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In healthcare, we often talk about 'never events'—serious incidents that should not occur if appropriate systems are in place. But what happens when they do occur? I recently had the great pleasure of working with a group of anaesthetic resident doctor colleagues on a patient safety project that began with exactly that question. Within a short period in 2025, our large UK teaching hospital experienced two wrong-sided peripheral nerve blocks after six years without a single reported incident. We wanted to understand why. Looking beyond individual error Both incidents occurred during a major transition: we were moving anaesthetic records, consent forms and safety checklists from paper to digital. At first glance, the timing felt more than coincidental. After initial governance processes were completed, our team used the Patient Safety Incident Response Framework (PSIRF)[1] to explore what had happened. Introduced in the NHS in 2022, PSIRF promotes a systems-based approach rather than searching for a single 'root cause'. It examines how elements such as people, tasks, tools and technology, environment and organisational factors interact to increase risk. For us, this shift in perspective proved crucial. Instead of asking “who made this mistake?”, we were able to consider “what conditions made this error more likely?”. What we found: small gaps in a complex system We brought together a multidisciplinary 'learning MDT', combining insights from staff interviews and systems analysis. A clear pattern emerged: no single failure caused these incidents. Instead, multiple small vulnerabilities aligned. One issue stood out. In our previous paper-based system, clinicians used a 'Stop Before You Block' (SBYB) sticker—a simple but effective visual cue prompting a final safety pause before performing a nerve block. During the digital transition, this physical prompt disappeared. Other contributing factors reinforced the problem: Staff worked under cognitive overload, juggling interruptions, changing plans and high-acuity patients. Digital consent processes made SBYB checks feel more cumbersome, drawing attention away from the patient and towards the computer. Poor visibility of surgical site markings increased the barriers to performing SBYB. Ergonomic challenges in anaesthetic rooms made equipment setup frustrating. Time pressure on theatre lists encouraged task compression. In both cases, clinicians skipped the SBYB pause entirely—not out of negligence, but because the system no longer reliably supported it. These events didn’t reflect individual failure. They reflected a system under strain during organisational change. From insight to action: designing safer systems We knew we couldn’t eliminate complexity from clinical environments, but we could design systems that make the safe action the easy action. We developed a multi-faceted improvement plan. 1. Strengthening standards and education We updated our local guidance, aligning it with national recommendations from the Safe Anaesthesia Liaison Group and Regional Anaesthesia UK.[2] We rebranded it as the 'Prep Stop Block LocSSIP' (Local Safety Standard for Invasive Procedures). We promoted this through clinical governance meetings and delivered targeted teaching to consultants, trainees and anaesthetic practitioners. To support sustainability, we embedded a training video into the anaesthetic resident doctor induction programme and uploaded it to our intranet. 2. Fixing friction in the system We addressed practical barriers: Improved access to longer ultrasound cables. Standardised surgical site markings to improve visibility. Explored integrating anaesthetic complexity into theatre scheduling. Trialled LED signs to indicate when the anaesthetic room is in use; thus creating a 'sterile cockpit' by discouraging interruptions during anaesthetic procedures. Introduced electronic tablets so consent forms could be viewed alongside the patient and checklist. Each of these changes aimed to reduce cognitive load and create space for safer practice. 3. Introducing a physical safety barrier Our most impactful intervention was the 'Prep Stop Block Lid'. We designed a lidded box displaying a safety infographic. Clinicians place prepared local anaesthetic inside and cannot access it until they complete the SBYB pause. This shifts safety from memory to physical design, creating a clear pause point in the workflow. We refined the intervention through Plan–Do–Study–Act (PDSA) cycles with frontline feedback before wider rollout. What we’ve learned so far Early data show improvements in process measures, including increased visibility of the SBYB step. Audits of Prep-Stop-Block compliance suggest an improvement from 34% during digital transition to 100% at most recent review. However, we remain cautious. We are still in a 'zone of vulnerability', where changes are ongoing and their full impact is unclear. Because never events are (fortunately) rare, it will take time to determine whether these interventions reduce harm. That said, several key lessons have already emerged: Never events are rarely about individuals. They arise from system conditions that make errors more likely. Digital transformation can unintentionally remove safety cues. We must actively design these back into new systems. Education and policy are necessary but insufficient. The most reliable safety interventions are embedded into workflow, especially physical or procedural 'forcing functions'. A call to action If your department is undergoing digital transformation, take a moment to ask: “What safety cues might we be losing—and how will we replace them?” We need to move beyond simply digitalising existing processes. Instead, we should use these transitions as opportunities to design safer, more resilient systems from the ground up. Because when it comes to patient safety, 'never' is not a guarantee, it’s a goal we must actively work towards. References https://www.england.nhs.uk/long-read/patient-safety-incident-response-framework/ https://www.salg.ac.uk/salg-publications/stop-before-you-block/

