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Things can and do go wrong in health and social care. There is an expectation that when things do go wrong, HSC organisations treat those affected with respect, compassion and honesty. That they help members of the public understand what happened and they demonstrate that they have learned from the incident, to reduce the risk of it happening again. Recommendations arising from a number of Inquiries and Reviews have contributed to a clear and strong evidence base underpinning the need to redesign the current approach to learning following Adverse Incidents and SAIs. The Department of Health is therefore holding a public consultation on the redesign of the current Serious Adverse Incident (SAI) procedure in Northern Ireland. The SAI review process is intended to play an important role in securing improvements in the quality and safety of health and social care (HSC) services by ensuring that incidents are identified, reported and investigated as appropriate so that learning can be shared across the HSC system. Some of the key aims of the new draft Framework include: Providing a more streamlined and simplified process for reviewing Patient Safety Incidents, to ensure reviews are of a high quality; Place all those affected at the heart of the process; Focus on understanding how and why a Patient Safety Incident has occurred to identify system-wide learning leading to demonstrable and sustainable improvements in care. The proposed framework for Learning and Improvement from Patient Safety Incidents will form a key part of the HSC’s patient safety system and it is therefore crucially important that it is the right approach. The Department of Health would therefore like to hear directly from the public on these important proposals. The PCC is facilitating an online consultation event, to be led by Department of Health officials, on Thursday 15 May 2025, at 17:30. This event will also assist those intending to make a written response to the consultation. Register

In this blog, Patient Safety Learning highlights key issues included in its response to the Department of Health consultation on the draft ‘Being Open’ Framework and establishment of a Duty of Candour in Northern Ireland. In December 2024, the Department of Health launched a public consultation asking for views on its draft ‘Being Open’ Framework. Describing the proposed Framework, Health Minister Mike Nesbitt stated: “The ‘Being Open’ Framework aims to ensure that individuals within our health and social care system are fully empowered to exercise candour and openness, and that health and social care organisations have in place the necessary support and systems required to enable and nurture a truly open culture.”[1] The Framework aims to address some of the recommendations made in the 2018 report from the Inquiry into Hyponatraemia Related Deaths (IHRD) by Justice O’Hara KC.[2] This Inquiry was published following an extensive investigation into the deaths of five children in hospitals. The report’s recommendations included the introduction of a Duty of Candour in Northern Ireland. The purpose of the ‘Being Open’ Framework set out in the consultation document is as follows: To improve patient safety and the quality of services by developing an open, just and learning culture. To ensure that all people in contact with healthcare organisations (employees, patients, relatives and the public) can expect to be treated in an open, fair and compassionate way. That patients and those supporting them will be listened to, understood and treated with respect. That healthcare staff are entitled to visible, engaged and inclusive leadership. That senior leaders will listen to concerns and create safe spaces for learning. That learning will be promptly disseminated across the system.[3] Below we summarise the key points included in Patient Safety Learning’s response to this public consultation. Openness and culture The ‘Being Open’ Framework at its core places a strong emphasis on the principle of openness in the healthcare system. It looks at this on three levels: Routine openness: being honest in everyday care and communication. Learning from mistakes: reflecting on errors to improve and avoid repeating them. When things go wrong: clear communication and accountability when harm is caused. We welcome the Framework’s commitment to openness with patients and its focus on learning from mistakes. We stated this in our consultation response, while highlighting the need for proposed training and support for staff to be accompanied by a commitment by their organisation to support a culture of openness. We believe that this requires a clear leadership commitment to create a working environment for their staff where they feel psychologically safe to raise patient safety concerns. In our response, we also mentioned the importance of being open with patients and families following patient safety incidents and in the incident investigation process itself. To facilitate this, we set out that: It is important for staff to understand who is responsible for ensuring meaningful and compassionate engagement with patients and families. This needs to be accompanied by processes that enable organisations to evaluate how both to assess and meet the needs of patients and families in these processes. Having sufficient well-trained staff, with time for engagement, is essential if this is to be achieved. These issues around patient safety investigations is something we will come back to in more detail at a later date as part of our response to the new public consultation on the redesign of the current Serious Adverse Incident procedure for Northern Ireland.