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Patient perceptions of safety are critical to the patient experience

Coauthored by Heather Reed, Senior Director, Patient Safety Organization Clinical and Reliability.

Routinely asking patients about safety is critical to achieving zero harm and an optimal patient experience. Asking patients about safety in healthcare broadens the approach to safety issue identification beyond safety event reporting, and it can capture concerns that are important to patients but overlooked by clinical safety reporting systems. Forward-thinking safety and experience leaders recognize that patient perceptions of safety in healthcare have strong correlations to the patient experience.

Patient perceptions of safety in healthcare and ‘Likelihood to Recommend’

Patients with optimal perceptions of safety are more likely to recommend a hospital than patients whose perceptions of safety in healthcare are nonoptimal. When patients feel safe—and they trust their caregivers—they feel protected, and their positive perspectives are reflected in data results. A recent Press Ganey data analysis shows how integral safety is to the patient experience (PX).

Even when care providers treat patients with courtesy and listen carefully, healthcare organizations can lose ground in terms of patient loyalty if they don’t feel safe.

This strong connection between patient perceptions of safety and PX was first identified during the pandemic in the outpatient setting. And this connection has persisted in our new analysis of more recent data (from June 2022 to May 2023) in both the inpatient and outpatient settings.

Inpatient experience of safety directly relates to LTR: Overall safety scores and LTR

In the BMJ Quality & Safety Journal article, “How Do Hospital Inpatients Conceptualise Patient Safety? A Qualitative Interview Study Using Constructivist Grounded Theory,” its authors aimed to understand how hospital inpatients think about patient safety in healthcare. The study adds to the growing body of evidence that suggests patients predominantly conceptualize patient safety in the context of what makes them “feel safe,” which is distinct from clinical and academic definitions of safety. So it is critically important to understand if patients are feeling safe.

Patients differentiate elements of safety from other aspects of their experience. They recognize that bedside manner isn’t the same thing as safe care. Even when patients have optimal perceptions of their doctors and nurses in the hospital setting, perceptions of safety in healthcare still impact “Likelihood to Recommend” (LTR) scores. And even when care providers treat patients with courtesy and listen carefully, healthcare organizations can lose ground in terms of patient loyalty if they don’t feel safe.

Worries about safety degrades patient recommendation even when care team interactions are optimized  

Perceptions of safety by race and ethnicity 

It's important to bring the equity lens to patient perceptions of safety. In doing so, we see consistency in safety’s impact on LTR across racial groups. For example, the gap in LTR based on safety perception spans 90 percentiles for White respondents and 93 percentiles for Asian respondents—a difference of just 3 percentiles. In contrast, when it comes to other drivers of the patient experience, such as friction, we see much larger variation in the impact on LTR by race or ethnicity.

So, why might the impact of safety be so consistent? One likely explanation is because safety is foundational—it matters to everyone. Maslow’s hierarchy tells us that protection from harm is a fundamental need. If a person doesn’t feel safe, they will seek out safety before they consider any higher-level needs like belonging, esteem, and self-actualization—needs that are often met by care provider behaviors, such as good communication, respect, and listening. Not feeling safe impacts every race and ethnic group in very similar ways. 

Impact of safety on inpatient ‘Likelihood to Recommend’

The patient voice and its impact on safety

The patient voice is critical in understanding safety throughout the health system. For example, when asked to rate “your level of confidence that staff had provided care in a safe and secure manner,” one inpatient at a Press Ganey partner hospital said: “I did not feel safe at night. There was no response to alarms on machines. They would go off for hours. There was no way to rest. Too few staff members to feel safe.” 

It’s patient comments like these that underscore the need for routinely asking patients about safety issues in healthcare. Without patients’ observations, we cannot understand the full picture of patient safety. Asking patients about safety issues has not been a standard part of how health systems engage. But we should not underestimate their ability to identify safety concerns. We must value and act on the information they provide us about safety.  

3 ways to learn about safety  issues in healthcare from patients and families 

1. Add safety-related survey questions to patient experience surveys, for example:

  • Inpatient: 
    • Extent to which you saw staff washed their hands before examining you
    • Degree of safety/security felt in the hospital 
  • Outpatient
    • Cleanliness of facility 
    • Degree of safety and security you felt in the center 
  • Medical practice 
    • How well staff protected your safety (by washing hands, wearing ID, etc.) 
    • Information the care provider gave you about medications (if any) 
  • Ambulatory surgery 
    • Safety and security felt in the emergency room/department 
    • Extent to which staff washed their hands before examining you 

2. Conduct Patient and Family Advisory Council(s) in person or virtually.

3. Leverage artificial intelligence to mine patient comments and identify themes in patient experience surveys and online consumer reviews.

For many years, engaging patients and families in their care has been a foundational strategy for achieving a culture of safety in healthcare. An essential component of this engagement is to better understand patient perceptions of safety. Patients and their family members can reliably observe medical error and other patient safety concerns that are often left undocumented in the electronic medical record and unnoticed by clinicians.

Top 2 takeaways for healthcare organizations

  1. Patient perceptions of safety are important, and they strongly correlate with patient loyalty and trust. Loyalty and trust built through optimal care provider behaviors can still be eroded by negative experiences of safety. When working to drive patient loyalty and trust, breaking down silos between experience and safety is mission critical to making sure patients feel safe.
  2. Safety matters to everyone, regardless of race or ethnicity. While we do see some differences in perceptions of safety by race, the differences are small. Not feeling safe impacts every race and every ethnic group in very similar ways. We should be routinely asking all patients about safety, as it’s a common, widely held concern.

Whether via patient experience surveys, through patient family advisory councils (PFAC), or focus groups, Press Ganey can support data collection, analysis, and safety improvement based upon patient perceptions of safety. We can also partner in high reliability organizing for safety culture transformation. Current Press Ganey patient experience partners can add questions to measure patient perceptions of safety to existing surveys .

To get started on your journey to high reliability, get in touch with Press Ganey’s safety team.  


  1. Gandhi TK. "Now Is the Time to Routinely Ask Patients About Safety." Jt Comm J Qual Patient Saf. 2023 Apr;49(4):235-236. doi: 10.1016/j.jcjq.2023.01.009. Epub 2023 Jan 29. PMID: 36858869. 
  2. BMJ Quality & Safety Published Online First: 02 February 2023. doi: 10.1136/bmjqs-2022-015573 

About the author

As Chief Safety and Transformation Officer, Dr. Gandhi, MPH, CPPS is responsible for improving patient and workforce safety, and developing innovative healthcare transformation strategies. She leads the Zero Harm movement and helps healthcare organizations recognize inequity as a type of harm for both patients and the workforce. Dr. Gandhi also leads the Press Ganey Equity Partnership, a collaborative initiative dedicated to addressing healthcare disparities and the impact of racial inequities on patients and caregivers. Before joining Press Ganey, Dr. Gandhi served as Chief Clinical and Safety Officer at the Institute for Healthcare Improvement (IHI), where she led IHI programs focused on improving patient and workforce safety.

Profile Photo of Dr. Tejal Gandhi, MPH, CPPS