Health Innovation East Midlands and the Midlands Clinical Senate are hosting a new Innovation Insights webinar exploring the key challenges to implementing artificial intelligence (AI) in healthcare, and the practical steps that can help organisations overcome them. The webinar will share insights from the Midlands Clinical Senates’ work examining the barriers to the widespread adoption of AI in health and care, including findings published in the peer-reviewed journal article ‘A Systematic Review of the Barriers to the Implementation of Artificial Intelligence in Healthcare’. This session will include: Insights from the Clinical Leadership Fellows who led the research. Case studies from health and care teams who have experienced – and successfully navigated – the challenges of introducing AI into practice. Actionable insights to apply in your practice to mitigate AI implementation barriers. Speakers: Dawn Plummer, Digital Health Innovation Lead, Health Innovation East Midlands Emma Orrock, Head of Clinical Senates, Health Innovation East Midlands Midlands Clinical Senate Fellows: Brendan Spooner, John Isherwood, Imad Ahmed, Mark Lane Health care case studies from: Ben Madden, Lead Reporting Radiographer, Kettering General Hospital NHS Foundation Trust Neil Frazer, Medical Director, Primary Integrated Community Service (PICS). This session is free to attend and open to everyone, regardless of your role or organisation. Register

Working across frontline emergency care, patient safety and digital patient safety over the course of my 22-year career in the NHS has given me a unique perspective on how digital systems shape real clinical practice. As a paramedic now working as a Clinical Safety Officer within NHS Wales, I’ve seen first‑hand how digital tools can support safer care—but also how they can contribute to patient harm when things don’t work as intended. In this blog, I reflect on the challenges of identifying issues and, more importantly, assessing patient harm in a digital context. These thoughts aren’t theoretical, they come from day‑to‑day reality: the calls, the investigations, the conversations and the moments where something in the digital healthcare system doesn’t work the way it should—and a patient feels the impact. I’m sharing these thoughts to stimulate conversation, hopefully build shared understanding and help strengthen our collective approach to digital patient safety across the UK. The growing complexity of digital healthcare Digital healthcare has evolved rapidly, and with that evolution comes complexity. Electronic health records, diagnostic platforms, telehealth solutions, national and local systems—all interacting with each other in ways that aren’t always obvious. When something goes wrong, pinpointing where the issue originated can be incredibly challenging. Was it a configuration setting? A workflow design flaw? A user misunderstanding? A vendor update? A mismatch between national and local versions of the same system? Add to that, the fact that some third‑party suppliers are unable or unwilling to share detailed technical information (I assume due to concerns that competitors may gain access to it) makes it even harder to determine how the incident occurred or how to prevent it from happening again. Interconnected systems, shared responsibilities Because digital care rarely sits within a single organisation, the responsibilities for harm often cross boundaries too. Different organisations use systems differently. Local configurations vary. Some teams rely on national services; others are still using legacy versions. All of this makes investigation slower, more complicated and highly dependent on strong cross‑organisational collaboration. No single organisation can fully assess digital‑related harm in isolation, but still we try! The challenge for non-patient‑facing Health Bodies For organisations like mine, there is an added complexity: we don’t have direct clinical access to patients. This means our ability to assess harm depends on the engagement of colleagues across health boards and trusts—many of whom are experiencing significant operational pressures. Data security and privacy Sharing information about harm while protecting patient data is essential, but not always simple. We must balance transparency with strict confidentiality requirements. Digital errors, diagnostic risks and human interpretation Not all harm is caused directly by digital systems. Sometimes the system works correctly, but the presentation of the data creates an issue, or the clinician/user interaction or interpretation of the data is the issue. Other times, issues stem from algorithmic limitations, technical malfunctions or messaging fabric (infrastructure that connects the system components and allows them to communicate) problems. Determining whether harm originated with the tool, the user or the interaction between them is rarely straightforward, and tools like Systems Engineering Initiative for Patient Safety (SEIPS) are vital in breaking this complexity down. Training, local workarounds and the gaps no one talks about Training remains a significant challenge. National bodies like mine are not responsible for delivering frontline training, and local approaches vary widely. This leads to several risks: Depth and quality of training varies. Important system features may be misunderstood or overlooked. Safety considerations are not always emphasised during training. Local 'shortcuts'—never designed, tested or approved—become normal practice. Once these shortcuts become embedded in everyday workflows, they can be incredibly difficult to unwind. Yet they