[4] Duty of Candour The consultation poses questions about the introduction of a Statutory Duty of Candour for organisations and individuals in Northern Ireland, a key recommendation of the IHRD. In our response, we state our support for this. Everyone working in healthcare must be open and honest in all their dealings with patients and the public. We also make clear that the introduction of Duty of Candour is a process that takes time and requires significant resources to embed. Highlighting the challenges of this, we pointed to the experience of introducing a Statutory Duty of Candour for health and care providers in England, first enshrined in law for all NHS Trusts in 2014. As results of last year’s call to evidence illustrate, even now there is still a significant gap between what is said and understood in regard to Duty of Candour, and what takes place in practice at many healthcare organisations.[5] Patient Safety Commissioner We also expressed our support for the potential introduction of a new role of Independent Patient Safety Commissioner in Northern Ireland. This is one of the options that the ‘Being Open’ Framework suggests exploring to help to monitor and scrutinise its implementation. This new post alone cannot improve openness and patient safety. However, with the right remit and responsibilities, we believe that it could play a potentially important role in supporting this and championing the voice of patients. In our response, we stressed that if such a role was introduced it was important to ensure that they had a clear remit, with the ability to advocate for systemic improvement and look at safety issues across health and care. The Patient Safety Commissioner for England currently has a remit that is restricted to medicines and medical devices, which in our view places an unnecessary limitation on the role. This can also create confusion for patients who want to highlight a clear patient safety issue that does not fall under the guise of medicines and medical devices. This can reinforce an inequity of treatment for patients affected by these issues, with there being no alternative pathway for them to raise such concerns outside the Commissioner’s scope. This is a problem that has been highlighted directly by the inaugural Patient Safety Commissioner for England, Professor Henrietta Hughes.[6] We also stated the need to ensure that a new Patient Safety Commissioner in Northern Ireland would have clear operational independence. They should feel able to ‘speak truth to power’ and represent the best interests of patients and the wider public. To support this aim, we believe that this role would need to be independent from those funding and delivering healthcare. Finally, we noted that it would be useful for the new postholder to establish a strong working relationship with the Patient Safety Commissioner for England and, when appointed, the Patient Safety Commissioner for Scotland. This would enable them to coordinate in the future on emerging patient safety concerns and share examples of good practice. Engaging with patients and the Patient and Client Council One area where we felt that the ‘Being Open’ Framework could be strengthened was in relation to patient engagement and involvement. While further changes may emerge in this area from feedback to the consultation itself, we also highlighted in our response the value of giving greater consideration to the role the Patient and Client Council (PCC) can play in the delivery of this. The PCC is a statutory body in Northern Ireland that provides a powerful and independent voice for patients, clients, carers and communities on health and social care issues through: Representing the interests of the public. Promoting the involvement of the public. Assisting people in making, or intending to make, a complaint. Promoting the provision by health and social care bodies of advice and information to the public about the design, commissioning and delivery of services. Undertaking research into the best methods and practices for consulting and engaging the public.[7] We believe that these functions of the PCC align with the core aims of the ‘Being Open’ Framework, and their existing knowledge and experience could help to support the implementation of this. Commenting on specific aspects of this, we noted the following points: In potentially creating a new Patient Safety Commissioner role, consideration would need to be given as to how its remit and responsibilities relate to and complement the existing role of the PCC. When discussing “Openness with a focus on learning” and “Openness when things go wrong”, the Framework talks about organisations having patient safety incident investigations that involve patients. The PCC’s work involving patients and communities in the design, delivery and evaluation of services could support embedding these principles in practice. Training and education We also welcome proposals in the ‘Being Open’ Framework to provide training and support to staff to properly understand and exercise their responsibilities to be open routinely and focused on learning and when things go wrong. In our consultation response we also placed particular emphasis on the need to consider how this applies to those in leadership positions. At Patient Safety Learning we believe that good leadership can drive patient safety performance, supporting learning from unsafe care and putting in place clear governance processes to enable this. In our Patient Safety Standards we identify the need for Board members (Executives and Non Executives) and governors to be provided with training and support in relation to compliance with Duty of Candour and being open as a key requirement for healthcare organisations.