“I just thought you were supposed to know”: bridging the gap between patient safety knowledge and practice

Summary

Nurses are expected to practise patient safety—to escalate, document, report and speak up—yet few are ever explicitly taught how.

After more than 13 years across clinical, governance, consulting and patient safety roles, Aderonke Opawande kept hearing the same sentence from colleagues: "I just thought you were supposed to know."

In this blog, she shares the research she carried out with 50 practising nurses across several countries, which confirmed the gap was systemic rather than personal, and explains why it led her to write the Patient Safety 101 Suite: six practical resources covering foundation of patient safety, escalation, internationally educated nurses, preceptorship, second victim support and organisational learning.

Aderonke has also shared a free CLEAR™ escalation quick-reference tool attached at the end of the blog for staff to print, laminate and use on the ward.

Content

"I just thought you were supposed to know."

It sounds unremarkable at first. After a while, it becomes one of the most troubling sentences you can hear in healthcare. I have heard it more times than I can count.

I have been a nurse for over 13 years: at the bedside, in governance teams, in patient safety roles and as a learning lessons analyst in NHS trusts. Across all of them, the same pattern repeats. A nurse notices something is wrong but doesn't know who to tell, or how. A concern is raised informally, nothing is documented, and by the time the incident crystallises, the moment for early intervention has passed.

I have sat with nurses after serious incidents, watching them carry the burden of a mistake for months, sometimes years. I have seen colleagues told to "write a reflection" without anyone explaining what reflection means in the aftermath of harm. I have seen dismissals, Nursing and Midwifery Council (NMC) referrals, and managers facing coroners years after an event. I have seen families disappointed, not by a lack of care but by a lack of answers.

When I quietly asked one nurse whether anyone had ever actually taught her how to escalate a concern; what to say, to whom, in what order, she thought about it for longer than I expected. "Not really. I just thought you were supposed to know."

That sentence became the reason I wrote the Suite.

The questionnaire that confirmed it wasn’t just my experience

Before writing the Suite, I distributed a structured questionnaire to practising nurses in the UK, Ireland, Canada and the United States.[1] Most respondents were nurses practising in the UK. Across the 50 responses, a recurring theme was that patient safety education often covered frameworks, definitions and responsibilities, but gave less practical guidance on what to do in real situations.

The consistency of the responses suggested that this was not simply an individual knowledge gap, but a wider challenge in how patient safety education translates into practice.

What I built in response

The Patient Safety 101 Suite is six resources, each addressing a specific, documented gap, each usable without a specialist budget or a decade of safety experience.

• Patient Safety 101 is the foundation: risk, escalation, documentation, human factors and systems thinking in plain language for any nurse at any grade.

• Speak Up, built around the CLEAR™ Escalation Standard, exists because 'speak up' is easy to say and hard to do: staff need language and structure, especially when junior, new, tired or facing hierarchy.

• The IEN Field Guide responds to my Freedom of Information investigation, which documented a 60% rise in fitness-to-practise referrals involving internationally educated nurses over three years. Across that period, 2,373 referrals were recorded, raising important questions about how well internationally educated professionals are supported to navigate unfamiliar systems, expectations and unwritten rules.

• The Preceptorship Companion equips those guiding newly registered, internationally educated and returning nurses through the transition space.

• The Second Victim Roadmap addresses the well-evidenced, under-resourced psychological cost of being involved in a serious incident; supporting staff after harm is not separate from patient safety, it is patient safety.

• The CASCADE™ approach addresses organisational learning: helping teams connect signals across incidents, complaints, risks and other sources, identify recurring contributing factors and track whether learning actually leads to change. The Practitioner Workbook provides a structured way to apply that approach.

This matters now. The Health Services Safety Investigations Body (HSSIB) October 2025 report on investigating under the Patient Safety Incident Response Framework (PSIRF) found a significant gap between staff knowing that tools exist and having the support and expertise to use them in practice.[2] That is exactly the space the Suite tries to fill; not replacing national frameworks, but bridging the distance between policy and confident practice.

An invitation

To make one part of this immediately useful, I have shared a free CLEAR™ quick-reference escalation tool below—a single page to print, laminate and keep in a pocket or on a noticeboard. Use it. Share it with your team. Pass it to the colleague who goes quiet in handover, or the newly arrived nurse decoding a system nobody has formally explained.

CLEAR-Escalation-Standard-Quick-Reference.pdf

We need to move beyond knowing about patient safety. We need to practise it, with confidence, with structure, with compassion and with a commitment to learning that leads to change.

References

1. Opawande A. The pressure on our international workforce is reaching a breaking point. Nursing Times, 25 June. Available at: https://www.nursingtimes.net/workforce/the-pressure-on-our-international-workforce-is-reaching-a-breaking-point-25-06-2026/ [Accessed: 9 July 2026].

2. Health Services Safety Investigations Body. Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development’. HSSIB, 9 October 2025. Available at: https://www.hssib.org.uk/patient-safety-investigations/investigating-under-the-patient-safety-incident-response-framework-psirf-sharing-hssib-learning-for-future-development/ [Accessed: 9 July 2026].

Opinions expressed in blogs and other content are those of the author. Patient Safety Learning welcomes sharing content and opinions that promotes safer patient care and for the reduction of avoidable harm.  The views expressed on the hub however do not necessarily represent Patient Safety Learning's views or values. References to a specific product or service does not imply a recommendation or endorsement.

About the author

Aderonke Opawande is a registered nurse specialising in patient safety and organisational learning, with more than 13 years’ experience across clinical care, governance and NHS safety roles.

She founded SoughtOut SafeSystems Ltd, created the CASCADE™ Learning Intelligence System and wrote the Patient Safety 101 Suite. Her work has appeared in Nursing Management and Nursing Times.

Further blogs on the hub from Aderonke:

• When psychological safety fails, patient safety follows