There are many pockets of individual excellence (individual teams or units or areas) right across the country. We are helping hundreds of participants to share what does and doesn’t work when it comes to implementation across our community, while ensuring those at the front-line still own the change and improvement that is key to a safer NHS.

Over the last year, organisations signed up to the campaign have brought their pledges to life in a myriad of exciting ways. From creating learning events for staff and patients through to awarding incident reporting. Our recent birthday celebrations showed many examples of organisations adopting this positive and open approach.

Each participant organisation has created a bespoke and tailored safety improvement plan which sets out what they want to prioritise over the next three to five years to improve safety in their organisation. Their safety improvement plan is based on their own data, what has worked over the last three years and what they want to do differently over the next three to five years. This local ownership is creating a strong connection between frontline staff, delivery and improvement.

We are also advocating an approach to safety which is about ‘stopping stuff’ and ‘thinking differently’ about the subject – our aim is to influence across the system to stop doing things that are not working and to rethink how we can do it better – so that we move from Safety I to Safety II – we think there is a transition phase between I and II and again are setting out a think piece on this.

The campaign is also one of the levers for change – we use the extrinsic levers of energising, motivating, rewarding, valuing and supporting to achieve three key things;

  1. improved learning and sharing
  2. just culture for safety to enable staff to be supported to speak out
  3. improving the timeliness and effectiveness of implementation of safer practices

Another lever also linked to the campaign is the incentive scheme owned by the NHS LA.

What is a just culture?

A just culture is one where:

  • People who make an error (human error) are cared for and supported
  • People who don’t adhere to policies (risky behaviour) are asked first before being judged
  • People who intentionally put their patients or themselves at risk (reckless behaviour) are accountable for their actions

The just culture is also reliant on the use of design – so that we design out the error producing conditions and support humans to get it right.

The just culture is reliant on a preoccupation with failure – to create a resilient system so we are adaptable and prevent the little things getting bigger.

Why is there a need for a just culture?

“The single greatest impediment to error prevention is that we punish people for making mistakes” Dr Lucian Leape, 12 October 1997

Systems need to be designed to take into account that the best people can make the worst mistakes; that systems will never be perfect and humans will never be perfect.  If we accept and expect this then we can design our systems to try to make mistakes impossible.

We need a just culture so that staff are able to speak out without fear of retribution and therefore we are able to maximise the ability to learn from when things go wrong.

How is Sign up to Safety helping improve the culture of the NHS?

All organisations which have joined Sign up to Safety so far are united in their common goal; to create the right culture where staff and patients can feel supported and listened to when things go wrong and are able to speak out when they are concerned about safety, so that we can learn about what we can do differently to make care safer.

Those taking part in the campaign gain the opportunity to celebrate their progress and share their passion, knowledge and experience in patient safety with others, to help create broad-based learning that’s shared throughout the NHS.

How is Sign up to Safety helping to create a culture of continuous learning?

Over the last fifteen years in the patient safety field there has been a lot of guidance (alerts, solutions, interventions, standards) for those that work in healthcare  to help them ‘make care safer’.

Many of us have tried to realise ideas and introduce new methods, but after a while we have been forced to admit that things didn’t turn out as we had originally intended and planned.

Sign up to Safety is proactively exploring the subject of implementation with our community, topic experts and expert practitioners in delivery of healthcare through webinars and learning events.

Our hope is that we will increase our understanding and knowledge in this area and over the course of the campaign, acquire new knowledge about how we can facilitate learning.

Sign up to safety is developing a learning methodology for implementation of safer practices to help create the ‘culture of learning and continuous improvement’.

What is different about Sign up to Safety from previous campaigns?

What is unique and fundamentally different is that this campaign is about bottom up, locally owned change and it is for everyone. It transcends organisational boundaries and aims to align the whole system to achieving our shared ambition. There are no mandatory interventions, targets or ‘performance management’ from the centre – the energy, ideas and expertise are being found deep inside the NHS and within each organisation.


It is also urging a move forward in how we approach patient safety. Over the last 15 years, there has been a persistent failure to learn from mistakes and incidents and we know that while many of the interventions that can make care safer already exist, there is a known gap between this evidence and every day practice.

The campaign is encouraging participants to move beyond just a focus on single areas of harm and shift efforts to also addressing the myriad of contributory factors that impact on safety every day; communication failures, the availability and the design of the right equipment, inexperience, stress, attitudes and relationships, and the way we observe patients and use information. All of these impact on safety and apply across the NHS from secondary to primary, acute to community, hospital to GP practice, board to ward.

