Professor Rob Galloway is an Emergency Medicine Consultant at University Hospitals Sussex and Honorary Clinical Professor at Brighton and Sussex Medical School. He is dual-trained in Emergency Medicine and Intensive Care Medicine, though now works exclusively in the Emergency Department—largely because his attention span is better suited to the pace and unpredictability of A&E. For over 15 years, he has delivered nationally recognised Human Factors training and is an Ambassador for the Clinical Human Factors Group. He has led multiple projects to improve patient safety, including the development of widely used clinical prompt cards, and is the Medical Lead for HealthRota, an electronic rostering system designed to improve both safety and staff well-being. He also serves as medical advisor to Brighton & Hove Albion Football Club and is a columnist for the Daily Mail, helping to translate complex medical issues for a broader public audience. Under the pseudonym Dr Nick Edwards, he is the author of In Stitches: The Highs and Lows of Life as an A&E Doctor which shows an honest insight into life on the NHS frontline. He has co-written textbooks on critical appraisal as well as numerous research papers. He was once named one of the HSJ’s wildcard top ten most influential people in the NHS—though has had virtually no influence since—and was made a Member of the Order of St John, although he suspects the Queen was probably misinformed when bestowing this award.Miss Eleanor Crossley is currently an ST7 Specialist Registrar in Otolaryngology in the South London Deanery and was the President of the Association of Otolaryngologists in Training (AOT) in 2024–25. She graduated from the University of Birmingham Medical School, where she also completed a BMedSci Intercalated degree in Public Health and Population Sciences. She continues her involvement in various research projects and medical education and has a long-standing interest in global health and charity work. Dr Mitul Patel is an Anaesthetic Registrar in South London with interests in medical education and multidisciplinary simulation-based teaching.Dr Chloe Rutherfoord is a Paediatric Registrar in the Department of Paediatrics at University Hospitals Sussex NHS Foundation Trust, Brighton.Melanie Whitfield is a Registered Midwife in the NHS with over 25 years’ experience in clinical care, including more than 10 years in senior leadership roles at Trust-wide level. In 2023, Melanie completed her fellowship with the internationally recognised Patient Safety Movement Foundation. She also holds a Master’s degree in Patient Safety and is a recognized leader in patient safety, clinical governance and risk management. Melanie currently holds the roles of Associate Director of Patient Safety, Clinical Governance and Risk Management and Trust Patient Safety Specialist at an NHS Trust in southwest London. Melanie is committed to fostering a culture of constructive challenge, promoting reflective learning, and creating safe spaces for honest dialogue, improvement and continuous learning. She works alongside clinical teams to co-design patient-centred care, placing patients, families and caregivers as active partners in improving safety and quality in healthcare. Melanie is passionate about growing a culture where patient safety is everyone’s business.

• 1 Introduction 2 Why errors happen 3 Decision making 4 Situational awareness 5 Checklists/prompt cards 6 Leadership and followership 7 Communication 8 Human Factors and ergonomics 9 The culture needed to improve patient safety 10 Human Factors in simulation 11 Escalating acute deterioration 12 Investigating incidents 13 Afterword—why Human Factors matter

Professor Rob Galloway is an Emergency Medicine Consultant at University Hospitals Sussex and Honorary Clinical Professor at Brighton and Sussex Medical School. He is dual-trained in Emergency Medicine and Intensive Care Medicine, though now works exclusively in the Emergency Department—largely because his attention span is better suited to the pace and unpredictability of A&E. For over 15 years, he has delivered nationally recognised Human Factors training and is an Ambassador for the Clinical Human Factors Group. He has led multiple projects to improve patient safety, including the development of widely used clinical prompt cards, and is the Medical Lead for HealthRota, an electronic rostering system designed to improve both safety and staff well-being. He also serves as medical advisor to Brighton & Hove Albion Football Club and is a columnist for the Daily Mail, helping to translate complex medical issues for a broader public audience. Under the pseudonym Dr Nick Edwards, he is the author of In Stitches: The Highs and Lows of Life as an A&E Doctor which shows an honest insight into life on the NHS frontline. He has co-written textbooks on critical appraisal as well as numerous research papers. He was once named one of the HSJ’s wildcard top ten most influential people in the NHS—though has had virtually no influence since—and was made a Member of the Order of St John, although he suspects the Queen was probably misinformed when bestowing this award.Miss Eleanor Crossley is currently an ST7 Specialist Registrar in Otolaryngology in the South London Deanery and was the President of the Association of Otolaryngologists in Training (AOT) in 2024–25. She graduated from the University of Birmingham Medical School, where she also completed a BMedSci Intercalated degree in Public Health and Population Sciences. She continues her involvement in various research projects and medical education and has a long-standing interest in global health and charity work. Dr Mitul Patel is an Anaesthetic Registrar in South London with interests in medical education and multidisciplinary simulation-based teaching.Dr Chloe Rutherfoord is a Paediatric Registrar in the Department of Paediatrics at University Hospitals Sussex NHS Foundation Trust, Brighton.Melanie Whitfield is a Registered Midwife in the NHS with over 25 years’ experience in clinical care, including more than 10 years in senior leadership roles at Trust-wide level. In 2023, Melanie completed her fellowship with the internationally recognised Patient Safety Movement Foundation. She also holds a Master’s degree in Patient Safety and is a recognized leader in patient safety, clinical governance and risk management. Melanie currently holds the roles of Associate Director of Patient Safety, Clinical Governance and Risk Management and Trust Patient Safety Specialist at an NHS Trust in southwest London. Melanie is committed to fostering a culture of constructive challenge, promoting reflective learning, and creating safe spaces for honest dialogue, improvement and continuous learning. She works alongside clinical teams to co-design patient-centred care, placing patients, families and caregivers as active partners in improving safety and quality in healthcare. Melanie is passionate about growing a culture where patient safety is everyone’s business.

