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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.

In February, Public Policy Projects (PPP) hosted their annual Patient Safety Forum in partnership with Patient Safety Learning. Held at the Royal College of Surgeons of England in London, it was attended by senior healthcare leaders, patient safety experts, representatives from the HealthTech industry, frontline healthcare professionals and patients. A wide-ranging conversation between Penny Dash, Chair of NHS England, and the PPP Chair, the Rt Hon. Stephen Dorrell, offered a rare, candid look at the thinking behind the forthcoming National Quality Strategy and the complex trade-offs shaping it. The session was a live debate on the priorities, pressures and realities of improving care across the NHS. In this blog, Patient Safety Learning reflects on the key takeaways from this keynote session. A strategy nearing the finish line Penny Dash confirmed that the National Quality Strategy is in its final stages, with publication anticipated in April 2026. The process has involved extensive input from across the system, with the National Quality Board—co-chaired with the Care Quality Commission—playing a central role in refining the final draft. While the timeline reflects urgency, it also highlights the challenge of aligning political, clinical, and operational perspectives in a single framework. However, there was a concerning lack of focus on the NHS Patient Safety Strategy. Will it be updated or subsumed into the National Quality Strategy? This interview made it clear that while patient safety may have become less of a focus for NHS leadership, for the delegates in the room it was front and centre. During a panel session earlier in the day, Bola Owolabi (CQC Chief Inspector of Primary Care and Community Services) had a clear focus on patient safety, saying that we are all patient safety practitioners and that interfaces between episodes of care are the biggest patient safety risk, with many patients falling between the cracks. Did we witness a complete difference of opinion and priority between key senior NHS leaders and, if so, what hope is there for coherent strategies that will align to bring safer care and improvements? No surprises—but a sharper focus At its core, the strategy reaffirms three familiar pillars of quality: Effectiveness (outcomes). Safety. Patient and user experience. But what matters is how these are prioritised. Penny Dash was clear that improving life expectancy and healthy life expectancy is the overarching goal. That means focusing on major drivers of population health, particularly cardiovascular disease and cancer, while aligning with broader NHS reforms around prevention, community care and digital transformation. The big insight: effectiveness versus safety One of the most striking moments came when Dash revisited a controversial finding from her earlier review: Improving effectiveness could save ~100,000 lives per year. Improving safety could save between 1,000 and 10,000. Her message was clear: this is not a choice, but it does challenge how the system has historically prioritised safety over other aspects of quality and the outcomes from that; aspects of patient safety have not improved over the past 25 years. Audience members pushed back on this framing, arguing that safety and effectiveness are often intertwined in practice. Penny Dash agreed, acknowledging that quality cannot be meaningfully separated into silos and should instead be addressed as a whole. A system out of balance Penny Dash also pointed to a deeper structural issue: how resources have been allocated across the NHS. Over the past decade: Hospital spending has risen significantly. Primary care has seen modest growth. Community care funding has declined. At the same time, life expectancy and healthy life expectancy have fallen. The implication is stark: the system may be investing heavily, but not always in the areas that deliver the greatest long-term health impact, reinforcing the need to prioritise prevention, neighbourhood care and earlier intervention. The role of Integrated Care Boards Integrated Care Boards (ICBs) were highlighted as critical to delivering change. Their role is to: Plan services for local populations. Improve outcomes and reduce inequalities. Ensure value for money. Penny Dash emphasised that ICBs must take responsibility for entire populations, including underserved groups such as prisoners and the homeless, while being supported by national guidance and shared best practice. As ICBs implement more strategic commissioning, the performance management of the outcomes will fall to the regions. Given the current situation with resource reductions and redundancies, will anyone be focussing on ensuring the right staff are in place with the right skills to understand safety indicators and analyse the data? A lack of appropriate people in place who understand this agenda will leave a void, meaning we will see no progress in how the available data is used to review implementations, learn lessons and make improvements. Patient experience: leadership without mandates A major proposal within the strategy is the creation of a National Director of Patient Experience, aimed at strengthening how patient feedback informs decision making. However, this sparked debate around a broader theme: the approach of not