often play a significant role in digital‑related incidents. The existing DCB0129 and DCB0160 standards provide a useful foundation, but they offer limited guidance on how to investigate and learn from digital incidents. They were designed at a time when digital healthcare was far less complex than it is today. Suppliers don’t like to highlight their products weaknesses or errors made; therefore, there is vast variation in the quality of investigation reports shared post incident. Rather than worrying about reputational damage, I wish the focus was on candour and opportunities for learning and development. The timeliness problem: when harm takes time to surface Digital harm isn’t always immediate. It may be a misfiled result, a confusing display or a workflow that gradually introduces delay. Additional challenges include: Variation in national policy timescales (in Wales six differing policies provide timescale guidance). The need for clinical review to confirm harm. Limited capacity among clinicians supporting digital investigations. This can make it difficult to meet regulatory expectations for timely disclosure—even when everyone involved is committed to doing the right thing. Freedom to Speak Up: a critical enabler of early detection Speaking up plays a vital role in identifying digital‑related safety issues early. Many concerns emerge informally at first—“this doesn’t look right” or “this field always causes confusion.” If staff feel unsure about raising these concerns, they can remain hidden until harm occurs. Strengthening a Freedom to Speak Up culture is essential. It provides all staff a protected route to escalate concerns, even when they feel uncertain or worry that a system issue might be dismissed as user error or a training gap. I firmly believe that a strong speaking up culture means digital risks are more likely to be surfaced early, before they become incidents. A rapidly changing safety landscape Wales has seen significant changes in digital governance and health policy in recent years, from the transition from NHS Wales Informatics Service (NWIS) to Digital Health & Care Wales (DHCW) to updates in national structures (NHS Executive now NHS Performance & Improvement) and regulatory expectations. As I type, the National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011 (often referred to as 'Putting Things Right') are undergoing review and update. These shifts can create uncertainty about roles, responsibilities and reporting pathways. When something goes wrong, it’s not always clear who is responsible for what—and this ambiguity can complicate harm assessment. Where digital meets traditional healthcare Digital systems are embedded into clinical workflows, communication pathways and multi‑team processes. Every interface, integration point and manual interaction/data entry represents a potential source of risk. Reviewing these interconnected pathways is rarely quick or straightforward, but it is essential for understanding how digital harm occurs and how it can be prevented. Conclusion and call to action: building a safer digital future together The reflections in this paper highlight the complexity of digital patient safety work. Digital systems bring enormous potential for improving care, but they also introduce new risks that we are still learning how to manage. To address these challenges, we need a coordinated national approach that brings together healthcare organisations, digital suppliers, clinical safety experts, policymakers and frontline staff. This means: Updating and strengthening digital safety standards. Improving consistency in both incident investigation and harm assessment. Enhancing training and digital literacy. Supporting timely, transparent reporting. Facilitating availability of clinicians to undertaken harm reviews. Encouraging openness and speaking up. Improved incident data triangulation. Thematic analysis of incidents and nationally shared learning. Building stronger cross‑organisational collaboration. Most importantly, we need a culture where digital concerns are raised early and acted upon quickly. The opportunity ahead is significant, as are some of the challenges… But I truly believe that by working together, we can shape a safer digital health landscape—one that protects patients, supports professionals and ensures that innovation enhances care rather than complicating it. Further reading on the hub: How do we harness technology responsibly to safeguard and improve patient care? NHS England warns electronic patient record could pose ‘serious risks to patient safety’: what can we learn? The foundations for a safe digital service delivery in health—A blog by Rob Ludman Applying a robust approach to digital clinical safety in diagnosis b

This SafetyNet webinar will explore findings from PremPath, an NIHR‑funded qualitative study examining how the perinatal optimisation pathway is implemented across NHS settings. In this session, Dr Julie Roberts will share new insights from extensive interviews with regional perinatal safety leaders, ethnographic case studies across four NHS sites, and parent experiences of preterm birth. The webinar will highlight the relational and emotional work behind implementation, the challenges and opportunities of data‑driven improvement, gaps in coordination of care, the importance of equity and respectful care, and what families themselves tell us about navigating the pathway. In this webinar, they will present findings around: The relational and emotional work of regional leads to engage stakeholders in implementation and improvement. The opportunities and challenges of the extensive data work that underpins improvement. Gaps in coordination of care, particularly between neonatal units and postnatal care. The importance of equity and respectful care across the pathway Parents experiences of the pathway. Register here.