How much is Sign up to Safety costing?

Patient safety is the organising principle of high quality healthcare; only safe healthcare services are truly efficient, effective and able to offer the best experience to patients and carers. A focus on patient safety can offer the best and practical solution to building a healthcare system which is financially sustainable and able to offer the best Patient outcomes and experience.  The cost of the campaign is around 900k per year with 4.5 WTE staff.

How many lives have been saved so far by Sign up to Safety?

Sign up to Safety was launched with an aspirational aim.  The shared aim across the NHS in England is of a reduction of harm by half and saving 6000 lives.  The campaign’s contribution is through the implementation of locally owned, self-directed safety improvement. These local safety improvement plans are owned by those delivering care locally, and so the impact of the implementation can only be measured at a local level. Each local organisation is measuring their local implementation to judge local impact, in a way that is meaningful for them, using data to expand their understanding of the work underway in their specific projects. There are a number of additional reasons measuring at a national level would be inappropriate;

  • Sign up to Safety is just one of a set of initiatives to help the NHS improve the safety of patient care including; the Patient Safety Collaboratives, the Q initiative and the work of the national patient safety leadership team. This combined programme has a shared cause of saving lives and reducing avoidable harm. Measuring each in isolation would not be possible. For more information about measuring mortality see Hogan (BMJ Q&S, October 2015).
  • Measuring mortality is not the only way to demonstrate improved safety; there are multiple qualitative and quantitative measures that show impact.  For example see our library of free webinars where members share their stories, which in itself is a way to measure.
  • The Sign up to Safety team will be creating an evaluation document that shares what we’ve learned about campaigning, engagement and motivating to help people feel valued and supported in a challenging healthcare environment.

Is our healthcare system not already safe?

Over a million patients are cared for in the NHS each day and the vast majority of care experienced by patients is high quality and safe. Patient Safety is a worldwide issue with research studies demonstrating that on average one in ten patients are subjected to avoidable harm.

Patient safety issues are the avoidable errors in healthcare that can cause harm to patients.  Not all harm is avoidable. Some treatments or drugs are even expected to cause harm, such as chemotherapies or certain drug therapies.

Those working with patients are human and so mistakes can happen.  Sign up to Safety is helping organisations tackle the causes of errors in care that can come from badly designed systems or as a result of the lack of awareness of what can make a difference amongst those delivering care – these errors are avoidable and steps can be taken to reduce them.

A critical step is to ensure our healthcare system is safe for staff as well as patients, by creating an open environment where all feel safe to discuss errors, confident that lessons will be learned.

It is important to remember that making care safer is a challenge shared by all advanced healthcare systems across the world. With the NHS, a unified system, we have a unique opportunity to spread continuous learning.

Resources include the extrinsic motivational factors (professional regulation and organisational regulation, alerts, guidance, standards, policy and legislation, financial incentives such as that of the NHS LA, constitution, embracing the just culture by leaders and HR teams), intrinsic motivational factors (values, behaviours, reward, recognition, knowledge, learning, sharing).

How does Sign up to Safety align with other patient safety programmes and initiatives?

The key components of the coordinated national programme for improving patient safety in England are:

  • National leadership through the national patient safety team (moving to NHS Improvement under the leadership of Mike Durkin)
  • Learning from incidents and improved incident investigation via the National Reporting and Learning System and the  new Independent patient safety investigation service under the leadership of Mike Durkin
  • Creating a culture of safety via Sign up to Safety: engaging, energising and mobilising across the whole of the NHS in England to improve patient safety and the safety culture locally and share learning.  The campaign was launched to run over three years
  • Collaboration through the fifteen patient safety collaboratives sited in each Academic Health Science Network; teams of people who will take on intractable problems and find out how they can be solved and develop the right solutions or safer practices e.g. medication safety, pressure ulcers, and falls.  The programme will run over five years
  • Building individual capability and a network of quality improvers via the Q initiative – a partnership with The Health Foundation to create 5000 quality improvers over the next five years
  • Buddying through the five organisations that will be supported by staff from the Virginia Mason Institute (US) who will spend time in the five trusts over the course of the next five years helping the doctors, nurses and leaders figure out how they can improve using the tools developed in Seattle. The programme will run over five years and set five NHS trusts on the road to becoming leading healthcare institutions, at the same time sharing learning and benefitting the NHS as a whole
  • Patient safety and education via Health Education England and the Patient Safety Commission including leadership and human factors
  • Patient safety standards and regulation via the professional and organisational regulators and inspections