Five Lessons for Improving Patient Safety: Learning, Culture and Action

Patient safety does not improve simply because organisations collect more data. It improves when data leads to learning, learning leads to action, and action is sustained by a culture that supports it.  

That sounds straightforward. The reality is harder.  

The latest Global State of Patient Safety report places the UK 21st out of 38 OECD countries, based on measures including treatable mortality, adverse effects of medical treatment, maternal mortality and neonatal disorders. The analysis found that if the UK had matched Switzerland’s rate of treatable mortality, there could have been 22,789 fewer deaths in 2021, the latest comparable year for this measure. 

The finding is not simply about how much information healthcare organisations collect. It raises a more important question: how effectively does the health and care system turn insight into meaningful, lasting improvement? 

Conversations with patient safety leaders, clinicians and governance professionals continue to surface a consistent set of themes. They cut across organisations, sectors and borders, and they point to shared challenges and shared opportunities for anyone working to make care safer.  

Reporting is the start, not the finish  

The NHS has collected over 20 million incident reports through its national reporting system. But reporting volume was never the measure that mattered. What matters is what happens next.  

Claims data tells a similar story. NHS Resolution holds over 25 years of claims information. When triangulated with incidents and complaints, it can reveal whether the same themes keep recurring years later. But too often, the learning loop does not close. Reports are submitted, but nothing visible comes back.  

"If you don’t get feedback, why are you going to report?”

Helen Hughes, Chief Executive, Patient Safety Learning

If the people raising concerns never see evidence that something changed, the system gradually loses both their trust and their insight.  

The first lesson is simple: reporting creates the signal. Organisations need a reliable feedback loop to turn that signal into learning. 

Psychological safety underpins everything  

Staff who do not feel safe to speak up, raise concerns or challenge decisions cannot contribute to a learning organisation. And when psychological safety is absent, the consequences are not just cultural. They are clinical.  

"It’s more than a nice-to-do. It’s more than a moral imperative. If you don’t have it, it actually contributes to there being avoidable harm.”

Helen Hughes, Chief Executive, Patient Safety Learning

Psychological safety is therefore closely connected to incident reporting. People need to feel able to raise concerns, discuss mistakes and challenge what is not working without fear of blame or ridicule. As Mark Linggood puts it who’s been actively part of Patient Safety for over 30 years, if people cannot speak openly, it directly affects an organisation’s ability to learn. 

Practical tools exist. NHS Scotland’s safety culture cards give teams a set of questions designed to open up honest conversations about reporting, learning and speaking up. Having the question on a card removes the personal confrontation of raising it directly. Therefore, becoming part of the process rather than an act of individual courage.  

Building psychologically safe environments is not about writing another policy. It is about how leaders behave, how consistently organisations follow through, and whether people see accountability modelled at every level.  

The second lesson: people are more able to contribute to learning when they know they will be heard, supported and taken seriously. 

Systems thinking reveals what blame obscures  

When something goes wrong, the instinct to ask who was responsible is strong. But focusing on individuals often misses the system conditions that made the error possible in the first place.

"Neither of us focus on blame, and we both want to know what happened and why that happened.”

Steph Cormack, Head of Patient Safety, Sandwell and West Birmingham NHS Trust

This principle is particularly relevant when learning from patient safety incidents. In the session on PSIRF and coroners from RLDatix’s Connected Health & Care Summit, Steph Cormack described work to bridge the different requirements and perspectives involved in patient safety investigations and coronial processes. The approach recognised that both need to understand what happened and why, while working with different requirements around evidence, causation and learning. 

The session highlighted the value of collaboration with coroners and of developing approaches that bring together different perspectives rather than treating them as competing processes. 

Applying a systems-based approach to patient safety events, whether through SEIPS analysis, human factors methods or structured learning responses, consistently surfaces contributing factors that a blame-focused investigation would miss entirely. And behind every claim, the motivation is rarely financial. Families overwhelmingly want one thing: to prevent the same harm happening to someone else.  

A systems lens does not remove accountability. It can make accountability more meaningful by helping organisations understand the conditions that need to change to reduce the risk of recurrence. 

The third lesson: effective learning asks not only “what happened?” but also “why did it happen, and what does the system need to learn?”

Learning must travel beyond individual organisations  

The countries with the strongest patient safety outcomes share a common trait. They balance compliance with genuine investment in the conditions and capabilities that enable safe care. Rules and standards matter, but regulation alone does not create safer systems. Learning that stays within one team, one ward or one trust cannot prevent the same harm recurring elsewhere.  

Persistent challenges remain in this space: embedding learning on the frontline, supporting staff through investigation processes, sharing lessons across organisations, and closing the gap between reporting an incident and seeing visible change as a result.  

Peer engagement, cross-organisational collaboration and shared learning standards are not optional extras. They are what separates organisations that learn locally from systems that learn collectively.  

The fourth lesson: safer care depends on learning that travels, across teams, organisations, professions and the wider health system. 

Culture is the connective tissue  

Safety culture can be described as the interrelationship between an organisation’s values, behaviours and beliefs. When these are aligned, the conditions for learning, improvement and safer care follow. When they are not, even the best processes will fall short.  

"Organisations can have nice statements of values, but if your leaders behave in a different way, it’s not going to work. You’ve got to have that alignment of values, behaviours, and beliefs.”

Helen Hughes, Chief Executive, Patient Safety Learning, and Clare Wade, Director, Patient Safety Learning

Culture shapes everything: reporting leads to learning, learning leads to action and action is sustained. Helen Hughes describes It determines whether staff feel safe to raise concerns, investigations focus on systems or individuals, and if governance drives genuine improvement or simply records compliance.  

The fifth lesson is that culture connects values, behaviours and beliefs. When these are aligned, they create the conditions for speaking up, learning and improving patient safety. 

What this means in practice

For teams looking to act on these lessons, five practical starting points stand out:  

• Close the loop. Whatever the reporting route, make sure the person who raised a concern hears what happened as a result.  

• Use a structured prompt, not a policy. Tools like NHS Scotland’s culture cards work because they turn an abstract expectation into a concrete conversation.  

• Investigate systems, not people. Build SEIPS or human factors thinking into how incidents are reviewed, before defaulting to individual blame.  

• Share learning outward. Bring insights to a peer network or cross-organisational forum, not just an internal board report.  

• Audit the gap between values and behaviour. Ask staff, not just leaders, whether what’s written down matches what they actually see day to day.  

Better decisions start here  

Patient safety is not a single initiative or a once-a-year conversation. It is the product of daily decisions made by leaders, clinical teams and governance professionals at every level of an organisation.  

Reporting must lead to learning. Learning must lead to action. And action must be supported by a culture where safety, quality, compliance and governance work together rather than in silos.  

Better decisions. Safer care.  

Continue the conversation  

This article is part of RLDatix’s Patient Safety Month, exploring how organisations turn reporting into learning and learning into safer care. These themes are explored in depth across a selection of patient safety sessions from the Connected Health and Care Summit 2026, now available to watch on demand.