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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 healthcare, developing a culture of psychological safety is essential to ensuring patient safety; a priority identified in the NHS Patient Safety Strategy. In the context of 10 Year Health Plan for England and healthcare leaders' commitments to psychological safety across all developed nations, it is essential that the safety of patients and staff is at the core of its design and delivery to avoid harm and reduce incidents. If the healthcare system is to truly be transformed over the next decade, matters of culture need to be addressed. At this event, attendees will: Meet experts in culture, clinicians, patient safety who will be highlighting why changes need to be made and how individual healthcare professionals can apply good practice to address the challenges. Gain a deep understanding of what psychological safety is and why it is essential to promote and deliver a safety culture in healthcare. Comprehend the actions needed to improve psychological safety in healthcare - what does good look like? Be provided with an opportunity to make personal commitments for better patient safety. Opportunity to engage with key note presentations, panel session discussions, and listen to personal experience of those than have been damaged by poor culture. Learning outcomes will include: Attendees will be able to identify what psychological safety is, how it shows up in team behavior, and how it differs from trust, comfort, or simply being “nice. Be able to apply practical strategies to build psychologically safe environments by learning specific behaviors - such as framing work as learning, modeling vulnerability, and responding productively to patient safety incidents and risk. Identify, evaluate, and address barriers to psychological safety. Attendees will be able to spot common organizational, cultural, and interpersonal obstacles and use structured approaches to reduce fear, friction, and silence. Find out more and register here.

Last month, Public Policy Projects 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. In this article, Patient Safety Learning reflects on the recurrent theme of safe systems and safe cultures.  Safe systems and cultures formed an integral theme throughout the Forum. Across the discussions, one message stood out clearly—safety cannot be something we focus on only when inspections are approaching or when things go wrong. It has to be built into everyday practice. One speaker framed this idea simply—every day should be a CQC (Care Quality Commission) day. Not because staff fear inspection, but because the systems around them consistently support safe care. When systems work well, healthcare professionals can deliver the care they want to give without constantly battling the structures and culture around them. Yet the conversations during the day also highlighted how far many parts of the system still have to go… Fatigue—“I’ll sleep when I’m dead” A significant discussion focused on staff fatigue and the culture that has developed around it in healthcare. Rather than being treated as an exceptional risk, fatigue is something that is just expected. In some cases it has become a misplaced badge of honour—evidence of dedication to the job. The example phrase of “I’ll sleep when I’m dead” resonated with many. A response no doubt born from a sense of utter powerlessness and lack of evidence that things will change. But normalising exhaustion creates unsafe systems for both staff and patients. Senior Nurse, Maggie Pacheco, shared an example from her own experience. After working six consecutive night shifts she was asked to take on a seventh. It did not feel safe, and during that shift a near miss occurred. Her story reflected a wider reality—systems that rely on exhausted staff are systems that increase risk. Sue Strudwick, Patient Safety Partner, highlighted that fatigue also shapes how care is delivered. When staff are constantly depleted, the system pushes them into reactive responses rather than preventative thinking. Creativity, reflection and improvement require energy and time, both of which fatigue removes. If healthcare is serious about safe systems, then fatigue cannot remain normalised. Staff support must be prioritised and built into the design of rotas, policies and expectations. Structural change is required, not symbolic gestures. Staff safety as a foundation of safe systems The forum also highlighted the importance of ensuring that staff themselves feel safe at work. Healthcare workers continue to face violence, harassment, racism and sexual abuse in some workplaces. These experiences damage morale, wellbeing and the ability to focus on patient care. A safe healthcare system cannot exist if the people delivering care do not feel physically and psychologically safe themselves. Protecting staff is therefore not separate from patient safety—it is part of it. When silence signals risk Another strong theme was the importance of psychological safety, particularly when it comes to speaking up and raising safety concerns. Silence in an organisation is sometimes interpreted as stability. In reality, it can indicate the opposite. Panellists described the presence of “shut up signals” within teams and organisations—signals that speaking up is unwelcome or risky. These signals may appear through dismissive responses, defensive leadership or negative consequences after raising concerns. Once staff recognise them, they quickly learn that raising issues carries a personal cost. The impact on patient safety is