Occupations and Terms of Reference › Patient safety officer
Universal terms of reference · POS-026 · version 1.0 · status: draft · next review 2027-10-27
Patient safety officer
To lead patient safety work across services, so that harm is reduced, incidents are learned from, and staff are supported to report.
Each part of this page links to the related trainings, competencies and policies. The links are the same for every facility, so an organisation can see at a glance what a role requires and what it is trained in.
Job description
Job summary. You lead patient safety. You review incidents, coordinate learning, support safety improvement projects, and make sure staff can report safely and see what changes as a result.
Reports to: Quality manager.
Leads or supervises: Incident reporting coordinator.
What you do on a typical day
- Review new incidents and check immediate safety actions.
- Lead incident reviews and learning sessions.
- Track safety improvement actions.
- Support staff who report concerns.
- Report safety trends to the quality committee.
Working conditions and demands
- Works closely with clinical teams during incidents.
- Must be calm and fair under pressure.
- Handles confidential information.
What good looks like
- Incidents are reviewed promptly.
- Learning reaches the ward or clinic.
- Staff feel safe to report.
Place in the organogram
Reporting line, from the top: see the organogram on the Occupations page. The lines above and below this role are listed in section 3.
1. Golden rules
These rules apply in every setting.
- Every decision that affects patient safety is made on evidence and recorded.
- Quality means the patient's experience as well as the clinical result; both are measured.
- Problems are reported early and without blame, and learned from.
- Standards are followed the same way on every shift and at every site.
- Every staff member can raise a concern without fear of reprisal.
- Improvement work is planned, measured and kept going until it is embedded.
- Data is used to improve care, and is protected while it is used.
- Where a standard cannot be met, the gap is recorded and escalated the same day.
2. Identification
| Item | Detail |
|---|---|
| Position code | POS-026 |
| ISCO-08 | 2221 (skill level 4) |
| ESCO | to map |
| Department | Quality and safety |
| Facility types | Hospital, Ambulatory, Transport, Medevac, Fitness, Aesthetic |
3. Reporting line and working relationships
Reports to: POS-024. Supervises: POS-036.
| Works with | Nature of the relationship |
|---|---|
| Quality manager | Safety improvement plan. |
| Risk manager | Risk register links. |
| Chief quality and safety officer | Serious incident reviews. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Incident review | Reviews incidents promptly and leads investigations where needed. | Reviews completed within policy timeframe | Monthly | C-01 | T-05 | POL-INC | 2 |
| Learning | Turns incident learning into changes on the ground. | Learning actions recorded and checked | Monthly | C-02 | T-05 | POL-INC | 2 |
| Safety culture | Supports staff who report, and makes sure reports are handled fairly. | No reprisal substantiated; reporting rates reviewed | Quarterly | C-03 | T-08 | POL-WHISTLE · POL-SAFEG | 2 |
| Safety reporting | Reports safety trends to the quality committee. | Trend report issued quarterly | Quarterly | C-02 | T-05 | – | 2 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Immediate safety actions after an incident | Serious harm or patient death (CQO and medical director) |
| Scope of incident investigations within policy | Harm events that need external reporting (quality manager and CQO) |
| Immediate safety measures for a reported event |
6. Qualifications and experience
| ID | Qualification | Mandatory | Validity |
|---|---|---|---|
| Q-01 | Degree in nursing, medicine or a patient safety related field | Yes | Lifetime |
| Q-02 | Patient safety or incident investigation qualification | Yes | Lifetime |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Patient safety, incident investigation or clinical quality experience | 5 | Yes |
7. Training requirements
Recommended common practice. Each facility adapts the list to its national law. Essential items apply in every setting; recommended items apply where resources allow.
