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In healthcare a single report—no matter how minor—can challenge an assumption and shift an entire system toward safer care. 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 Office of Inspector General. Hospitals Did Not Capture Half of Patient Harm Events, Limiting Information Needed to Make Care Safer. 2025. 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): 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.

We hear time and time again on the hub about the lack of joined up care and communication within and across organisations. Patients and their families and carers not knowing who to contact to chase up a referral, having to travel miles for appointments, miscommunication, diagnostic errors, or having to repeat the patient’s history and medications to every new healthcare professional they see because the notes haven’t been shared or clinicians "don’t have time to read them all". These issues are widespread and urgently need to be addressed if we are to prevent people falling through the gaps and suffering worse health outcomes. In this blog, David* shares his story about his elderly sister and a mix up with an urgent referral which led to a near miss. Background My sister has cancer and she's got a diagnosis of dementia too. The cancer is very aggressive and it causes her a lot of pain. Her care team are managing her pain very well. Due to her age and frailty, chemotherapy was out of the question but she had surgery and it seemed to go well. She was having routine check ups post-op to monitor her. An urgent referral A few months later unfortunately the cancer came back and we got an urgent referral from her GP for her to see her consultant. So when within a couple of weeks we got an invite to the hospital for an appointment we assumed it was for her urgent cancer referral. When we got to the appointment, neither the consultant or her advanced nurse practitioner team, who were all familiar with her diagnosis and history, were there. Instead there was a junior doctor on his own. He asked my sister how she had been since her surgery and was she doing well. When my sister said, well no, the tumour had grown significantly and we think the cancer had come back, he went white and rushed out of the room saying he needed to speak to someone else. Communication issues He came back and said my sister would need 20 days of successive radiotherapy in the hospital (which is at least a two-hour round trip). We had many questions we wanted to ask but he wasn’t able to answer them, and I was very concerned whether this was the right course of treatment for her. There were a number of issues—I had questions about how aggressive the cancer was, whether the cancer had spread elsewhere, whether this was palliative or curative treatment, what impact this would have on my sister’s health. Radiotherapy is harsh and my sister was physically very frail. In the end, because I phoned the advanced nurse practitioner and explained what had happened and my concerns, we were invited back for another appointment, and a few days later we saw the consultant. On the advice given, my sister was told about the significant risks and unsuitability of radiotherapy because of her co-morbidities and she decided not to go ahead with the radiotherapy. This was a relief as I didn’t want her to have unnecessary treatment, especially treatment that would not address her cancer and make her remaining months painful and distressing. The consultant was wonderful, and I’ve written him a lovely letter thanking him, but there has been a big communication issue here which could have led to a different outcome altogether. A 'near miss' The issues here, as I see them, are that the urgent referral got mixed up with the routine post-op appointment, which led to a doctor in training being placed in a situation for which he was untrained and unprepared in making significant treatment decisions. The advice he received and acted upon was from an unnamed consultant who didn’t even speak with or examine my sister. There is also the fact that they didn’t have a conversation with my sister about her options and they just told her she needed the radiotherapy. This is not informed consent! If we hadn't been there with her and questioned it, would she have had that course of treatment, accepted the radiotherapy, even though it was completely unnecessary, which would have led to avoidable harm? This really is a big ‘near miss’. What would have happened if she hadn’t had anyone there to intervene and advocate for her. She has absolute confidence in the health system but, for her family trying to navigate the system, this was incredibly stressful. What happens to the patients who haven’t got a family around to support and advocate for them? We need to look at the whole care pathway and try to design it from the patient and family’s perspective. *The names in this blog have been changed to ensure anonymity. Are you a patient, relative or carer frustrated with navigating the healthcare system? Or is your GP practice or Trust doing something innovative to make it easier for patients? We would love to hear your stories. Please add to our community forum (you will need to register with the hub, it's free and easy to sign up) or email us at [email protected]. Related reading The challenges of navigating the healthcare system: Margaret's story The challenges of navigating the healthcare system: Sue's story Navigating the healthcare system as a university student: My personal experience Lost in the system? NHS referrals "I love the NHS, BUT..." Preventing needless harms caused by poor communication in the NHS (DEMOS, November 2023) Robust collaborative practice must become the bedrock of modern healthcare Robbie: A homeless patient’s struggles with the system Digital-only prescription requests: An elderly woman sent round the houses Lost in the system: the need for better admin Digital-only prescription requests: An elderly woman sent round the houses

After attending a recent Patient Safety Management Network session, Emma Walker reflects on reporting on near misses. I was on one of the great Patient Safety Management Network drop-ins the other week, where they were sharing the learning from a safety observation session. The Session had been in a busy A&E department and at one point the observer flagged that a patient hadn’t been given a name tag for their wrist. The observer stepped in, identified the harm and it was rectified. I asked in the meeting chat if the organisation in question had flagged this as a near miss? "No, I don’t think so" was the response – "there are just too many near misses, and we are just too busy to report every one." Many folk on the call agreed. I was surprised to hear this. Having spent nearly 20 years married to a chemical engineer and spending a lot of my free time with engineers from across industry, I know that this behaviour would be totally unacceptable across the organisational cultures they work in, and potentially a reportable/disciplinary issue. Interestingly, their ingrained behaviours and cultures are such that it doesn’t usually get to that stage as everyone just knows what the right thing to do is and there are systems and cultures to make it easy. However, not the NHS it seems. As my husband said when we discussed this later, "this is free learning, and there are hundreds of firms across the country willing to show you tools and techniques to make reporting quick and easy". A colleague of mine, who was recently clinical, mentioned how ‘busy’ and ‘longwinded’ some reporting forms are... having to log into a computer (if one is available) while so busy: "I used to do mine at the end of a shift, not getting home till after 10 at night despite finishing at 20:15". Going back to the PSMN drop-in, what was really interesting was a nurse from the USA at the meeting was one of the few who agreed that not reporting near misses was really poor safety culture. She talked about how they are an aspiring high reliability organisation and how "we love near misses – we call them great catches". What can you do today to start changing your safety culture? How can you make it easy for all staff to do the right thing? A culture that doesn’t blame with easy, quick processes to follow, and support for staff to do just that. Go and make a great catch and prevent the next patient/member of staff suffering the same harm. As we know, a great catch missed today could become something far worse tomorrow. Do you have a 'good catch' reporting system? Share your experiences and questions in our Community thread or comment below You'll need to register for free first. . Related reading: Near-Miss and Good-Catch Reporting Promote a culture of safety with good catch reports Using good catches to increase worker ownership of safety 5 Examples of good catches in healthcare and how to implement a near miss campaign

'The Family Oops and Burns First Aid' is a free children's book written by Kristina Stiles, beautifully illustrated by Jill Latter, created to support children and their families learning about burns prevention and first aid principles together. The book describes an accident prone family who are not burns aware, who have to go to school to learn about burn safety and first aid principles within the home. The book is aimed at KS1 children and their families, and is available as hard copy book by request from Children's Burns Trust and also as an audio/video book via YouTube.

This free webinar will explore near misses in three different sectors and how controls can, or cannot, be developed to prevent future events. It will start with an introduction to the concept of near misses in healthcare and the challenges faced in learning from these near misses to improve safety. You will then hear how near misses are approached in rail and nuclear and how controls are developed in their processes. At this event, you’ll: Gain valuable insights from all three sectors: healthcare, rail and nuclear. Hear discussion about defining near misses with respect to controls. Learn how to build barriers in systems. Who will this be of interest to? This webinar will be of interest to anyone involved in the management of safety events in their industry/ organisation, and especially human factors practitioners, safety investigators, policy leads and regulators. Register