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Hosted by RLDatix, this event brings together Europe’s largest community of health, care, and social care professionals, uniting leaders in service planning, clinical operations, workforce management, and safety to share insights, exchange best practice to help raise the standard of care, everywhere. Over two days, you’ll hear from leaders tackling some of the biggest challenges in healthcare today, from workforce transformation to patient safety and system-wide innovation. Agenda Register

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.

This blog captures a recent discussion at a Patient Safety Management Network (PSMN) meeting, where members of the network raised a number of important questions and issues relating to the Patient Safety Incident Response Framework (PSIRF). PSIRF is currently being rolled out across all NHS trusts in England and takes a new approach to investigating patient safety incidents. Autumn marks the deadline for all NHS trusts in England to transition to PSIRF, so it was fitting that our PSMN meeting on 1st September dealt with some of the key issues the new framework is presenting. Patient safety colleagues from a wide range of organisations shared their reflections, concerns and questions about the complex and pressing issues they are facing as they seek to adopt PSIRF’s new approaches to patient safety incident responses. There were rich discussions about variation in how trusts are implementing the framework, the resource implications of meeting the expectations of NHSE regarding PSIRF, how patients engage with the process and who should work with them. Perhaps the most important question that was discussed was about the purpose of patient safety investigations—families may have very different ideas to managers or incident investigation teams about why a loved one’s death should be investigated, and that can hugely affect how they respond to and experience the process. What are the implications of increasing engagement with families and patients? PSIRF introduces a range of new approaches to incident investigation, aiming to make the process shorter and simpler, more collaborative and transparent, and easier to implement learning from. Trusts’ existing patient safety structures and teams will need to adapt to significantly different ways of working under PSIRF. One of the key topics was how to highlight and deal with the consequences of these changes, some of which have been predicted and some of which have possibly not yet been considered by NHS England and individual trusts. Here are some of the implications that members highlighted: There is a resourcing and capacity issue linked to the increased work involved in engaging with families. For example, some organisations are separating the role of engaging with patients and families from that of undertaking investigations, to reflect different staff positions, experiences and skill sets. Across some organisations there is a huge gap in family liaison and support, and that extends to PSIRF. This is a significant resourcing issue that needs to be addressed, as without adequate communication and support, investigations can be very distressing for patients. Different ways of working will require changes and updates to trusts’ technology. For example, some trusts are designing trackers to record and monitor engagement with patients and families by multiple staff members. While this should improve communications between staff and patients, trusts may need to invest in digital and other solutions to make sure systems are reliable and that staff know how and when to use them. Does the language and approach of PSIRF create barriers for patients? The discussion then moved on to the fact that how we engage with patients and families can compound the harm they have already experienced. Working with harmed patients isn’t easy and needs the right people, equipped with right skills and the right resources. Many members voiced the need for more guidance and training for all clinical staff, as PSIRF means that their role in investigations and patient engagement is changing. For example, some organisations are updating their Duty of Candour policy to reflect the requirements of PSIRF, and these changes will affect all clinical staff. During the discussion, several members pointed to incidents where families had found the approach and language of PSIRF difficult, or even offensive. There was some discussion about how the language used is a barrier to patient engagement, with names and descriptions in the framework laden with what is being seen as NHS jargon such as ‘learning leads’ and ‘patient safety partners’. Members pointed out that this language is inaccessible and doesn’t make it easy for patients to understand what’s going on in the investigation process. One member suggested learning from the way the Parliamentary and Health Service Ombudsman has used accessible language in its new NHS Complaints Standards. Several members reported instances where families had found the language of PSIRF insensitive. For example, one family member had told a member of staff, “my mother’s death is not a learning opportunity.” Perceptions that the investigation process is detached from the reality of a person’s lived experience can lead to difficulties in maintaining supportive and positive relationships with patients and families. It highlights a need to consider whether the language used in the implementation of PSIRF is adequately compassionate and respectful. We also talked about when the best time to involve patients in different PSIRF processes is. For example, one member pointed out that if you involve patients in an After Action Review (AAR) too early on, then you won’t have any answers for them, and this can be frustrating for everyone involved. On the other hand, conducting an AAR without the patient won’t include the patient's direct insight and might be seen as ‘rehearsing the truth’. This can undermine trust in the transparency of the investigation. We also looked at the resources and literature available for patients engaging with PSIRF, and the general feeling was that there is a big gap here. There is no guidance from families from NHS England, and while some excellent resources have been produced by the Learn Together collaboration, they are quite lengthy, which may put patients off. It was suggested that a summary version of the resources would be a helpful tool to offer patients. What’s the purpose of patient safety investigations? The issues we looked at around the language of PSIRF led on to a broader discussion about why we investigate, and whether PSIRF is aligned with patient views on this. PSIRF places a big emphasis on learning from patient safety incidents, which is clearly vitally important for improving patient safety. However, patients who have been harmed or people who have lost a loved one to avoidable harm are likely to have different reasons for wanting an investigation. The family member previously mentioned, who did not like their mother’s death being referred to as a ‘learning opportunity’, did not see organisational learning as the primary purpose. Patients and families may be looking for: a sense of justice and, in some cases, compensation. compassionate support and clear information on what happened to them or their relative. assurance that changes will be made to prevent future harm. This is a strong motivator for most patients, but it may not be the only reason they want to be involved in the process of investigation. It was also pointed out that the proportionate approach that PSIRF promotes presents us with a big gulf in the nature and approach we take to patient and family engagement. The level of engagement will depend on the severity and impact of avoidable harm, meaning patients involved in incidents that don’t reach the threshold for a patient safety incident investigation (PSII) may not receive the answers and support they need. Staff engagement and support for patient safety specialists As well as the challenges PSIRF presents in terms of patient engagement, the new framework will also require buy-in from staff right across the organisation. Some members shared concerns about attitudes they had encountered in front line clinicians and patient safety leads. For example, it was reported that some doctors are taking the view that if no AAR is submitted, they don’t need to have a Duty of Candour discussion with patients or families. One very important question we discussed was what additional support might be needed for staff who conduct investigations or work in patient safety roles. Exposure to traumatic events and awful harm, day in and day out, is painful and causes harm in itself. There is a clear gap here; dealing with patient safety incidents can be emotionally draining, and we talked about the need for clinical supervision and psychological support for staff. At past PSMN meetings we have discussed at length the need to provide support and resources for harmed patients and their families. It is an important area that we will return to at future meetings. Variation between trusts The key theme that ran throughout the session was variation in how different organisations are implementing PSIRF. Each organisation’s culture and commitment to patients and family involvement will be an important factor in how PSIRF is implemented. While some organisations have a strong base on which to implement PSIRF patient engagement recommendations, others don’t. Some of the key variations discussed include: different practical approaches to engagement. Some trusts will have informal discussions with families, while others undertake more formal reviews and investigations. a wide range of structures across patient safety teams, with roles carrying different responsibilities from trust to trust. differences in how tools are applied. For example, some trusts are using AARs to assess how effective the investigation process is, while others are using them as a learning response directly. Some trusts are involving patients directly in AARs, while others are using their Patient Engagement Leads as the patient representative in the process. Patient Safety Partners have different levels of involvement in learning responses. PSIRF was deliberately designed to allow trusts to adapt their approaches according to their own contexts, which means that variation is an inevitable part of PSIRF implementation. However, members of the PSMN are expressing concern about how this will exacerbate inequities for patients based on where they happen to live—an incident that qualifies for an AAR in one trust may not qualify in others. Reflections on the way forward These wide-ranging issues feel like a lot to try and deal with while doing the day-to-day work of patient safety management. But as one colleague pointed out, there has been little funding or training on these complex issues, and members shouldn’t be too hard on themselves. There is a long way to go before PSIRF makes tangible improvements to the methods and outcomes of learning responses and incident investigations, for both patients and staff. It was highlighted that research and evaluation funding to consider dissemination and implementation is available for another year and members should consider how they might access and use this to look at tackling some of these key issues. Joining the Patient Safety Management Network Do you work in patient safety and want to join the Patient Safety Management Network? You can join by signing up to the hub today. If you are already a member of the hub, please email [email protected].