• 1 Introduction 2 Why errors happen 3 Decision making 4 Situational awareness 5 Checklists/prompt cards 6 Leadership and followership 7 Communication 8 Human Factors and ergonomics 9 The culture needed to improve patient safety 10 Human Factors in simulation 11 Escalating acute deterioration 12 Investigating incidents 13 Afterword—why Human Factors matter

Professor Rob Galloway is an Emergency Medicine Consultant at University Hospitals Sussex and Honorary Clinical Professor at Brighton and Sussex Medical School. He is dual-trained in Emergency Medicine and Intensive Care Medicine, though now works exclusively in the Emergency Department—largely because his attention span is better suited to the pace and unpredictability of A&E. For over 15 years, he has delivered nationally recognised Human Factors training and is an Ambassador for the Clinical Human Factors Group. He has led multiple projects to improve patient safety, including the development of widely used clinical prompt cards, and is the Medical Lead for HealthRota, an electronic rostering system designed to improve both safety and staff well-being. He also serves as medical advisor to Brighton & Hove Albion Football Club and is a columnist for the Daily Mail, helping to translate complex medical issues for a broader public audience. Under the pseudonym Dr Nick Edwards, he is the author of In Stitches: The Highs and Lows of Life as an A&E Doctor which shows an honest insight into life on the NHS frontline. He has co-written textbooks on critical appraisal as well as numerous research papers. He was once named one of the HSJ’s wildcard top ten most influential people in the NHS—though has had virtually no influence since—and was made a Member of the Order of St John, although he suspects the Queen was probably misinformed when bestowing this award.Miss Eleanor Crossley is currently an ST7 Specialist Registrar in Otolaryngology in the South London Deanery and was the President of the Association of Otolaryngologists in Training (AOT) in 2024–25. She graduated from the University of Birmingham Medical School, where she also completed a BMedSci Intercalated degree in Public Health and Population Sciences. She continues her involvement in various research projects and medical education and has a long-standing interest in global health and charity work. Dr Mitul Patel is an Anaesthetic Registrar in South London with interests in medical education and multidisciplinary simulation-based teaching.Dr Chloe Rutherfoord is a Paediatric Registrar in the Department of Paediatrics at University Hospitals Sussex NHS Foundation Trust, Brighton.Melanie Whitfield is a Registered Midwife in the NHS with over 25 years’ experience in clinical care, including more than 10 years in senior leadership roles at Trust-wide level. In 2023, Melanie completed her fellowship with the internationally recognised Patient Safety Movement Foundation. She also holds a Master’s degree in Patient Safety and is a recognized leader in patient safety, clinical governance and risk management. Melanie currently holds the roles of Associate Director of Patient Safety, Clinical Governance and Risk Management and Trust Patient Safety Specialist at an NHS Trust in southwest London. Melanie is committed to fostering a culture of constructive challenge, promoting reflective learning, and creating safe spaces for honest dialogue, improvement and continuous learning. She works alongside clinical teams to co-design patient-centred care, placing patients, families and caregivers as active partners in improving safety and quality in healthcare. Melanie is passionate about growing a culture where patient safety is everyone’s business.

• 1 Introduction 2 Why errors happen 3 Decision making 4 Situational awareness 5 Checklists/prompt cards 6 Leadership and followership 7 Communication 8 Human Factors and ergonomics 9 The culture needed to improve patient safety 10 Human Factors in simulation 11 Escalating acute deterioration 12 Investigating incidents 13 Afterword—why Human Factors matter