Improving patient safety through reporting incidents, learning and implementing change

In 2025, the Linnaeus Medical Quality Team were recognised as Champions in the Knowledge Awards’ QI to Lead Organisational Change category for their work embedding psychological safety across the group. By analysing error and near-miss data, they identified patient safety risks at a group level and empowered local teams to take ownership of improvements through tailored guidance and action, fostering a positive culture of learning and continuous improvement.

Key takeaways

• Embedding a culture of safety takes time but yields results
  Initial resistance to incident reporting was overcome through training, leadership support, and the creation of psychologically safe environments. By 2021, 100% of practices were actively reporting, with sustained high review rates and engagement across the group.
• Team training, patient safety champions and tailored support are key enablers: Each practice appointed a patient safety champion, supported by webinars, drop-in sessions, and practical tools. This role was crucial in driving reporting, reviewing incidents, and implementing local changes.
• Data-driven interventions lead to improvements: Reported incident data informed targeted QI initiatives, resource creation and protocol adjustments, which significantly reduced harm events. The shift toward reporting near misses also indicated improved awareness and prevention.
• Systematic monitoring: The use of systematic monitoring allowed the group to identify and address issues promptly, leading to continuous improvement in patient care at both the local practice and group-wide levels.
• Human factors approach: The project focused on system-based solutions, like visual cues, checklists, and equipment modifications, rather than individual blame. This holistic approach helped reduce errors and fostered a positive culture across the organisation

Download the PDF and read the case example to get deeper insights into the methods and outcomes, and to apply these strategies in your own practice to enhance patient safety and care.