What is patient safety, and why is it important?

Earlier this month, more than a thousand leaders, academics, practitioners, and patient advocates gathered at the 18th HSJ Patient Safety Congress in Manchester. Across two intense days, one theme echoed throughout the discussions: patient safety is at a crossroads. While there was broad agreement about what unsafe care looks like, the room divided on a deceptively simple question: what is patient safety - and how does it relate to quality?

The former Secretary of State for Health, Sir Jeremy Hunt, put it bluntly: “Deliver high-quality care, and you deliver safety.” Others argued that safety and quality are distinct - or at least different enough to warrant their own language, measures, and governance.

That tension matters. It shapes what boards prioritise, how teams measure risk, and how patients experience care. In this blog, Dr Richard Dune draws on the Congress conversations and the broader evidence base to answer core questions: What is patient safety? Does an agreed definition matter? What are the risks of ambiguity? Why is urgency necessary? The discussion also explores the global and UK scale of harm, unpacks the practical implications for regulated providers, and concludes with clear, actionable recommendations - and a hopeful view of what comes next.

What is patient safety?

The cleanest, most widely used definitions align in spirit even if the wording differs:

• World Health Organization (WHO) - The absence of preventable harm to a patient and the reduction of unnecessary damage to an acceptable minimum

• NHS England - The avoidance of unintended or unexpected harm to people during the provision of healthcare.

By contrast, quality has long been framed internationally across six domains: safe, effective, patient-centred, timely, efficient, and equitable. In that schema, safety is a domain of quality - but it is also its foundation. Without safety, effectiveness and experience are undermined; efficiency is illusory; equity becomes a promise unfulfilled.

A practical, operational sentence many organisations find useful is:

Patient safety is the proactive, system-wide prevention and mitigation of avoidable harm during care - measured and improved through learning, reliability, and resilience.

This blends WHO’s outcome emphasis (“freedom from harm”) with NHS England’s operational focus (“avoidance of unintended harm”), and adds how safety is achieved in practice: reliable processes, resilient systems, and continuous learning.

Importantly, patient safety is increasingly recognised as a discipline in its own right. It is not just a by-product of care quality but a field of research, policy, and practice dedicated to understanding and reducing unintended harm. This discipline moves beyond blaming individuals to examining how culture, processes, and technology shape care delivery, to build safer, more reliable systems.

Do definitions really matter?

Yes - because definitions hard-wire how an organisation measures, governs, and improves. Ambiguity isn’t just academic; it creates practical risks:

• Inconsistent measurement - If “safety” means different things across teams, metrics, and dashboards become non-comparable. The signal is lost in noise

• Unclear accountability - Boards and Integrated Care Systems struggle to assign risk ownership or to answer, “Are we safe enough, right now?”

• Fragmented improvement - Without a shared frame, teams chase long lists of actions and duplicate effort (“reinvention waste”) rather than concentrating on what makes the most significant difference

• Cultural fatigue - Staff are drowned in tick-boxes and “assurance theatre” that doesn’t translate into safer care at the bedside or in the community

• Public confusion - Patients are told services are “safe” but can’t see how that is evidenced, escalated, or improved.

Bottom line - Clarity is a precondition for credible assurance, transparent performance, and intelligent improvement.

Core principles of patient safety

To move beyond abstract debate, it helps to ground patient safety in a few practical principles that organisations can apply day to day:

• Systemic approach - Most harm arises from systemic weaknesses, not isolated mistakes. Analyse processes to find flaws, then redesign them

• Culture of safety - Create an environment where staff feel safe reporting incidents and near misses without fear of punishment

• Patient involvement - Engage patients and families as active partners in care - they often spot risks earlier than the system

• Transparent reporting - Use straightforward, accessible reporting systems to identify patterns, analyse causes, and share lessons learned

• Standardisation and best practices - Reduce variation by applying evidence-based protocols consistently, such as surgical checklists

• Technology and automation - Utilise tools such as electronic health records and automated prescribing to minimise errors and enhance communication efficiency.

These principles reinforce that safety is not just about counting harms - it is about building cultures and systems that make harm less likely in the first place.

The scale of the problem - Global context

Unsafe care is a major, and largely preventable, global public health burden:

• Around 1 in 10 patients is harmed while receiving healthcare

• Over 3 million deaths each year are linked to unsafe care worldwide

• In low- and middle-income countries, up to 4 in 100 people die from unsafe care

• More than half of this harm is preventable, with medication errors accounting for nearly half of the avoidable harm

• In primary and ambulatory care, up to 4 in 10 patients may experience harm; up to 80% is preventable.

The economic burden is equally stark. The OECD estimates that adverse events and their consequences consume 13–15% of hospital spending. Globally, unsafe care is routinely costed at over USD 1 trillion annually when both direct treatment costs and broader economic losses are considered.