[8] We believe there would be value in also reflecting that in the ‘Being Open’ Framework. Concluding comments We strongly support the introduction of the ‘Being Open’ Framework in Northern Ireland. We also welcome that it directly acknowledges the importance of having a clear implementation plan to take this work forward. Importantly, it also recognises that neither legislation nor policy alone will necessarily inspire the behaviours that are intrinsic to an open organisation, emphasising the importance of taking action needed to promote behaviours and beliefs that enable this. In our concluding comments to the consultation, we highlighted further consideration how the implementation of the Framework could potentially form part of a wider application of a safety management system approach to health and social care in Northern Ireland. A safety management system is a proactive approach to managing safety that is used in other industries. It sets out the necessary organisational structures and accountabilities to manage safety risks. It requires safety management to be integrated into an organisation’s day-to-day activities.[9] References Department of Health. Consultation on ‘Being Open’ Framework and Duty of Candour launched, 10 December 2024. IHRD. Report of the Inquiry into Hyponatraemia related Deaths, 31 January 2018. Department of Health. Draft Regional being Open Framework for the HSC, 10 December 2024. Department of Health. Framework for Learning and Improvement from Patient Safety Incidents Consultation, 11 March 2025. Department of Health and Social Care. Findings of the call for evidence on the statutory duty of candour, 26 November 2024. Emily Townsend. Safety watchdog urges Streeting to expand her role. HSJ, 24 October 2024. PCC. Who we are and what we do. Last accessed 28 March 2025. Patient Safety Learning. Why Standards? Last Accessed 24 March 2025. HSSIB. Safety management systems: accountability across organisational boundaries, 13 February 2025.

On Wednesday 1 May 2024, the National NatSSIPs Network hosted a webinar to discuss the NHS England consultation on the Never Events framework. The consultation is concerned with whether the existing framework is an effective mechanism to drive patient safety improvement. This blog gives an overview of the discussion at this webinar, which had over 200 participants. The NHS England Never Events policy and framework defines Never Events as: “Serious Incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers. Strong systemic protective barriers are defined as barriers that must be successful, reliable and comprehensive safeguards or remedies—for example, a uniquely designed connector that stops a medicine being given by the wrong route.” In February 2024 a consultation was opened seeking views on whether the existing Never Events Framework remains an effective mechanism to drive patient safety improvement. This follows the findings of reports such as the Care Quality Commission’s Opening the door to change and the former Healthcare Safety Investigations Branch’s analysis of Never Events, which highlighted that for several types and sub-types of Never Events, the existing barriers were not strong enough to make an incident wholly preventable. Considering its effectiveness, the consultation asks respondents which of the following options they would prefer for the future of the Never Events framework: Option 1: No change; continue with the current framework. Option 2: Abolish the Never Events framework and list. Option 3: Revise the list of Never Events to only include those with current barriers that are ‘strong, systemic, protective’. Option 4: Revise the definition of and process for Never Events to create a new system that does not require all relevant incidents to be ‘wholly preventable’. Webinar panel This webinar, held to discuss these proposals, was chaired by Dr Annie Hunningher, Consultant in Anaesthesia and Group Safety Lead at Barts Health NHS Trust. She was joined by the following panel: Claire Cox, Patient Safety Lead at King's College Hospital NHS Foundation Trust and Founder of the Patient Safety Management Network. Dr Claire Morgan, Consultant in Restorative Dentistry, Patient Safety Specialist at Royal London Hospital, Barts Health NHS Trust and Deputy Chair for the Patient Safety Group for the Royal College of Surgeons of Edinburgh. Helen Hughes, Chief Executive of Patient Safety Learning. Professor Iain Moppett, Professor of Anaesthesia and Perioperative Medicine and Honorary Consultant Anaesthetist at the University of Nottingham and Nottingham University Hospitals NHS Trust. Kellie Bryan, Head of Patient Safety Investigations and Patient Safety Specialist at University Hospitals Sussex NHS Foundation Trust. Dr Samantha Machen, Associate Director of Patient Safety and Head of Patient Safety Incident Response at University Hospitals Sussex NHS Foundation Trust. Initial opinions At the beginning of the webinar, a poll was conducted to ascertain initial views on which of the four options in the consultation attendees favoured. The results, pictured below, showed that the fourth option had the greatest support among those in attendance. Attendees were also asked to state the first word that came to mind when asked the question ‘Is the Never Events Framework an effective mechanism to drive patient safety improvement?’ Their responses resulted in the word cloud pictured below. Key themes and issues Subsequently, each of the panellists was asked to set out their views on the Never Events framework and consultation proposals. This was interspersed with and followed by comments and questions from attendees of the webinar and conversations between the panel. There was a consensus that protecting patients from avoidable harm is the number one priority, but the question was how to do this within the current healthcare system and environment. Below are some of the themes and issues that emerged from this lively and engaging debate. ‘Wholly preventable’ incidents Reflecting on a key issue raised by option 4 in the consultation, whether Never Events need to be revised so that they are not required to be ‘wholly preventable’, there were a number of comments by panel members and attendees. There was a suggestion that making this change would not be a significant departure from the status quo, but simply a recognition of the practical reality that many of these events are not ‘wholly preventable’. The difference between ‘work as imagined’ and ‘work as done’ in relation one specific type of Never Event, the scalding of patients, was also discussed. It was noted that while in principle hospitals should be able to put in place a series of mitigations to reduce the risk of this, what is done in practice can be significantly limited in ageing hospital estates with outdated infrastructure. These challenges are not recognised by the existing framework when considering this type of incident as ‘wholly preventable’. Another example given by one of the presenters considered a case study of wrong intraocular lenses, a type of wrong implant/prothesis Never Event. Although initially this may appear ‘wholly preventable’, an investigative approach revealed a significant degree of complexity that is not adequately addressed or mitigated by existing checking procedures. Indicators of patient safety There was considerable discussion around how the reporting of Never Events is currently used and whether this is a useful means of measuring overall patient safety in an organisation. It was noted that Never Events data only represents a small part of all the healthcare and patient safety activity in an organisation. Furthermore, it is focused on specific areas of care, with three surgical Never Events broadly accounting for around 80% of all Never Events in total. It was suggested that this narrow scope means that organisations’ performance in relation to Never Events, good or bad, is not necessarily a reliable indicator of the approach to safety across an organisation. The issue was also raised that the current incidents listed as Never Events apply to procedures that are much more frequent in Acute Trusts. So, while you would be likely to have significantly fewer Never Events at a Mental Health or Community Trust, this isn’t an indicator of higher levels of safety at those organisations, just of a measure being set by NHS England. Public visibility and transparency Panellists and attendees discussed the level of public attention and focus that Never Events received compared to other patient safety incidents, highlighting the following points: The purpose and benefit of publishing the names of organisations and their numbers of Never Events in the public domain is unclear. There is no context or nuance to help the public understand or find balance (such as numbers of surgeries performed or the size and complexities of the Trust, for example, teaching hospitals). Public awareness of Never Events appears to be low. One attendee noted that people do not tend to look at this data until they are impacted by it, at which point it is too late. The patients and families that do look at Never Events do so because they have suffered from one of these incidents. Simply publishing the number of incidents alone is not a good measure of safety. The data as currently published does not consider responses to these incidents or accompanying plans for improvement. The term ‘Never Event’ A prominent issue of discussion was the appropriateness of the description ‘Never Event’ itself. Some in attendance suggested it felt disingenuous to patients, staff and public given the consistent number of these incidents that continue to occur, implying that this can be reduced to zero. Alternative names were posited, such as ‘Priority Safety Events’. It was noted that ‘never’ is not often used in other safety critical industries, and hazard management phrases including 'as low as reasonably practical' should be considered. The point was also raised by several participants that the term itself could be seen as punitive, contributing to a blame culture. In a counterpoint, it was suggested that this stemmed from wider issues of a lack of safety culture in parts of the NHS. In this context, changing the name of Never Events will not address the problem. Level of attention and focus on Never Events Another significant area of discussion in the webinar concerned whether too much emphasis is placed on Never Events, distracting from other areas of patient safety focus. It was noted that although a significant amount of time and resources is invested into investigating Never Events, there is little evidence to suggest this is translating into wider system level improvement. In the context of this, it was