On the 27 November 2025, the Health Services Safety Investigations Body (HSSIB) published a new report looking at patient safety issues associated with electronic patient record (EPR) systems. It is a thematic review which draws on findings from investigation reports by HSSIB and its predecessor organisation – the Healthcare Safety Investigation Branch (HSIB). In this article, Patient Safety Learning sets out its reflections on the report’s findings. HSSIB investigates patient safety concerns across the NHS in England and in independent healthcare settings where safety learning could also help to improve NHS care. Their latest report, Patient safety issues associated with electronic patient record (EPR) systems – a thematic review, summarises and analyses their previous investigation findings relating to EPR systems.[1] Its intention is to identify themes arising from these investigations and to share any additional safety learning. Patient Safety Learning welcomes HSSIB undertaking this work. We contributed to this report during its consultation stage and, in this article, we set out our reflections on its findings. EPR systems An EPR is a set of electronic information about a single patient. It can include: a patients’ own notes test results observations by a range of different clinicians prescribed medications. EPR systems are a way of managing clinical information with the intention of making it more easily accessible to both patients and healthcare professionals. They are becoming increasingly common in healthcare settings across the world and are a core part of how patient care is delivered. Patient Safety Learning perspective When safely implemented, EPR systems can help to support and improve care and treatment. However, there are also significant patient safety risks associated with their implementation and use. At Patient Safety Learning we highlighted a number of these issues last year in our report, Electronic patient record systems: Putting patient safety at the heart of implementation.[2] We believe patient safety should be core to all EPR systems, with robust safety considerations integrated throughout every stage of their introduction: Development Patient safety must be at the heart of the initial procurement, design, configuration and development of EPR systems. There should be a focus on: Interoperability (the ability to work with other computer systems or software used by the organisation to exchange and make use of information). Usability and design for safety, taking a user centred systems and human factors approach. Designing EPRs in collaboration with the staff who will use them. Rollout As EPRs are introduced into organisations, it is vital that the appropriate training and support is provided to staff. There needs to be: Sufficient usability testing (allowing staff who would be using these systems the opportunity to try them and provide feedback) Time allowed for amendments being made to reflect the most efficient and effective processes. Staff should not have to undertake significant workarounds to make an EPR functional; it needs to meet their needs as healthcare professionals and decision makers. A greater role for EPR manufacturers in providing training and support to staff. Implementation Once an EPR is in place, monitoring how it is operating in practice and learning and acting on any risk assessments, incidents or near misses that take place relating to this, is essential. In each of these stages there should be clear steps to involve and engage both patients and frontline staff as part of this process. HSSIB report Considering the patient safety issues associated with EPR systems, HSSIB’s new report states: “The review found that EPR systems could contribute to the risks of patient care being missed, delayed or incorrect. These risks were persistent despite national recommendations and actions seeking to mitigate them.” They grouped their findings into three main categories: Choosing an EPR system capable of meeting the needs of an organisation Implementing an EPR system that meets the needs of users Seeking feedback and ongoing EPR system optimisation Choosing an EPR system capable of meeting the needs of an organisation Before introducing a new EPR system into a healthcare organisation, it is vital that the appropriate planning and preparation takes place. Introducing these systems should be recognised as major organisational change programmes, and as such require the requisite investment of time and commitment from organisational leaders. HSSIB’s report picks up on a number of issues in this area, highlighting that: Organisations do not always have a clear understanding of their requirements/needs from an EPR system, limiting their ability to match requirements to system capabilities. Choosing an EPR system at the procurement stage is complicated by this lack of understanding, which is often compounded by limited awareness of how these systems meet national