significant. When staff do not feel able to speak openly about risks or mistakes, organisations lose their early warning systems. Problems remain hidden until they escalate into serious harm. Language and responses after incidents play an important role here. Punitive reactions can discourage openness and suppress learning. Safe cultures, by contrast, make it easier for staff to raise concerns and share information when something goes wrong. Many of the guests in our Speaking up for patient safety interview series highlight the same issues surrounding psychologically unsafe cultures, and the devastating impact this can have on patients and staff. From blame to systems thinking Closely linked to speaking up is the way organisations respond when incidents occur. Healthcare is a complex system where harm rarely results from a single individual’s actions. During the forum, Ted Baker, Chair of the Health Services Safety Investigations Body (HSSIB), highlighted the importance of shifting the question from “who is to blame?” to “how did the system allow this to happen?” Frontline staff frequently create workarounds to protect patients when systems or policies do not function well in practice. These adaptations often keep services running safely despite structural weaknesses. If organisations focus only on individual blame, they risk overlooking the system conditions that allowed harm to occur in the first place. A systems approach enables learning and improvement rather than fear and defensiveness. Leadership and culture change Underlying many of these issues is the need for a different style of leadership. Creating safe systems requires leaders who listen, collaborate and engage with those delivering and receiving care. Solutions are more likely to be sustainable when they are developed with frontline staff and patients rather than imposed from above. Working with patients, the public and Patient Safety Partners were repeatedly highlighted as an important part of cultural change. A healthcare system that values patient experience alongside operational metrics is more likely to identify risks early and respond effectively. What organisations measure also shapes their culture. When success is defined solely through activity and productivity, the human experience of care can easily be overlooked. Balanced measures that include safety and experience are essential for creating systems that truly support quality care. Culture is the system The conversations at the Patient Safety Forum made clear that safety cannot be separated from culture. Policies and processes matter, but the everyday behaviours, expectations and norms within organisations matter just as much. Safe systems are created when staff are supported rather than exhausted, when concerns can be raised without fear, and when organisations seek to understand system failures rather than simply assign blame. Changing culture is never quick or easy. But if healthcare systems want to improve patient safety, they must be willing to challenge the norms that have become embedded in everyday practice and redesign systems that allow safe care to happen consistently. Share your insights Have you seen patient safety affected either positively or negatively by culture and systems? Share your thoughts on this article and the issues raised by commenting below (sign up first for free). Or you can email our editorial team at [email protected].

The Cheshire and Merseyside Cancer Alliance (CMCA) were finalists in the 'Partnership Working to Improve the Experience' category at the Patient Experience Network 2025 Awards. In this blog, CMCA explain how patient stories are deliberately integrated into their governance, learning and pathway redesign, and how this approach transforms storytelling from passive listening into active improvement. Beyond data—listening to lived experience Modern healthcare systems are built on measurement. We track waiting times, referral-to-treatment targets, survival rates and performance indicators. These metrics are essential and tell us whether services are efficient, timely and clinically effective. Yet some of the most powerful drivers of improvement do not originate from a dashboard—they begin with a story. Cancer care is one of the most complex, emotionally charged and high-risk areas of healthcare delivery. A single cancer journey may span primary care, diagnostic services, multidisciplinary team (MDT) discussions, surgery, treatment, supportive services and palliative or end-of-life care. Along the way, patients navigate multiple appointments, handovers between teams and often life-altering decisions. Delays in diagnosis, unclear communication, fragmented pathways and missed escalation opportunities can have profound consequences. A cancer patient’s story does more than recount a sequence of clinical events. It reveals what mattered most to them in moments of uncertainty. It highlights where systems worked well—and where they did not. It brings into focus inequalities, access barriers and communication gaps. The question is no longer whether patient stories matter. It is how we use them responsibly, consistently and systematically to improve care. From patient story to structured improvement To create measurable impact, storytelling must move beyond powerful listening sessions. It must be embedded into structured quality improvement and safety culture. At CMCA, patient stories are deliberately integrated into governance, learning and pathway redesign. Stories are shared across meetings, events, training sessions and improvement programmes. Rather than treating stories as