The ant that moves the elephant: a lesson in building safer reporting cultures

Summary

In healthcare a single report—no matter how minor—can challenge an assumption and shift an entire system toward safer care.

Content

We often assume that better tools, smarter systems and stronger procedures should naturally lead to safer care. Yet across many healthcare organisations, familiar patterns of preventable harm continue to reappear. This raises an important question: why do these incidents persist—even in environments that invest heavily in quality and safety?

Recent national reviews offer a revealing insight. A 2025 U.S. Office of Inspector General report found that hospitals captured less than half of actual patient harm events—meaning a significant portion of risks never even enters the learning system.[1] A 2024 analysis of more than 280,000 safety events reached a similar conclusion, highlighting ongoing gaps driven by underreporting and inconsistencies in how incidents are documented.[2][3]

In my experience, these findings reflect a deeper truth: the issue is rarely a lack of systems—it is a lack of signals. When reporting is incomplete, when near misses remain invisible, and when staff underestimate the value of submitting a report, organisations lose the very information needed to learn, adapt and prevent future harm.

In healthcare, we often talk about systems, structures and processes. Yet sometimes, the most powerful lessons come from simple ideas. More than twenty years ago, my mentor, Dr Katrin Kleijnhans, shared a metaphor that continues to shape how I understand patient safety culture: the 'ant' and the 'elephant'.

In her view, the ant represents a single incident report—the kind of small observation that frontline staff may overlook or dismiss. The elephant, on the other hand, symbolises the healthcare system with all its complexity, pressures and latent risks.

She would often remind our teams that even the tiniest ant can move an elephant. One report—no matter how minor it may seem—can challenge assumptions, reveal hidden vulnerabilities and spark meaningful change. And when many ants come together through consistent reporting, they form a 'colony' that creates a force strong enough to shift an entire system toward safer care.

Across my work in risk management, I have witnessed this principle repeatedly. A seemingly simple report—a nurse noticing an unusual pattern, a technician raising a concern, a physician describing a near miss—often became the starting point for redesigning workflows, strengthening barriers or preventing harm before it reached a patient.

The impact was almost never in the size of the report itself. It was in the organisation’s willingness to listen.

Although Dr Katrin Kleijnhans is no longer with us today, the mindset she instilled continues to influence how teams speak up, take ownership of safety and recognise the value of reporting. Her legacy lives on in every improvement driven by someone who chooses to report a concern.

As healthcare evolves and technologies advance, one challenge remains deeply human: how do we build cultures where people feel safe—and motivated—to report?

The answer begins with reinforcing a simple truth:

• Small reports reveal big risks.
• Repeated patterns expose system weaknesses.
• Reporting is not an administrative task—it is an act of protection.
• Every voice matters.

To all healthcare professionals: your report might be the ant that moves the elephant. Your observation could be the insight that uncovers a hidden risk, prevents harm, or sparks the next improvement that protects patients and colleagues alike.

Building a safer healthcare system does not begin with large projects. It begins with a single report—and the courage to submit it.

References

1. Office of Inspector General. Hospitals Did Not Capture Half of Patient Harm Events, Limiting Information Needed to Make Care Safer. 2025.
2. Kepner S, Jones R. Patient safety trends in 2023: An analysis of 287,997 serious events and incidents from the nation’s largest event reporting database. Patient Safety 2024; 6(1):
3. Hoops K, Pittman E, Stockwell DC. Disparities in Patient Safety Voluntary Event Reporting: A Scoping Review - Joint Commission. Journal on Quality and Patient Safety 2024; 50(1):46-48.

About the Author

Saed Saleh Abed is a senior leader healthcare quality and patient safety professional with more than 20 years of expertise in risk management and system resilience. Currently, he is the risk management supervisor at the Royal Commission Health Services Program (RCHSP) in Jubail, Saudi Arabia, and he is nationally recognised as a senior quality Ambassador with the Saudi Standards, Metrology and Quality Organization (SASO).

Throughout his career, Saed has focused on cultivating organisational cultures where frontline staff feel empowered to report, speak up and drive meaningful safety improvements. As a strong advocate for moving from individual blame to systemic learning, he believes that every voice matters and that even the smallest incident report can be the 'ant' that moves the 'elephant' of complex healthcare systems.