NPC Archive Item: Training Programme to Improve the Safety of Patients

NOTE – This is an archive post from the NPC and has not been updated since first publication. Therefore, some hyperlinks may no longer be working.

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The National Patient Safety Agency (NPSA) has recently launched a Foresight Training Resource Pack to improve the safety of patients treated in the NHS. It covers many areas of patient safety including medicines management topics such as:

  • Incorrect administration of medicines
  • Missed doses
  • Management of LTCs in the community
  • Nurse prescribing
  • Multiple prescriptions

The aim of the Foresight Training programme is: “to help healthcare staff develop and practice the skills needed to identify situations when a patient safety incident is more likely to occur” and the resource pack has been developed to:

  • Improve the awareness of nurses and midwives to the factors that increase the likelihood of patient incidents
  • Increase local learning through sharing experiences
  • Improve understanding of “risk prone situations”.
  • Improve understanding of situations that could be considered as a near miss

The Foresight Training tool provides guidance for a range of healthcare staff such as nurses, midwives, risk managers and ward managers to facilitate a Foresight Training session. The training consists of a number of scenarios relating to staff in primary care, acute care and mental health settings. The scenarios raise the awareness of participants to the factors that lead to a patient safety incident. Some of these scenarios focus on key areas of patient safety relating to medicines management.

Although the training is primarily for nurses and midwives working in primary care, acute care and mental health settings it can be adapted for use in other settings and with other healthcare professionals. It is designed for flexible training so that it can be delivered at team meetings, handovers and mandatory training sessions.

What is the background to this?
A patient safety incident is any unintended or unexpected incident which could have had the potential to harm or did harm one or more patients1. The Foresight Training programme is based on a model developed by Professor James Reason (2004)2 called the ‘three bucket model’. Reason states that healthcare staff can avoid patient safety incidents through evaluating three aspects of the job they are undertaking:

  • How safely they are working
  • The context they are working in
  • The task being carried out


  • The Foresight Training Pack provides guidance for health care professionals to facilitate a Foresight Training session
  • Foresight involves frontline healthcare staff recognising the potential safety risks in the healthcare system, and considering intervening to prevent an incident
  • The training is primarily for nurse and midwives working in primary care, acute care and mental health

So what?

  • The training is designed to enable frontline healthcare professionals to recognise error-prone situations, thereby minimising the likelihood of a patient safety incident occurring.
  • The sections that focus on medicines should lead to safer medicines management for patients.
  • The training also provides staff with the opportunity to talk about their own experiences, where they have used foresight or instances where foresight could have been used.

If you are involved in training front-line healthcare professionals in the medicines management aspect of patient safety, the following scenarios from the Foresight Training Resource Pack could be helpful to you:

Reflection on action – paper-based scenarios
1. The hydralazine/hydroxyzine confusion
3. Incorrect administration of morphine
6. Failure to administer insulin on a home visit

Spot the difference – video-based scenarios
1. Management of diabetes in the community
2. Nurse prescribing in primary care

Garden path – video-based scenarios
3. Dual prescription for a mental health patient

Item details
Foresight Training Resource Pack, National Patient Safety Agency, March 2008.

1. National Patient Safety Agency. Foresight Training Resource Pack – Introduction to Foresight and Foresight Training. March 2008
2.The three bucket model for assessing risky situations, Reason 2004

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