The NHS Patient Safety Strategy

This strategy describes how the NHS will continuously improve patient safety, building on the foundations of a safer culture and safer systems.


The NHS Patient Safety Strategy

Patient safety is about maximising the things that go right and minimising the things that go wrong. It is integral to the NHS’ definition of quality in healthcare, alongside effectiveness and patient experience.

This strategy sets out what the NHS will do to achieve its vision to continuously improve patient safety.

NHS Patient Safety Strategy updates

We are committed to ensuring the strategy remains focused on activity that will have the greatest impact on patient safety improvement.

The principles and high-level objectives of the strategy will remain unchanged. However, the underlying actions will evolve in line with any changes in priorities for patient safety and the NHS as a whole, and to reflect progress with the strategy’s implementation.

The updates below outline any changes that have been made, including new areas that have been added to the scope of the strategy. These documents should be read as an appendix to the original strategy, and specifically as an update to the section on ‘delivering the strategy’ (p62 of the strategy document).

Strategy implementation updates

We are working with our partners to develop the new patient safety initiatives the strategy introduced. We will provide brief updates below to show progress:

  • Patient Safety Incident Response Framework (PSIRF) – August 2022, we have published the new Patient Safety Incident Response Framework (PSIRF) , which will replace the current Serious Incident Framework with a new approach to how NHS organisations respond to patient safety incidents for the purpose of learning and improvement. Secondary care organisations are now preparing for the transition to PSIRF which we expect to be complete by Autumn 2023.
  • Patient Safety Specialists – September 2021, after launching the patient safety specialists initiative in Autumn 2020, over 700 individuals at NHS trusts and ICSs have now been identified as patient safety specialists to provide leadership and oversee and support patient safety activities across their organisation. The Identifying patient safety specialists document supports trusts and ICSs to identify their patient safety specialists.
  • Learn from patient safety events service (LFPSE) – July 2021, LFPSE (previously called the patient safety incident management system – PSIMS – during development) commenced its public beta stage in Summer 2021. LFPSE will be a major upgrade to the existing National Reporting and Learning System (NRLS), creating a single national NHS system for recording patient safety events. Organisations with compatible local risk management systems are now able to record patient safety events on LFPSE instead of the NRLS. Organisations without a local risk management system, such as general practice, dental surgeries and opticians, are also able to record safety events directly to LFPSE by registering for an online account. Find out more on our LFPSE webpage.
  • Framework for involving patients in patient safety – 29 June 2021, we have published the final version of our ‘Framework for involving patient in patient safety‘, providing guidance on how the NHS can involve patients, families and carers in their own safety; as well as being partners, alongside staff, in improving patient safety in NHS organisations.
  • Patient Safety Syllabus – 13 May 2021, Health Education England in collaboration with Academy of Medical Royal Colleges (AoMRC) and NHS England, has published the first National patient safety syllabus. The syllabus will underpin the development of patient safety curricula for all NHS staff.
  • National Patient Safety Alerts –  the first National Patient Safety Alert was issued by our national patient safety team in November 2019 following its accreditation to issue the new types of alerts. All national bodies that issue alerts are going through a process of accreditation to issue National Patient Safety Alerts to ensure they meet a set criteria to improve their effectiveness and support providers to better implement the required actions. In March 2020 the MHRA became the second national body to be accredited

National Patient Safety Strategic Research Needs 2022/23

Worldwide, patient safety incidents cause death and disability. Patient safety is about maximising the things that go right and minimising the things that go wrong for people receiving healthcare. It is integral to the NHS’s definition of quality in healthcare, alongside effectiveness and patient experience, and the NHS Patient Safety Strategy aims for continuous improvement of patient safety, alongside wider quality improvement. This strategy underlines how crucial patient safety research and innovation is to this aim.

Much has been accomplished in patient safety research, but much more still needs to be done. Many questions about how to improve safety remain unanswered; there are significant knowledge gaps where research is needed to provide a far better understanding of the issues and potential solutions.

The National Institute of Health Research (NIHR), funded by the Department of Health and Social Care, conducts need assessments to identify, prioritise, commission and co-ordinate health services research topics in partnership with the NHS, universities, local government, other research funders, patients and the public.

Our ‘National Patient Safety Strategic Research Needs’, highlight the strategic research needs identified by the National patient safety team, particularly in relation to the priorities in the NHS Patient Safety Strategy. Our patient safety partners (people who advise us on improving patient safety from their perspectives as patients, carers and members of the public) supported us in this work.

Key components of the strategy

Aidan Fowler, National Director of Patient Safety, introduces the NHS Patient Safety Strategy.

A key principle of the NHS Patient Safety Strategy is continuous improvement. Hugh McCaughey, National Director of Improvement, discusses the relationship between Quality Improvement and patient safety.

Dr Suzette Woodward, director of the Sign up to Safety Campaign that ran from 2014 to 2019, describes the equally important behaviours of kindness and civility that support patient safety.

There is a clear interest in widening patient safety thinking beyond things that go wrong. Dr Suzette Woodward, describes the concept of Safety II and the importance of also looking at why things routinely go right in healthcare.

The National Reporting and Learning System (NRLS) has been at the heart of NHS patient safety insight since 2004, but it uses outdated technology, Lucie Musset, product owner for a new digital system to replace the NRLS describes what it will do and how it will benefit patient safety.

Developing the strategy

Between December 2018 and February 2019 we held a consultation on our original set of ideas for a national patient safety strategy for the NHS.

We received 527 contributions from organisations and individuals (staff, patients and carers), and attended stakeholder meetings and engagement events. We also held workshops with staff, patients and senior leaders across the country and hosted online discussions. See Annex 1 above for a summary of the results of the consultation.

You can also view our original proposals and the online consultation questions in our consultation discussion document.

NHS patient safety strategy oversight committee

Contact us

If you would like further information about the NHS Patient Safety Strategy, or have any questions, please email