The modern patient safety movement was galvanised by the 1999 U.S. Institute of Medicine report, To Err Is Human, which estimated tens of thousands of annual deaths from medical errors in American hospitals. It captured public attention and spurred a global recognition that safety required systemic solutions, not piecemeal fixes.

Examples of patient safety issues

While numbers are helpful, they help to translate risk into real-world terms. Common safety challenges include:

• Medication errors - Wrong drug, dose, patient, or route of administration

• Surgical errors - Wrong-site surgery or retained instruments

• Healthcare-associated infections - Infections acquired in the course of treatment

• Falls - Preventable inpatient falls that cause harm and extend recovery

• Diagnostic errors - Missed, delayed, or incorrect diagnoses.

These are the frontline realities that statistics represent - and they are the issues every organisation must address daily.

The UK picture - Progress and persistent risks

The UK benefits from exceptional professionals, mature institutions, and a strong tradition of improvement. Yet the data still points to systemic, preventable harm:

• Medication safety (England) - ~237 million medication errors occur annually; ~66 million are potentially clinically significant. These errors consume ~182,000 bed-days, cost about £100 million per year, and contribute to ~1,700 deaths

• Avoidable mortality - In 2023, roughly 1 in 5 deaths in England were classified as avoidable (preventable or treatable), signalling persistent gaps in prevention and timely care

• Litigation footprint - NHS Resolution paid out ~£3.1 billion in 2024/25 across clinical schemes - money that ultimately reflects harm and opportunity costs

• Sepsis - Approximately 48,000 UK deaths each year are associated with sepsis; many could be prevented with earlier recognition, escalation, and consistent treatment

• Incident reporting evolution - The new Learning from Patient Safety Events (LFPSE) system reveals a wide variation in reporting cultures, with some providers reporting ~7 incidents per 1,000 bed-days, while others report around 130. This highlights how culture, not just systems, shapes the visibility of risk.

Conclusion - Unsafe care is not rare. It is distributed, costly, and preventable - and it demands a disciplined, system-level response.

Why urgency matters now

If patient safety is so important, why isn’t there a single agreed-upon definition? And why, under the same national standards and regulations, do organisations continue to experience avoidable harm?

Because ambiguity diffuses energy. Without a shared, operational definition that anchors measurement, governance, and improvement, systems drift into:

• Measurement mismatch - Safety dashboards that don’t align with risk; KPIs that reassure but don’t predict; missed learning signals

• Accountability fog - No clear “owner” of safety risk; too much scrutiny, not enough responsibility

• Cultural strain - Teams are overloaded with admin, while the reliability of basics, such as handover, escalation, and infection control, varies daily

• Lost legitimacy - Patients hear the word “safe” but see gaps when concerns aren’t acted on.

The Congress reinforced a simple truth: patient safety is not just technical; it is cultural, systemic, and moral. The costs of delay are measured in lives, trust, and wasted resources.

From debate to delivery - A pragmatic model

To move beyond definition wars, boards and leaders can adopt a four-pillar operational model, attaching a small, disciplined measurement set to each:

1. Harm outcomes (Safety-I)

• Aim - Reduce preventable harm and mortality

• Examples - Severe harm incidents, deterioration outcomes, high-harm falls, medication safety, infection, VTE, diagnostic error proxies.

2. Reliability of safety-critical processes

• Aim - Make the right thing easy, every time

• Examples - Bundle adherence (e.g., sepsis), handover quality, test tracking, escalation response times, “first-time-right” rates.

3. Resilience and learning (Safety-II / PSIRF)

• Aim - Strengthen the system’s ability to anticipate, adapt, and recover

• Examples - Proportionate investigations, implementation of learning, after-action reviews, evidence from “work-as-done.”

4. Patient and staff voice - plus conditions for safety

• Aim - Ensure people can raise concerns and be heard; protect safe working conditions

• Examples - Escalation calls (Martha’s Rule), Freedom to Speak Up cases, fatigue/roster safety indicators, patient-reported concerns and closed-loop responses.

This model is compact enough to manage, rich enough to matter, and aligned with frameworks such as the CQC Single Assessment Framework and PSIRF.

Voices and lessons that cut through

From the Congress and wider literature, several cross-cutting insights stand out:

• Institutional complexity is itself a risk. Too many overlapping mandates fragment focus. The fix is prioritisation and coordination - doing fewer things once, and doing them well

• Tick-box assurance doesn’t equal safety. Real safety comes from reliable workflows, psychological safety to speak up, and learning that changes practice

• Patient and staff experience are safety data. Complaints, near-miss narratives, escalation calls, and staff fatigue are not soft signals; they are leading indicators of risk

• Diagnostic safety is a frontier. Delayed or missed diagnoses may be the largest source of preventable harm. Better tracking, handover, and second-look processes are essential

• Technology is a force multiplier - if co-designed. Digital tools can reduce duplication and provide real-time safety insight, but only if designed with clinicians, AHPs, and patients.