mandating process and practice across the NHS. The perspective from Penny Dash was that too many mandates can stifle innovation and local responsiveness; however, too few can lead to inconsistency and inaction. Rather than imposing roles or structures from the centre, the strategy will lean towards defining best practice and encouraging adoption locally—a move that drew both support and scepticism from the audience. Patient Safety Learning has recently highlighted through our blogs the concerns that the patient voice is being dissipated given the structural changes resultant from the implementation of the Dash review. We will look to support initiatives strengthening the patient voice that might come from the new National Director of Patient Experience. Technology as a game changer Another key theme from the keynote was the role of technology, particularly through Modern Service Frameworks. Unlike traditional guidelines, these are envisioned as live, digital tools that will integrate with patient records with the ability to provide real-time prompts to clinicians. Early focus areas include cardiovascular disease and sepsis, with ambitions to expand into mental health, frailty and children’s services. If successful, this could mark a shift from static policy documents to dynamic, data-driven care pathways. Beyond healthcare: the wider determinants The discussion also touched on the limits of the NHS alone in improving health outcomes. Penny Dash highlighted the importance of social prescribing, housing and legal support, and community and mental health services. These 'non-biomedical' interventions are increasingly recognised as essential but require closer collaboration between the NHS, local authorities and public health systems. The mandate dilemma—still unresolved Perhaps the most persistent theme throughout the session was the unresolved tension between national consistency and local autonomy. As the chair noted, this is “as old as the health service” itself. Dash’s position was pragmatic: neither extreme work. The challenge is to find a balance that ensures high standards across the country while allowing local systems the flexibility to innovate and respond to their populations. Audience Q&A Members of the audience were given the opportunity to pose questions to Penny. Following a comment from her, that our collective focus should have been on quality rather than patient safety, there was a noticeable edge to delegate’s questions. People were surprised that patient safety appeared to have been downgraded in importance and others seemed to question whether NHS senior leaders are in tune with the reality of frontline work. Some felt this was not a positive demonstration of leadership in a time of significant change within the NHS. A system in transition The conversation made one thing clear: the National Quality Strategy is not just a document, it’s an attempt to reshape how the NHS thinks about quality, signalling a shift from safety alone → to broader outcomes, from central control → to guided collaboration and from static policies → to dynamic, tech-enabled systems. But it also exposes the scale of the challenge. Balancing priorities, reallocating resources, integrating services and maintaining public trust all while improving outcomes will require more than strategy alone. It will require sustained alignment across one of the most complex healthcare systems in the world. And as this session showed, that conversation is only just getting started. At Patient Safety Learning, we look forward to the publication of the National Quality Strategy. We will reflect and engage with our network members before publishing on the implications for patient safety. Find out more about the Patient Safety Forum 2026 You can read more about different discussions and panel sessions at this year’s event in the below: Safe systems, safe cultures: reflections from the Patient Safety Forum 2026 Patient voice, safety and the NHS 10 Year Plan: Reflections from the Patient Safety Forum 2026 Designing AI with patient safety at its core: Reflections from the Patient Safety Forum 2026

ABHI Patient Safety System Foundations: A Call for Action is a comprehensive report outlining how the HealthTech industry can work with partners across the system to reduce avoidable harm and strengthen safety for patients and healthcare workers. Developed with Patient Safety Learning, the report highlights the persistence of avoidable harm, the pressures facing the health system, and the far-reaching opportunities created by the NHS 10 Year Health Plan. It sets out ambitions for patients, healthcare providers, Integrated Care Boards, system leaders, regulators and industry. A central theme is the role of HealthTech as a trusted partner, with case studies demonstrating how technologies already in use are reducing infections, improving surgical pathways, supporting antimicrobial stewardship and lowering mortality in critical care. These examples show how well-implemented innovation can save lives, improve outcomes and release system capacity. The report also outlines specific actions for industry, from strengthening post-market surveillance to advancing equity and sustainability in product design and implementation. These recommendations underscore the importance of partnership, transparency and shared learning.

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.