standalone testimonies, they are used to strengthen systems thinking. Each story prompts structured reflection: where were the faults in the pathway? what safety nets failed or were absent? how did workload pressures or process design contribute? were there missed opportunities to escalate concerns and could this scenario happen in our service today? This approach transforms storytelling from passive listening into active improvement. When patients see that their lived experience leads to tangible change, storytelling becomes partnership—not performance. On 23 May 2022, CMCA invited its first patient storyteller to a team away day. Hearing a personal cancer journey directly from someone with lived experience had a profound effect. It shifted conversations from abstract targets to real human impact. Since then, colleagues across the Alliance have increasingly invited patients to share their experiences to inform pathway redesign and programme development. Between 2022 and 2025, 73 patient stories have been shared. As a result, six significant changes have been implemented. These include improvements to the accessibility of diagnostic testing and the development of a patient engagement checklist for the pathology transformation programme. Other impacts are less immediately measurable but equally meaningful. Stories often leave a lasting impression, influencing how leaders think about service design long after the meeting ends. Empowerment through partnership For many patients, sharing their story is both courageous and empowering. Storytellers remain fully in control of what they share and how they share it. CMCA offers multiple formats—written narratives, audio recordings, video submissions or in-person presentations—ensuring that individuals can choose what feels safest and most authentic. One storyteller reflected: “Oh my word, it's always so amazing to know people hear what I say and take it in.” Another, a CMCA Patient Representative, shared: “Sharing a patient journey can feel daunting at first, but the team at CMCA have been empathetic, kind and supported me every step of the way. Knowing that my words can help others in some way gives me hope and helps me to heal.” Storytelling has also opened further opportunities for patient involvement. Some storytellers have joined project groups, contributed to service redesign or been connected to additional support services. What begins as a story can evolve into ongoing collaboration. Embedding the patient voice in leadership and education The influence of storytelling at CMCA has expanded beyond frontline teams. Patient stories are now a standing agenda item at Board and Diagnostics Board meetings, ensuring that strategic decisions remain grounded in lived reality. At one recent Board meeting, a storyteller who is both a wheelchair user and a cancer patient described the physical and systemic barriers they encountered across their pathway. The account was powerful and specific. It prompted Board members to commission a system-wide accessibility review—a direct example of lived experience shaping strategic action. Patient stories have also informed education. They became the foundation of the 123 Health Inequalities training programme, a CPD-accredited e-learning course developed by the CMCA Health Inequalities and Patient Experience team. Built from both staff and patient voice, the programme uses real experiences to illustrate how inequality manifests in everyday practice—and what professionals can do differently. As Jenny Brazier, Patient Engagement Senior Project Officer at CMCA, explains: “Listening to and acting on lived experience teaches us how to deliver better care and improve services for others. When we truly understand what matters most to patients and their loved ones, we create more equitable, person-centred care.” Conclusion: listening as a safety intervention In cancer care, success is often measured through survival rates, treatment standards and clinical outcomes. These are vital—but they do not tell the whole story. Safety is also about how patients experience their care. Did they feel heard? Were things explained clearly? Were they treated with dignity and supported during an incredibly vulnerable time? Patient stories are not just emotional accounts. They are practical tools for improvement. They help uncover risks that data may miss, reveal gaps in communication or coordination, and highlight where systems create barriers or inequalities. When listening is built into leadership and improvement work, it becomes a powerful safety intervention—helping ensure cancer care is not only effective, but truly centred on those who receive it. The Cheshire and Merseyside Cancer Alliance (CMCA) team. Further reading on the hub: How authentic patient stories can shift systems thinking and improve care Digital storytelling: Learning opportunity or reputational risk? Catching cancer early: what more can we do as GPs?