requirements, including interoperability (the ability to work with other IT systems) and clinical risk-management standards. They found evidence of limited support at a national or regional level to help organisations identify their local requirements/needs for an EPR system. Implementing an EPR system that meets the needs of users At Patient Safety Learning we believe that healthcare professionals and those who will be the primary users of EPR systems should be involved in each stage of their design, planning and implementation. HSSIB’s report also underlines the importance of this, noting issues including: Implementation of an EPR system was found to be a complex project that did not always effectively engage users to ensure it was safe and successful. When users were involved in EPR system implementation they were not always representative of those using the system in practice, with difficulties releasing staff from clinical work to contribute to implementation. Staff training in how to use an EPR system was often perceived to be limited. It did not always reflect how a system would be used in the ‘real world’, or offer advice on what to do if the EPR system failed. Seeking feedback and ongoing EPR system optimisation In our response as part of the consultation on this report, we emphasised the importance of the ongoing monitoring of how an EPR system operates after it has been introduced. This is a key issue we also highlighted in our report last year, connected with the often discussed concept in patient safety of the difference between ‘work as imagined’, ‘work as prescribed’ and ‘work as done’.[3] [4] With EPR systems, we need to look at the difference between how these are intended to work, and how they work in practice. Once an EPR system is live, there should be ‘continuous feedback loops’ to understand, and learn from, how it is working. We are therefore pleased to see that HSSIB highlight a number of these issues in their report, including: Staff reported limited routes for raising concerns about poor functionality and usability of EPR systems, and limited action when concerns were reported that could impact on patient safety. Ongoing management of EPR systems, including upgrades and changes, did not always align with the digital standards for clinical risk management. EPR systems were not always kept up to date in line with national guidance and standards, or changes to internal care processes. There were limited opportunities for organisations to share their experiences of implementing and optimising EPR systems for the benefit of other organisations. In seeking to assure the clinical safety of their health IT software, organisations in the NHS are required to meet a formal standard titled DCB0160: Clinical Risk Management: its Application in the Deployment and Use of Health IT Systems. This standard, which is completed by a trust purchasing a system: “… provides a set of requirements suitably structured to promote and ensure the effective application of clinical risk management by those health organisations that are responsible for the deployment, use, maintenance or decommissioning of Health IT Systems within the health and care environment.”[5] DCB0160 documentation is typically completed by the clinical safety officer before the system is launched. The standard suggests that this also applies post launch. We think this exercise would be of particular value in the case of EPR systems, if it was also completed several months after launch as such a system may look and operate quite differently to the way it was expected to pre-launch. At Patient Safety Learning, we believe that organisations should consider completing a DCB0160 post-implementation. Concluding comments This new report from HSSIB makes a strong and valuable contribution on the subject of EPR systems and patient safety. The local-level learning prompts in the report, intended to help organisations consider and mitigate risks around procuring, implementing and optimising EPR systems, are particularly helpful. EPR systems have the potential to improve patient treatment and safety, increase efficiency and reduce the costs of healthcare. However, there are patient safety risks associated with their introduction and implementation. To fully realise their benefits, we need to ensure patient safety considerations are at the heart of their design, development and rollout. References HSSIB. Patient safety issues associated with electronic patient record (EPR) systems – a thematic review. 27 November 2025. Patient Safety Learning. Electronic patient record systems: Putting patient safety at the heart of implementation. 31 July 2024. Steven Shorrock. The Varieties of Human Work. 5 December 2016. Claire Cox. Putting the writing on the wall: Explaining work as imagined vs work as done. 1 August 2023. NHS England, DCB0160: Clinical Risk Management: its Application in the Deployment and Use of Health IT Systems, Last Accessed 26 November 2025.