The eyewatering cost of clinical negligence claims to the NHS have dominated the headlines over the years, with spending increasing on average by 13% each year since 2010/11. Should costs continue to rise at the same rate, we could see the NHS paying out £4.4 billion a year by 2023/24, constituting a major threat to the sustainability and viability of the NHS. We need to tackle the problem at the source – by making improvements in quality and patient safety so that both patient harm and subsequent litigation are reduced. According to NHS England, by 2024, continuous improvements in patient safety could save an extra 1,000 lives and up to £100m in care costs each year. So how can this threat be reversed and where does technology come into play? The role of technology in enabling staff to shift from a reactive to a proactive approach to deliver patient care, subsequently preventing avoidable harm Investing in the right infrastructure to support staff identify risks, ultimately reducing litigation costs Really committing to learning and having a system in place which instils that learning Enabling and supporting system-wide safety improvements To register, please click here.

This website contains freely available resources for anyone undertaking or working within care homes. These resources were developed by infection prevention control (IPC) experts and supported by Care Home Relatives Scotland and include downloadable guidance on infection control, compassionate and safe care home interactions and leaflets that help reassure and support anyone who is planning spend time with a care home resident. Time to open up (part 1) - How infection prevention and control measures can enable safe and compassionate care home interactions; visual scenarios bringing this to life. Time to open up (part 2) - An information leaflet designed to further reassure and support anyone who is planning to spend time with a care home resident.