Six priorities for leaders and boards

To move from rhetoric to real change, leaders must focus on practical, high-impact actions that embed safety into everyday operations. The following six priorities highlight where attention, investment, and accountability are most urgently required:

1. Adopt a shared, operational definition of safety.

Ground policy in WHO/NHS wording, then localise it. Align outcomes, process reliability, resilience/learning, and voice/conditions indicators.

2. Prioritise, don’t proliferate.

Run a “stop - start - continue” review of safety asks. Retire low-value paperwork. Focus on the few interventions with the most significant impact.

3. Invest in workforce safety.

Safe staffing, protected CPD, supervision, and leadership development are strategic necessities, not luxuries.

4. Harness digital and data wisely.

Detect risks early, reduce duplication, and provide real-time insights - co-design tools with staff and patients.

5. Strengthen governance and learning cultures.

Use balanced leading and lagging indicators - demand implementable learning from investigations. Make psychological safety non-negotiable.

6. Centre the patient voice.

Move from tokenistic “stories” to co-design. Involve patients in pathway design, policy review, usability testing, and evaluation.

Why this can work - and why now

Momentum is real. The national push for transparency, the maturing of PSIRF, and the roll-out of Martha’s Rule demonstrate how policy can translate into protections at the bedside. Recognition of quality management as a blend of planning, assurance, and improvement gives boards a coherent framework. And most importantly, there is a growing consensus that safety is everyone’s business - from estates and procurement to digital, HR, and finance.

At the same time, patients expect to be safe, heard, and helped - the first time. Meeting this expectation is not only the right thing to do but also the way to retain staff, reduce cost, and build trust.

A concise call to action

If you lead a service, board, or system, here are six steps you can act on now:

• Write down your definition of safety and approve it formally

• Tighten your measurement set to 10–12 high-value indicators across harm, reliability, resilience, and voice

• Pick three safety-critical workflows and make them boringly reliable

• Protect time for learning: after-action reviews, huddles, CPD

• Make escalation visible and easy for patients and staff - then track outcomes

• Retire two low-value tasks for every new one you add.

Do these consistently, and you’ll feel the shift: fewer surprises, more proactive fixes, clearer accountability, and staff empowered to do their best work.

A positive way forward

Despite the scale of the challenge, there is cause for optimism. The direction of travel is toward clarity, coordination, and co-design. The sector is embracing real-time data, smarter digital tools, and more transparent governance. And most importantly, the conversation has matured: from “who is to blame?” to “how do we design systems that make the right thing easy and the safe thing certain?”

The message from Manchester was unambiguous: patient safety cannot wait. Every preventable death and every avoidable harm is one too many. Now is the time to move from debate to delivery - to build services where safe care is not the exception but the expectation.

If you’re ready to translate intent into impact, we’re ready to help. Together, across sectors and professions, we can reduce harm, restore trust, and redefine what “good” looks like - for patients, for staff, and for the communities we serve.

Our role in supporting patient safety

At The Mandatory Training Group, our mission is to help organisations turn commitment into capability. We support providers across NHS, independent, and charitable sectors with:

• Accredited training and CPD - Covering deterioration, diagnostic safety, human factors, and speaking up

• Digital compliance systems - Streamlining policies, competencies, and audits while reducing admin burden

• Governance enablement - Maturity assessments, templates, and board-ready dashboards aligned to CQC and PSIRF

• Workforce development - Leadership and team learning to build psychological safety, improve communication, and embed continuous improvement.

We believe safe care comes from skilled people, reliable processes, and learning systems and with the right tools and training, every organisation can progress rapidly.

Stay compliant, stay safe with ComplyPlus™

Patient safety is not just about policies and definitions - it is about having the systems, data, and culture to prove safety every day. That’s where ComplyPlus™ makes the difference.

With ComplyPlus™, providers can:

• Track safety-critical indicators in real time - From harm outcomes to escalation response times

• Streamline compliance evidence - Policies, training, audits, and incident reporting all in one secure system

• Strengthen governance assurance - Board-ready dashboards aligned with CQC, NHS England, and PSIRF frameworks

• Empower staff and patients - Simple tools that make raising concerns, closing feedback loops, and learning from incidents part of daily practice.

If your organisation is ready to move from tick-box compliance to demonstrable, inspection-ready assurance, explore how ComplyPlus™ can help you embed safety, strengthen culture, and reduce risk.