[Article] Patient Safety – What we learned in 2025 and how to plan for 2026
Patient safety has long ceased to be treated merely as a set of good intentions formalized in institutional documents.
In 2025, a clear paradigm shift was consolidated: effective safety is the result of structured governance, a mature organizational culture, well-defined processes, intelligent use of data, and the active participation of professionals and patients.
This article presents a retrospective of the key lessons learned in 2025 and proposes a practical path for the development of the Patient Safety Plan (PSP) for 2026, aligned with national and international best practices.
Patient safety as a management system
One of the key points for 2025 was the consolidation of the understanding that the Patient Safety Plan cannot be a static or merely regulatory document. The PSP should function as a living management tool, with clear objectives, defined responsibilities, a structured timeline, indicators, and mechanisms for continuous monitoring.
In this model, the PSP is treated as a portfolio of strategic initiatives, integrated into the institutional routine and leadership decision-making.
The role of the Patient Safety Center (NSP) has been greatly strengthened. More than merely complying with regulatory requirements, the NSP must act as a link between care delivery, management, and quality, ensuring coherence among risk analysis, priority setting, and execution of planned actions.
Safety culture and just culture
Another central pillar in 2025 was the strengthening of the patient safety culture, recognized as the foundational basis of any effective system. Punitive environments reduce incident reporting, distort data, and hinder organizational learning.
The just culture approach has gained prominence as an operational model. Distinguishing between human error, risky behavior, and negligent conduct allows for appropriate accountability without compromising transparency and trust. Without a psychologically safe environment, reporting and investigation systems lose strategic value and real impact.
Learning from incidents: from registration to prevention
The 2025 debates reinforced the importance of viewing incident reporting as a means, and not as an end. The true value lies in the ability to:
- Investigate in a manner proportional to risk;
- Identify systemic contributing factors;
- Implement effective action plans;
- Monitor and verify the effectiveness of the interventions.
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