As we reflect on another year dedicated to enhancing patient safety, Claire Cox, Chair of the Patient Safety Management Network, shares some key highlights and achievements. The Patient Safety Management Network (PSMN) is an innovative network for patient safety managers and everyone working in patient safety. Your unwavering commitment and collaborative efforts have been instrumental in making the network a success. Here’s a look back at this year’s key moments. Membership and engagement Membership growth: This year, our network of 1800 grew by over 400 members from across various healthcare sectors, including acute trusts, ambulance services, community services, mental health services, primary care and social care. Meetings and participation: We hosted 47 meetings with an average weekly attendance of 103 participants. These gatherings fostered robust discussions, knowledge sharing and collaborative problem solving. Participants are patient safety managers, clinicians, patient safety partners, educators, risk and governance managers, reflecting that the Network is open to anyone working in patient safety in the UK. Expert speakers: We welcomed 47 distinguished speakers from different areas of the healthcare system, who shared valuable insights and innovations in patient safety, inspiring discussion and ideas for patient safety improvement. Networking: Colleagues connected with each other outside of the Network meetings, collaborating and sharing perspectives and good practice. We inspired another Network: In November, Sarah Charles gave a presentation on the Multi Agency Review Group (MARG). MARG is a system-wide group that supports the review of joint incident investigations. It is a mechanism for the surrounding region to meet up, share and contact each other with ease. Key topics and discussions Throughout the year, we explored a wide range of crucial topics, including: Patient Safety Incident Review tools: We deepened our understanding of PSIRF tools such as ACCIMAP, FRAM (Functional Resonance Analysis Method), SEIPS (Systems Engineering Initiative for Patient Safety), observational studies and After Action Reviews. We learned about the tools and importantly how to apply them Engaging with families: Engaging discussions were held around thematic reviews, focusing on family and patient engagement models, learning about the harmed patient pathway from AvMA and improving safety culture. Improving safety culture: We heard from various Trusts about their PSIRF journey, learning reviews, Schwartz Rounds and strategies for supporting staff affected by patient safety incidents. Achievements Our inaugural PSMN Symposium In September, together with the Patient Safety Education Network (PSEN), we held our first Patient Safety Symposium. Our annual symposium was a hub of creativity, innovation and collaboration. Members shared experiences, strategies and solutions to emerging patient safety challenges. This year’s focus was on the practical application of SEIPS and ACCIMAP. We are grateful to BD for hosting the event at their Safety and Innovation Hub in Winnersh, Berkshire, which allowed us to offer the symposium free to PSMN and PSEN members. Our first book: 'Patient Safety - Emerging Applications of Safety Science' This year also marked the release of our first book, 'Patient Safety: Emerging Applications of Safety Science'. The book delves into the evolving landscape of patient safety, exploring the latest research, methodologies and applications of safety science in healthcare. Featuring contributions from leading experts within our Network, it offers practical insights into the implementation of safety principles and tools in real-world healthcare settings. The book serves as a resource for professionals seeking to improve patient safety through the application of scientific frameworks and evidence-based strategies. We’re delighted at how positively the book has been received and are already exploring ideas for a second edition. Looking forward to 2025 We are excited about the year ahead, and we look forward to building on our successes and continuing to collaborate on initiatives that make healthcare safer for all. We are already booked up to April with speakers and welcome ideas for topics and new speakers. With the appointment of new staff to our Patient Safety Team, we’re going to be developing new networks (watch this space!) with the PSMN being the hub of all our networks. A big thank you! I would like to extend a heartfelt gratitude to all members for your dedication and contributions to the Network. Your hard work and engagement are what make the PSMN so impactful. I’d also like to say a thank AQUA, who assist taking notes at Network meetings, and BD who provided some tech setup funding for the private forum on the hub. I’d especially like to thank Patient Safety Learning for hosting the Network on the hub and providing us with invaluable support to grow and develop the PSMN over the past three years. Together, we are making significant strides in patient safety. Wishing you a safe and happy New Year! How to join the Patient Safety Management Network You can join by signing up to the hub today. When putting in your details, please tick Patient Safety Management Network in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected].