suggested by some participants that the current approach to Never Events could be seen as disproportionate. It was suggested that this may be particularly the case under the new Patient Safety Incident Response Framework (PSIRF) where all Never Events, regardless of the level of harm, will require a full Patient Safety Incident Investigation (PSII). An example was given that if a patient had an incorrect mole removed, this would be classed as a Never Event (a form of wrong site surgery) requiring a full PSII, despite being a low harm event. Under PSIRF, this may be prioritised for investigation at the exclusion of a full investigation of missed diagnosis of a serious condition, despite the latter potentially resulting in a much more significant level of patient harm. There were also points raised about the opportunity cost of focusing significant resources on Never Events. Examples of this include: Not looking more closely at the majority of cases when Never Events do not happen, learning from when things go right and the activities and behaviours that lead to this. Whether a focus on Never Events lets system leaders ‘off the hook’ for significant safety issues elsewhere by defining events in such a narrow way. Not considering near misses more closely. A participant suggested that reporting of these can low because of the lack of capacity to report these and insufficient capacity in patient safety teams. Consequences of abolishing Never Events Reflecting on a key issue raised by one of the four options in the consultation, whether Never Events should be abolished, there were a number of comments by panel members and attendees. There were concerns about the negative perception this may create, including: Even if there is a strong rationale for removing this term, it could be seen as a reduction in transparency around the occurrence and frequency of these incidents. It could be interpreted as a signal that we are giving up the ambition of that these types of incidents should never occur. For a patient or family member involved in a Never Event with serious life altering consequences, it was noted it would be difficult to see how such a change could be viewed positively and not undermine their trust in the healthcare system. A concern was also raised that with some of these incidents being so rare, abolition of the Never Events framework may result in a loss of visibility for serious patient safety incidents. It was suggested this may reduce leadership focus on issues such as wrong site surgery and retained foreign objects. This could potentially reduce opportunities for investigation and improvement. Redefining Never Events At the beginning of the webinar, the proposed consultation option to revise the definition of Never Events was most favoured among attendees. Considering what this might look like, the following points were made: There should be a focus and priority given to the level of harm, rather than simply the type of incident. Events with catastrophic implications for patients should be prioritised. Focus should not be simply on reporting the number of events, but how they are responded to. What corresponding investment and training is put in place to address problems that have been identified? The events included in the definition should be expanded. Suggestions of this included types of incorrect medicine administration and surgical fires. Concluding views During the webinar, a poll asked whether participants had ever been involved in a Never Event, which produced the results pictured below. To close the webinar, another quick poll was conducted to ascertain whether participants’ views on the four options in the consultation had changed. The results, pictured below, showed a significant growth in support for the second option, ‘Abolish the Never Events framework and list’, at the end of the debate. However, significant support remained for the fourth option to ‘Revise the definition of and process for Never Events to create a new system that does not require all relevant incidents to be ‘wholly preventable’. There is still time to share your views with NHS England on whether the existing Never Events Framework remains an effective mechanism to drive patient safety improvement. The consultation is open to responses until Sunday 5 May 2024—respond and share your views. Networks on the hub This webinar was hosted by the National NatSSIPs Network, a voluntary group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. the hub hosts and supports a growing number of informal peer support networks for people involved in patient safety, providing a forum for meeting up, discussing and sharing ideas and initiatives, and learning from others. We also host the Patient Safety Management Network, an innovative network for patient safety managers and everyone working in patient safety. You can join by signing up to the hub today. When putting in your details, please tick the relevant Network in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected]. Related reading National learning report: Never Events analysis of HSIB's national investigations report (21 January 2021) How can Never Event data be used to reflect or improve hospital safety performance? (1 May 2021) The National Safety Standards for Invasive Procedures (NatSSIPs) (January 2023) Why are surgical never events still occurring: A Delphi study research sample across NHS England operating theatres (17 June 2023) You can also find a number of existing resources, tools and stories relating to Never Events on the hub.

