Introduction
The Infected Blood Inquiry (2024), the 10 Year Health Plan for England and the Department of Health and Social Care’s Review of patient safety across the health and care landscape (2025) have all highlighted the need for more systematic approaches to safety management in healthcare.
This statement summarises NHS England’s position on the potential for safety management systems to improve patient safety.
What is a safety management system?
All safety management systems (SMS) aim to provide a clear, structured approach to managing safety. Most are built around 4 core pillars:
- safety policy: a clear organisational commitment to safety
- risk management: processes to identify, assess and mitigate risks
- assurance: ongoing monitoring and evaluation of safety performance
- safety culture: promoting behaviours and values that prioritise safety
Although the NHS does not currently operate under a formally defined SMS, several national initiatives align with SMS principles. For example:
- the Patient Safety Incident Response Framework (PSIRF) and the Learn from Patient Safety Events (LFPSE) service support structured approaches to risk management and assurance
- The NHS patient safety strategy focuses on the development and promotion of a positive safety culture
NHS England’s position
Current state: Many SMS components already exist across healthcare organisations. However, while pockets of strong practice exist, overall maturity varies, with some elements remaining underdeveloped.
Opportunity: Further increasing our use of systematic and proactive approaches to patient safety management, tailored to the realities of healthcare can improve patient safety outcomes.
Key principles for organisations to consider
Organisations keen to explore the application of SMSs should consider the following principles:
1.1 Design for the unique operational, cultural, and structural realities of healthcare
Healthcare environments are complex. A safety management system developed outside of these realities can’t simply be inserted into an organisation and expected to function effectively.
While valuable principles and practices can be drawn from other safety-critical industries, a ‘lift and shift’ approach is not appropriate and risks creating a system that isn’t aligned with other systems and processes.
1.2 Test and evaluate
Any change to patient safety management should be tested in real-world settings with those responsible for their implementation and day-to-day operation.
1.3 Integrate but maintain the visibility of patient safety management
Patient safety management must be fully integrated into an organisation’s overall management system and must be explicitly prioritised as part of the quality agenda (alongside other core functions such as performance and finance).
While alignment with broader organisational principles is important, patient safety must retain its distinct purpose and visibility.
1.4 Embed equity and inclusion
Equality, diversity and inclusion (EDI) must be embedded as a core principle of patient safety management and systems must explicitly address inequalities in patient safety.
When improving the design or operation of a patient safety management system, check whether some groups face greater risks and act on what you find.
Embedding EDI is essential to ensuring that all individuals, regardless of background, feel safe, respected and supported.
1.5 Promote flexibility over bureaucracy
The goal must be meaningful, thoughtful practice, not box-ticking. Safety management should support good work, not get in the way.
Next steps
The national patient safety team will:
- contribute to the development of the upcoming Quality Strategy to ensure alignment of principles and reduce duplication.
- collaborate in the Yorkshire and Humber Patient Safety Research Collaborative’s work mapping safety management arrangements and co-design improvements in two NHS organisations.
- develop an updated NHS Patient Safety Strategy
Contact patientsafety.enquiries@nhs.net for more information.
Publication reference: PRN02227