This blog explores the ever-present risk of self-harm in inpatient mental health settings and looks at ways to reduce this risk.  Inpatient mental healthcare is intended to offer refuge. In theory, these are places where an individual in (mental health) crisis can step out of the chaos and venture into a structured environment that’s designed to stabilise and guide them back to balance. But for those struggling with self-harm, the reality of inpatient care is often far more complex: rules intended to keep these patients safe may suddenly become triggers. Research studies are unanimous: patients who rely on self-harm as a way to manage the intensity of their feelings can find inpatient spaces challenging. Deprived of a familiar coping mechanism, they might feel isolated or even punished (a situation that prompts an escalation of distress rather than relief). This paradox—the push and pull between patient safety and autonomy, control and compassion—makes managing self-harm in inpatient mental health settings a hefty ordeal. Self-harm in inpatient treatment: what do the studies reveal? One research study published in the Journal of Psychiatric and Mental Health Nursing has, among other results, concluded that, for some patients, the inpatient environment temporarily reduces the incidence of self-harm simply by making it physically more challenging to do so. Yet, the study underlines this sense of enforced security is fragile. For patients who have come to rely on self-harm as a form of release, removing that outlet without addressing the underlying pain can magnify feelings of helplessness. That also makes things difficult for the staff: they’re aware that while restrictions can reduce harm, they also risk pushing patients into more dangerous or desperate forms of self-harm. How to reduce the risk of self-harm in inpatient mental health settings Reducing self-harm risk in inpatient mental health settings requires a shift away from containment and toward a model that promotes healing through connection, trust and empowerment. Build authentic trust Safety isn’t simply about restrictions or even vigilance. Safety, in a setting meant for healing, is about creating trust. A staff member trained to listen without judgment and to approach the patient with calmness and empathy is often the first line of defence against self-harm. When patients feel they can freely communicate about their urges without the discouraging fear of punishment, it can reduce the compulsion to self-harm in secrecy. Offer practical coping tools Patients who self-harm typically do so because it serves as a reliable, although harmful, way to manage emotions they simply can’t handle. In an inpatient setting, replacing self-harm with skills like grounding techniques, mindful breathing, meditation or yoga, and keeping an everyday diary can be more than helpful. Introducing these skills as an alternative to self-harm will require time, practice and encouragement. Staff who guide patients through these techniques will be an important link; they’ll help patients see and feel that self-control, and not self-harm, is achievable. Provide plenty of safe outlets Patients frequently injure themselves because they don't have safe ways to express the overwhelming emotions they're experiencing. Establishing specific areas and times for patients to express themselves via art, journaling or group conversations provides a healthy means of processing challenging emotions. These kinds of therapeutic channels can lessen the urge for self-harm as a release mechanism while also making patients feel heard and understood. Collaborative care Involving patients in creating their treatment plans can foster a profound sense of agency they feel they lack. When patients participate in defining their goals and strategies, they are more likely to engage meaningfully with their treatment. Collaborative care doesn’t just manage symptoms—it affirms the patient’s role in their recovery. By involving patients as partners, we validate their insight and resilience, helping to counteract feelings of powerlessness that can trigger self-harming behaviours. Support staff resilience Working in mental healthcare, especially in crisis settings, demands both emotional endurance and self-care. In facilities where staff face constant pressure to prevent self-harm, the emotional toll can lead to burnout. A burnt-out staff member may unintentionally create a tense atmosphere that patients can sense. Facilities that invest in support systems—counselling, peer supervision or regular team check-ins—enable staff to maintain the compassion and resilience needed to connect with patients. When staff feel cared for, they can care more effectively, healing the inpatient environment. Conclusions Inpatient mental health settings face an immense challenge: to protect individuals from self-harm while also supporting the emotional work that is essential to recovery. Research underscores that while restrictions on self-harm may reduce immediate risk, they cannot address the pain that drives these behaviours. Without a shift in approach, the risk of self-harm in inpatient mental health settings remains. A treatment model that combines empathy with skill-building, collaborative care and staff support creates a space where healing can occur on a deeper level.