On 23 October 2024, the Patient Safety Commissioner for England published a set of Patient Safety Principles. In this blog, Patient Safety Learning sets out its reflections on these principles, highlighting key points included in its response as part of the public consultation process earlier this year. The Patient Safety Commissioner’s new Patient Safety Principles are intended to act as a guide for leaders at all levels on how to design and deliver safer care for patients and reduce avoidable harm, in a just and learning culture.[1] They are as follows: Create a culture of safety Leaders have a responsibility to lead by example to inspire a just and learning culture of patient safety and quality improvement. They should set out to keep people safe through the adoption of a safety management system and by embedding continuity of care, a culture of compassion and civility, effective listening, and restorative practice. Put patients at the heart of everything Leaders should put the patient at the heart of all the work that they do, with patient partnerships the default position at all levels of the organisation. They should consider the needs of patients and communities to deliver person-centred care. Leaders should ensure that the patient voice is central in the design of services, in obtaining fully informed consent and to the implementation of shared decision making. Treat people as equals People should be treated with respect, equity and dignity. Leaders should incorporate the views of all, and proactively seek and capture meaningful feedback from patients, workers, and communities, acknowledging that those from disadvantaged groups may need specific support and encouragement to contribute. They should act upon feedback, to embed equity of voice. Identify and act on inequalities Health inequalities, and their drivers, should be identified and acted upon at every stage of healthcare design and delivery to drive improvements in patient safety and experience. Identify and mitigate risks Targeted and coordinated action should be directed towards patient safety risks. Patients, workers and communities should be encouraged and empowered to proactively identify and speak up about risks, hazards and potential improvements. Leaders should promptly escalate new and existing risks to the most appropriate person or body. Be transparent and accountable Leaders should acknowledge that creating a culture of safety requires honest, respectful and open dialogue, where candour is the default position. This transparency should support a model of continuous improvement, which learns from both successes and events, and ensures that patients, workers and communities do not face avoidable harm due to a cover up culture. Use information and data to drive improved care and outcomes for patients and help others to do the same Leaders should enable patients to have access to their personal and other data to help them improve their own care. They should ensure that good quality data is collected and meets the needs of all patients, including those from underrepresented and inclusion health groups. Workers should be supported to use and share information and data to drive improved care and outcomes for patients, in accordance with the Caldicott Principles. Shared principles These principles were subject to a publication consultation, which we responded to on the 5 September 2024. You can find our full comments on each principle here. We welcome the principles that the Patient Safety Commissioner has set out today. There is significant overlap between these seven principles and the six foundations of safer care we identify in our report, A Blueprint for Action.[2] For example: “Put patients at the heart of everything” aligns with our foundation on “Patient engagement”. We believe that patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account. “Use information and data to drive improved care and outcomes for patients and help others to do the same” aligns with our foundation on “Data and insight for patient safety”. We would also consider that these principles, when taken together, align with our view set out in A Blueprint for Action about the need for a transformation in our approach to patient safety placing this as a core purpose of health and care. The Patient Safety Commissioner’s proposed principles also share much in common with the World Health Organization’s (WHO) Global Patient Safety Action Plan.[3] This sets out a vision of a “world in which no patient is harmed in healthcare, and everyone receives safe and respectful care, every time, everywhere” and a goal of achieving the maximum possible reduction in avoidable harm as a result of unsafe care. There is again significant overlap between the points included in its seven strategic objectives and these principles. The principle “Put patients at the heart of everything” also reflects a wider international initiative in patient safety, the WHO Patient safety rights charter that was published earlier this year.