This year will mark the publication of the first comprehensive Quality Strategy for the NHS in over fifteen years. In this blog, Patient Safety Learning and the Advancing Quality Alliance (Aqua) set out the need for safety to serve as a golden thread woven throughout the Strategy. The 10-Year Health Plan for England presents a significant opportunity to improve patient care, experiences, and outcomes. It is expected that the forthcoming NHS Quality Strategy will seek to deliver these improvements by placing a system wide focus on quality. We believe that improving patient safety is inextricably linked to this aim. Level of avoidable harm Prior to the Covid-19 pandemic, NHS England stated in its Patient Safety Strategy that there were around 11,000 avoidable deaths annually due to safety concerns, with thousands more patients seriously harmed.[1] Separately, a 2026 report from the Institute of Global Health Innovation has suggested that 22,789 lives could be saved if the UK matched the rate of treatable mortality of Switzerland.[2] In practice, both these sets of figures are likely to significantly underestimate the scale of harm given the ongoing enormous strain faced by the healthcare system in recent years. Particularly when also considering the pressures in service provision in primary care, emergency and urgent care and discharge planning with social care. This is an unnecessary tragedy for patients, families, and healthcare professionals. Cost of unsafe care This level of avoidable harm is also accompanied by a huge financial cost. The Organisation for Economic Co-Operation and Development (OECD) has estimated that the direct cost of treating patients who have been harmed during their care in high-income countries approaches 13% of health spending.[3] Excluding cases of avoidable harm that may not be preventable, this figure is 8.7% of health expenditure. NHS Resolution estimated that the “annual cost of harm” of clinical negligence claims alone in England in 2024/25 was £4.6 billion.[4] The problems created by unsafe care also undermine efforts to improve quality by increasing productivity. Avoidable harm and its consequences are inherently inefficient, leading to longer inpatient stays, higher staff turnover, reputational damage and reduced trust by patients and the public in the NHS. Improving safety to deliver improvement Patient Safety Learning and Aqua believe that improving patient safety should be a key cornerstone for creating a more effective and productive health system. This means that we should be designing for safety, to ensure safe outcomes, processes, and behaviours. We should know ‘what good looks like’ for safe care and apply this knowledge rigorously and transparently.[5] This should include: Improving the quality of patient safety reviews and investigations. Sharing learning widely and translating this into tangible improvements. Nurturing an open and restorative culture in the NHS. Listening to patients, families, and staff, to better understand risk, take action to prevent harm and give redress and support to people harmed. Board level oversight and reporting of safety incidents, reviews and learning applied. Greater use of technology, data and analytics to significantly improve the safety, effectiveness and responsiveness of care delivery.[6] We also believe it is important to embrace safety science and not oversimplify complex issues. We must respond to delivering safer ‘work as done’ and not be comforted by revising unrealistic and unachievable ‘work as imagined’.[7] Moving towards a safer healthcare system Leadership will be essential to driving these safety improvements. The creation of a new Quality Strategy presents a valuable opportunity for organisational and system leaders to embrace an integrated approach to patient safety. They should encourage a culture of openness and transparency among staff and patients regarding safety issues and related recommendations, while ensuring that safety and quality remain balanced priorities. We need to find better ways of working within organisations and across patient pathways and systems to design and deliver safer outcomes. We too often remain siloed in our response to avoidable harm and must share and work together to design system-wide solutions. There is a huge opportunity for Integrated Care Boards (ICBs) to drive a systemic approach to patient safety through their strategic commissioning responsibilities.[8] [9] There is however currently significant variation in ICBs involvement in safety management activities.[10] We believe they could take on a clear leadership role for system safety. This could have the potential to develop an integrated and coordinated approach to safety, reflecting patient care pathways across systems and ensuring consistency and collaboration. Patient Safety Learning and Aqua look forward to reviewing the Quality Strategy and contributing to its implementation, ensuring that patient safety is integral to how we design and deliver a transformed health care system. Get in touch For organisations wanting to engage in our work and networks, please contact us at: Aqua: [email protected] & 0161 206 8938 Patient Safety Learning: [email protected] References NHS England. The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients. July 2019. Institute of Global Health Innovation & Patient Safety Watch. National State of Patient Safety 2025: Prioritising improvement efforts in a system under stress. 29 January 2026. OECD and Saudi Patient Safety Centre. The Economics of Patient Safety. From analysis to action. 21 October 2020. NHS Resolution. NHS Resolution annual report and accounts 2024 to 2025. 17 July 2025. Patient Safety Learning. ‘What Good Looks Like’ in patient safety. Last accessed 23 February 2026. Alex Kafetz. Why data on quality of care is now more important than ever. 17 February 2026. Claire Cox. Putting the writing on the wall: Explaining work as imagined vs work as done. 1 August 2023. Aqua. What Should Safety Look Like at a System Level. 6 April 2023. Patient Safety Learning. The elephant in the room: Patient safety and integrated care systems. 11 July 2023. Health Services Safety Investigations Body. Safety management: accountability across organisational boundaries. 13 February 2025.