This report presents the first cross-sectional analysis of quality of care and patient safety in the World Health Organization (WHO) European Region. It is based on an analysis of macro-level data from international sources and the results of a WHO survey conducted in 53 Member States. Critical gaps identified include limited implementation of national action plans and policies for quality of care and patient safety and wide variations in indicator outcomes for dimensions of quality of care, health system functions and population health outcomes across the region. Key findings in this report included: A scaling up of implemented national action plans for quality and patient safety, including a demonstration of learning and continuous improvement of better practices, processes and outcomes, is needed in the majority of countries. Only one third of countries implemented both a national quality of care and patient safety action plan. Hospital accreditation systems are implemented in only a minority of countries, hindered by a limited availability of evidence, particularly on their cost-effectiveness. Antimicrobial resistance (AMR) plans are widely available in countries, but ample opportunities remain to combat AMR. The majority of countries (79%) have implemented an AMR plan, but persistent disparities in AMR prevalence for Escherichia coli (E. coli) and methicillin-resistant Staphylococcus aureus (MRSA) remain across the region. Patient or public representation in national health governance is nearly non-existent, with only 13% of countries using this policy mechanism. Health misinformation prevention plans are absent in nearly all countries. Only four countries reported the use of a health misinformation plan. Such plans are important because they allow countries to deal effectively with infodemics during emergencies, including disease outbreaks, as well as with behaviours related to immunization adherence and noncommunicable diseases. The scarcity of the health and care workforce has significant consequences for the delivery of high-quality care. A limited number of countries have a national approved priority/essential medical devices list. Data show that only 22 countries have a national list of approved priority/essential devices. Electronic health records (EHR) are implemented in a low number of countries, jeopardizing the effective uptake of quality improvement interventions. Less than three quarters of countries (70%) reported having implemented EHRs, with only 13% having guidelines for quality and safety in telehealth. Patient safety-related indicators suggest a need for improvement with a high number of patient-reported medical mistakes. People-centredness indicators highlight important gaps in data collection on patient-reported outcome measures and experiences. Less than one third of the countries report on people-centredness indicators. Patient-reported outcome measures (PROMs) and experiences (PREMs) have important consequences for public confidence in the health system, health-care utilisation patterns, retention in care, and people’s decision to bypass facilities. Aggregated data mask inequalities within countries, showing a need for local systems of data collection and an evidence-base for equity-oriented policies. Poor population health outcomes highlight the need for a life-course approach and intersectoral action taking a quality of care perspective on the health of individuals and generations. Policy actions Based on the findings of the survey and towards addressing some of the challenges revealed across countries, a number of prospective actions to promote and/or ensure quality of care and patient safety emerge from the analysis. Invest in whole-system quality that comprises integrated quality planning, quality control, and quality improvement activities. Invest in the development of national action plans and policies for quality of care and patient safety. Develop a harmonised set of indicators for measuring and continuously improving quality of care, including measures that matter most to patients. Ensure patient and public representation in national health governance. Establish clear, evidence-based standards for all care settings. Re-design models of care around the needs and preferences of patients. Invest in an health and care workforce with the capacity and capability to meet the demands and needs of the population for high-quality care. Invest in robust public budgeting for quality of care and reconfigure payments to incentivise value in health service delivery. Develop comprehensive and multistakeholder-led biotechnology sector policies to address quality and affordability for patients and health-care systems. Invest in digital health solutions that support quality of care.