[4] The Charter aims to outline patients’ rights in the context of safety and promotes the upholding of these rights, as established by international human rights standards, for everyone, everywhere, at all times. Areas not covered by the principles In our consultation response we also highlighted several areas not included in these principles. We would suggest these should also be considered when creating guidance for senior leaders on how to deliver safer care for patients and reduce avoidable harm. Shared learning This is one of the six core foundations of safer care we identify in A Blueprint for Action. Healthcare is systematically poor at learning from harm. If patients are to be safer, we need people and organisations to share learning when they respond to incidents of avoidable harm, and when they develop good practice for making care safer. It is vital that patients, clinicians, managers, and health and social care system leaders share learning about safety practice and performance to make care safer. This was the key driving force behind the creation of the hub, our platform to share learning for patient safety. Patient safety standards One of the primary reasons for the persistence of avoidable harm is that healthcare does not have or apply standards of good practice for patient safety in the way that it does for other issues. Standards that do exist are insufficient and inconsistent. At Patient Safety Learning, we believe that health and social care organisations need to have standards for patient safety. These can inform 'what good looks like' and enable organisations to self-assess against them.[5] Designing for safety and safety in use Treating patient safety as a core purpose of health and care requires us not just to respond to and mitigate the risk of harm, but also to design healthcare to be safe for patients and the staff who work within it. This would include greater use of human factors expertise and systems thinking to inform the safe design, safety management and approaches to investigating unsafe care. This is also covered in depth as part of the Global Patient Safety Action Plan’s second strategic objective, ‘High-reliability systems’. Challenge of implementation Publishing these principles, the Patient Safety Commissioner said that: “The Patient Safety Principles act as a guide for leaders at all levels on how to design and deliver safer care for patients and reduce avoidable harm, in a just and learning culture. They are relevant to healthcare providers as well as commissioners, regulators, manufacturers, and the broader supply chain. The principles provide a clear framework for planning, decision-making, and working collaboratively with patients as partners.”[1] While we welcome this aspiration, how these are used in practice will determine their success. We need everyone—politicians, policymakers, patients, families and communities, clinicians, managers, system and professional regulators, researchers and academics, and health and social care system leaders—involved in this effort. All too often when it comes to patient safety, there exists an implementation gap between what we know improves patient safety and what is said about this compared to what is done in practice.[6] An example of this can be seen concerning the first of these principles, “Create a culture of safety”. This emphasises the role of leaders having a responsibility to lead by example to inspire a just and learning culture of patient safety. A similar aspiration is also identified in the NHS Patient Safety Strategy, which includes patient safety culture as one of the two foundations required in working towards its safety vision “to continuously improve patient safety”.[7] However, despite this commitment in the NHS, blame cultures and a fear of speaking up continue to persist. As highlighted in our recent report analysing the NHS staff survey results, there often exists a significant gap in this respect between what organisations say about their approach to safety culture and how staff feel.[8] If these principles are to be realised, they will need not just to be accompanied by a endorsement from the Department of Health and Social Care and the NHS, but also clear action. References Patient Safety Commissioner for England, Patient Safety Principles, 23 October 2024. Patient Safety Learning. The Patient Safe Future: A Blueprint for Action, 2018. WHO. Global Patient Safety Action Plan 2021-2030, 3 August 2021. WHO. Patient safety rights charter, 18 April 2024. Patient Safety Learning. Standards, Last accessed 4 September 2024. Patient Safety Learning. Mind the implementation gap: The persistence of avoidable harm in the NHS, 7 April 2022. NHS England. The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019. Patient Safety Learning. We are not getting safer: Patient safety and the NHS staff survey results, 26 March 2024.