| ID | Training | Tier | When | Validity | Linked policies | Linked competencies |
|---|---|---|---|---|---|---|
| T-01 | Facility induction | essential | at_entry | Once | POL-WHISTLE · POL-EQUAL · POL-DATA | – |
| T-02 | Safeguarding adults | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-03 | Safeguarding children | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-04 | Data protection and confidentiality | essential | annual | Every 1 year(s) | POL-DATA | – |
| T-05 | Incident reporting and open disclosure | essential | periodic | Every 2 year(s) | POL-INC | C-01 · C-02 |
| T-06 | Governance, accountability and assurance | recommended | periodic | Every 3 year(s) | – | – |
| T-07 | Emergency and major incident command | essential | annual | Every 1 year(s) | POL-INC | C-01 |
| T-08 | Speaking up, inclusion and equality leadership | essential | periodic | Every 2 year(s) | POL-WHISTLE · POL-EQUAL | C-03 |
8. Health, fitness and language
| ID | Requirement | Frequency | Tier | Minimum in low-resource settings |
|---|---|---|---|---|
| H-01 | Immunity to vaccine-preventable diseases relevant to the setting, documented at entry | At entry or as set | essential | Documented hepatitis B status at entry |
| H-02 | Tuberculosis screening at entry, then as the national rule requires | At entry or as set | essential | Symptom screening at entry and after exposure |
| H-03 | Fitness-to-work assessment at entry and after serious illness or injury | Every 12 months | recommended | Fitness check at entry |
| Language | Level | Mandatory |
|---|---|---|
| Official language of the country of practice | professional | Yes |
| English | working | Yes |
9. Competencies by level
| ID | Competency | Foundation | Practitioner | Expert | Assessed by | Revalidate | Linked trainings |
|---|---|---|---|---|---|---|---|
| C-01 | Incident investigation and root cause analysis | Reports incidents | Leads incident reviews | Designs investigation methods across services | Investigation audit | Every 12 months | T-05 · T-07 |
| C-02 | Learning from incidents | Shares learning | Leads learning sessions | Designs learning systems | Learning review | Every 12 months | T-05 |
| C-03 | Just culture and speaking up | Supports reporting | Coaches teams on reporting | Designs a just reporting culture | Culture survey | Every 12 months | T-08 |
10. Performance evaluation
- Probation: 6 months, with a sign-off review (recommended value).
- Appraisal: every 12 months against the competencies and indicators below.
| ID | Indicator | Target | Data source | Frequency |
|---|---|---|---|---|
| PI-01 | Incidents reviewed within policy timeframe | 100% | incident register | Monthly |
| PI-02 | Learning actions completed | 100% | action tracker | Monthly |
| PI-03 | Staff reporting rate | set by facility | incident register | Quarterly |
| PI-04 | Harm incidents with completed review | 100% | incident register | Quarterly |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Patient safety officer | 5 years (recommended) | Q-01, Q-02 | C-01 expert, C-02 practitioner | T-05 · T-07 | Executive appointment and performance review |
12. Policies the post holder follows
Each policy is a standard template that the facility adopts and adapts. Templates are maintained centrally, so every facility works from the same version.
POL-SAFEG · Safeguarding adults and children
Purpose: Protect patients from abuse, neglect and harm, and make sure every concern is recognised and acted on.
Scope: All staff, volunteers and contractors.
Key rules:
Scope: All staff, volunteers and contractors.
Key rules:
- Recognise signs of abuse and neglect and record them factually.
- Report every concern to the designated safeguarding lead the same shift.
- Do not investigate alone.
- Share information only as the safeguarding procedure allows.
POL-DATA · Data protection and confidentiality
Purpose: Keep patient and staff information private, secure and used only for care and legal purposes.
Scope: All staff who access records or systems.
Key rules:
Scope: All staff who access records or systems.
Key rules:
- Access only the records needed for your work.
- Keep records secure; do not leave screens or paper unattended.
- Do not share information without a lawful basis.
- Report any breach to the data protection officer within 24 hours.
Linked trainings: T-10 · Review every 12 months · Template 0.1 (draft)
POL-WHISTLE · Speaking up (whistleblowing)
Purpose: Let staff raise patient safety or conduct concerns without fear of reprisal.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Raise a concern with your line manager or the named speaking-up officer.
- If that route fails, escalate to the board or the national regulator.
- Retaliation against anyone who speaks up is a disciplinary offence.
- Concerns are recorded, investigated and the outcome given to the person raising them.
Linked trainings: T-01 · Review every 12 months · Template 0.1 (draft)
POL-EQUAL · Equality, diversity and inclusion
Purpose: Give every patient and colleague fair access, respectful treatment and reasonable adjustments.
Scope: All staff and patients.
Key rules:
Scope: All staff and patients.
Key rules:
- Treat every person with dignity regardless of background.
- Make reasonable adjustments, including interpreters, for language and disability.
- Report discrimination through the speaking-up route.
- Monitor access and outcomes by group.
Linked trainings: T-01 · Review every 24 months · Template 0.1 (draft)
POL-INC · Incident reporting and open disclosure
Purpose: Report and learn from incidents and near misses, and tell patients honestly when things go wrong.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Report every incident and near miss the same shift.
- Give the patient and family an honest account and an apology where appropriate (open disclosure).
- Take immediate action to protect others.
- Learn: contribute to the review and follow the agreed actions.
13. Standards that name this role
14. Record history
| Date | Change | Approved by |
|---|---|---|
| 2026-10-27 | Draft record, batch 1 of the position build | Awaiting approval |