In this blog, Claire Cox, Associate Director at Patient Safety learning and chair of the Patient Safety Management Network (PSMN), describes how the PSMN is transforming from a community of interest to an emerging movement in patient safety. One where people are empowered to build openness, trust, and courage together. Four and a half years ago, the Patient Safety Management Network (PSMN) began in the simplest of ways: just four people on a Teams call. The new Patient Safety Incident Response Framework (PSIRF) was emerging, and each of us were trying to make sense of what it meant in practice. We weren’t looking for anything grand - just a space to connect, to share a little peer support, and to avoid feeling quite so alone in the work we do. Nervous beginnings Looking back now, it’s almost comical that we chose to hold our first meetings on a Friday afternoon. In retrospect, it sounds ridiculous - how was that sustainable? Why would anyone willingly show up at the end of the week, when energy is lowest and inboxes are fullest? And yet, people did. Perhaps it was the timing, coming at the moment when we were finally exhaling from the week. Perhaps it was the relief of finding others who were facing the same uncertainties. Whatever the reason, those early Friday sessions became the unlikely seedbed of what the PSMN would become. At first, even sharing the smallest thing - like a template - made us nervous. Did we even have permission from our organisations to share this? Every exchange carried a sense of caution. Some people were unsure if they were ‘allowed’ to join the meeting without permission. The network was transactional, useful, but tentative. From transactions to connections In those earliest meetings, the structure was simple. The majority of the time was spent with one person “teaching” the group something, it may have been about the role of the Academic Health Science Network or an update on the Patient Safety Incident Framework. It was mostly passive - people listened, a few had cameras on, but there wasn’t much interaction. And that was okay. The purpose back then wasn’t to force participation. It was to listen, share, and simply be present. If “being present” meant sitting quietly with your camera off, that was absolutely fine. People didn’t have to be there. The fact that they showed up - on a Friday afternoon no less - was the first sign that this network mattered. Presence became the foundation. Even in silence, people began to sense that they were not alone in their work, their questions, or their uncertainties. Over time, that quiet presence grew into participation. People began asking questions, adding their experiences, and opening up. The dynamic shifted from one-way teaching to two-way learning, and eventually into rich, many-to-many conversations where every perspective mattered. That was the turning point: the realisation that the PSMN wasn’t just about transmitting knowledge - it was about creating it together. Building psychological safety This deeper sharing required something crucial: psychological safety. Trust that questions wouldn’t be dismissed. Trust that missteps could be talked about without fear. Trust that every voice mattered, regardless of experience or role. Over time, members began modelling openness and vulnerability - admitting when they didn’t know the answer, sharing stories of what hadn’t worked, and inviting others to join them in learning. Bit by bit, the culture evolved into one where curiosity was celebrated, not questioned. A platform for shared learning Today, the PSMN is unrecognisable from those early Friday calls. It has become a psychologically safe learning platform where insights are not just exchanged but created together. What makes it truly special is the breadth of the community. The network brings together voices from every corner of the healthcare system - frontline staff from all sectors, Patient Safety Partners, carers, academics, commissioners, regulators, and more. You name it, the expertise is represented within our network. And that mix of perspectives is powerful. Because here, learning isn’t confined by organisational walls, geographical borders, or professional silos. Instead, knowledge flows freely across them. Each conversation is enriched by the fact that people are willing to step outside of their own context and learn from others. Now, the PSMN is moving into something we could only have dreamed of in those early days: sharing our Patient Safety Incident Investigations. To begin with, this means exploring how we are approaching them and what the learning has been. It’s an incredibly exciting step - because this is the first time in patient safety history that this kind of open sharing has been done. It is a sign of just how far the network has come: from tentative, nervous beginnings to breaking new ground in the way patient safety is learned and shared. Looking back, looking ahead When we reflect on this journey - from four people on a Friday afternoon call, hesitant to even share a template, to a thriving community that spans the entire UK healthcare system - it’s hard not to feel anything other than inspired. What started small, simple, and a little uncertain has grown into something transformational. The PSMN has become a beacon of what is possible when people come together with openness, trust, and courage. It is no longer just a community of interest, it’s an emerging movement Want to join us? Does your work involve Patient Safety? Are you based in the UK? Would you like to be part of this journey - learning, sharing, and shaping the future of patient safety together? Join the PSMN via the Patient Safety Learning hub The more voices we bring together, the stronger our collective learning becomes.

This webinar, hosted by the Royal College of Surgeons of Edinburgh, will provide a fascinating look inside how NASA manages risk, ensures that its culture supports safe human spaceflight and provides extraordinary leadership to explore the unknown. Aims To explore NASA’s approach to risk management and safety culture, demonstrating how effective leadership fosters an environment where every team member’s expertise is recognised, encouraged, and leveraged to enhance safe and reliable performance Learning Objectives By the end of this webinar, attendees should be able to: Understand the universality of risk: To recognise that risk is an inherent feature of all complex systems and tasks including across aerospace, healthcare, and other high-stakes environments. Examine the role of leadership in shaping safety culture: To understand how expert leadership develops, nurtures and sustains a robust safety culture that supports effective risk management. Apply cross-industry lessons to healthcare practice: To identify practical insights from NASA’s approach to safety and teamwork and to consider how leaders in health and care can empower teams, enhance organisational learning and reduce the risk of harm. Register here.