Adverse event reporting is critical for advancing patient safety within healthcare systems. A significant factor in enhancing reporting rates is establishing a 'just culture'; a framework that emphasises accountability and learning over punitive measures. While just culture significantly enhances adverse event reporting, its successful implementation requires robust commitment at all organisational levels. Reporting adverse events is essential for ensuring patient safety and fostering a culture of continuous improvement in healthcare. Adverse events, defined as unintended injuries or complications arising from healthcare management, offer crucial insights into systemic weaknesses that, if addressed, can prevent future harm. However, underreporting such events remains a significant challenge, often driven by fear of punitive actions, reputational damage or legal repercussions. To address these concerns and promote a robust reporting culture, healthcare organisations must adopt a just culture by implementing standardised frameworks for evaluating errors and establishing robust reporting systems. Transparency in handling reported incidents is critical for building trust among healthcare professionals. Understanding just culture Just culture represents a shift from a blame-oriented approach to one that balances accountability with a focus on systemic improvement. Originating in high-risk industries such as aviation, the concept emphasises that errors result from flawed processes rather than individual negligence. In a just culture, individuals are held accountable for their actions within a fair and transparent system that prioritises learning and improvement. Central to the philosophy of just culture is the idea of psychological safety. When healthcare professionals feel confident reporting errors will not lead to unjust punishment, they are more likely to disclose incidents. This openness enables organisations to identify trends, address root causes and implement preventive measures. Moreover, just culture recognises the distinction between human errors, at-risk behaviours, and reckless conduct, advocating for tailored responses that align with the nature of the behaviour. Barriers to adverse event reporting Despite its potential, the implementation of just culture faces several obstacles. A predominant challenge is the deeply ingrained blame culture within many healthcare organisations. Historical reliance on punitive measures has created an environment where professionals fear repercussions, discouraging transparency. Additionally, managerial inconsistency in addressing errors often undermines trust in the system. For instance, discrepancies in how similar incidents are handled can create perceptions of unfairness, further discouraging reporting. Another barrier is the lack of understanding and awareness of just culture principles among healthcare staff. Without proper training and education, employees may misinterpret the approach as being lenient or as failing to hold individuals accountable. Legal and regulatory pressures also pose challenges, as concerns about litigation can deter organisations from fully embracing non-punitive reporting frameworks. Strategies for implementing just culture Implementing a just culture in healthcare requires a multifaceted approach that addresses organisational, managerial and individual factors. Leadership commitment is paramount; leaders must model just cultural behaviours, demonstrate accountability and prioritise safety over blame. Developing clear policies and guidelines for error classification and response is equally important as it ensures consistency and fairness in how incidents are addressed. Education and training programmes are vital in promoting awareness and understanding of just culture principles. These programmes should emphasise the distinction between human errors, at-risk behaviours and reckless conduct, providing staff with the tools to respond appropriately. Role-playing scenarios, workshops and case studies can help reinforce these concepts and demonstrate their practical application. The integration of non-punitive reporting systems is another critical component. Such systems should be designed to facilitate easy and confidential reporting, with mechanisms to protect the anonymity of reporters when appropriate. Feedback loops are essential for ensuring that staff are informed about the outcomes of reported incidents, which can reinforce the value of reporting and build trust in the system. Measuring the impact of just culture Assessing the effectiveness of just culture initiatives requires the development of standardised metrics and evaluation tools. Key performance indicators may include reporting rates, staff perceptions of psychological safety and the frequency of systemic improvements resulting from reported incidents. Periodic surveys and interviews can provide valuable insights into staff attitudes and identify areas for improvement. Case studies from organisations that have successfully implemented just culture can also serve as benchmarks for best practices. For instance, hospitals that report significant increases in adverse event reporting rates following the adoption of just culture principles often attribute their success to strong leadership, comprehensive training, and consistent application of policies. Sustaining cultural change Sustaining a just culture requires ongoing commitment and adaptability. Organisations must regularly evaluate their policies and practices to ensure alignment with just culture principles. Staff feedback should be actively sought and incorporated into decision-making processes, fostering a sense of ownership and engagement. Continuous education and training are essential for reinforcing just culture behaviours and addressing emerging challenges. Additionally, leadership succession planning should prioritise candidates who are committed to upholding just culture principles, ensuring continuity in organisational values. Conclusion Adverse event reporting is a fundamental component of patient safety, and the principles of just culture provide a robust framework for enhancing reporting rates and fostering systemic improvements. By balancing accountability with a focus on learning and improvement, just culture creates an environment where healthcare professionals feel empowered to report incidents without fear of retribution. Leadership commitment, staff education and integrating non-punitive reporting systems are critical for overcoming barriers and sustaining cultural change. A just culture represents a paradigm shift in addressing adverse events, emphasising systemic improvement over individual blame. Its successful adoption has the potential to transform healthcare organisations, making them safer and more resilient. Future research should focus on developing standardized metrics to evaluate just culture initiatives and exploring their applicability across diverse healthcare settings.