Safety in 2025: Insights from Press Ganey’s annual PSO report

Coauthored by Heather Reed, Senior Director of the Press Ganey Patient Safety Organization (PSO).

Safety in healthcare isn’t static. It evolves with every shift, every system, and every experience. And, as demands on caregivers grow, so does the urgency to lead safety with clarity and intention.

An analysis of 508,000+ safety events, discovered between December 1, 2023, and November 30, 2024, by Press Ganey Patient Safety Organization (PSO) members, reaffirms what many safety leaders are already feeling: Care is becoming increasingly complex, clinical decision-making is under strain, and high-risk events—particularly those tied to care coordination and delayed diagnoses—continue to surface with alarming frequency. But alongside those challenges is a clear opportunity: the chance to reimagine what safety leadership looks like in a high reliability healthcare system.

Our 2025 PSO executive summary highlights the emerging trends, foundational practices, and actionable insights our Patient Safety Organization (PSO) uses to support healthcare organizations in their efforts to reduce harm and build a stronger culture of safety. As true partners in safety improvement, our PSO equips leaders to optimize cross-organizational learning with the tools, data, and direction to make getting safety right consistent and repeatable.

Where we're still fumbling: Familiar patterns emerge

Each year, new technologies emerge, policies evolve, care models adapt, and our industry furthers its march toward zero harm. But some safety trends have remained stubbornly predictable. Three categories continue to dominate: care management, environmental, and procedural events, which now make up 73% of all classified events.

The care management category includes a range of high-risk processes—like medication events, pressure injuries, and healthcare-associated infections. Drilling into this category, the most common safety events were other care management, medication, and delayed diagnosis or treatment—the same recurring types for the third year in a row. While these aren’t new trends, they pose significant risk and reflect persistent vulnerabilities in our systems.

• Other care management events include things like care coordination, and comprise over 27% of reported incidents.
• Medication events, involving issues like incorrect drug, dosage, patient, time, rate, preparation, or route, account for 13%.
• Delay in diagnosis or treatment events account for a growing share of precursor incidents, and they were among the top causes of serious safety events with permanent harm or death in 2024.

While "other care management” is often used as a catchall for event type classification, due to safety event review volume and team bandwidth, artificial intelligence (AI) tools help us to create efficiencies and quantify the data in this category. Using Press Ganey's next-gen text analysis AI tool, we’ve identified key drivers within the “other care management” bucket, including falls and mobility issues, gaps in handoff and communication with patients and families, documentation, and transfer and discharge issues.

The real challenge lies in translating awareness into system-wide action. And that starts by rethinking how we categorize, analyze, and learn from the events we see most often.

Safety and equity: A shared goal, a shared strategy

Care is only safe when it’s also equitable. When certain populations experience more frequent or severe harm, it indicates fundamental safety failures. With Press Ganey’s High Reliability Platform, organizations can segment safety data and disparities by race, gender, disability status, and more—and use these insights to drive targeted improvements.

AI can play a critical role, helping surface unclassified events, disparities, and root causes at scale. For example, a recent AI analysis of Press Ganey PSO data shows that patients with mental health disorders face both more frequent and more severe harm than patients with other disabilities—highlighting the urgency of equity-focused strategies.

High reliability: Blueprint, not buzzword

Organizations making the most progress in safety embrace the fundamentals, embedding high reliability practices like daily safety huddles and rounding for safety, and peer to peer coaching into day-to-day activities. and by building social capital, even when teams are under significant strain. But in too many organizations, safety event data is collected, reviewed, siloed, and shelved—too slow, too disconnected, and too buried to drive meaningful change.

The organizations leading the way are those that invest in continuous listening and learning, elevate patient and caregiver voices, and build structures that turn insight into action. Zero harm isn’t a slogan—and safety isn’t a dashboard metric. They're a cultural and system-level commitment that drives transparency and accountability.

Healthcare organizations must transform how they gather, analyze, and act on safety intelligence. That means moving from reactive reporting to proactive learning systems, like the Press Ganey High Reliability Platform. It means empowering front-line teams to speak up, and ensuring leadership not only listens, but makes direct, visible changes based on what they hear, closing the loop on safety issues reported by the front line.

Download the 2025 Press Ganey PSO annual report executive summary for more findings. To access the full report and to learn more about joining the Press Ganey PSO, contact Press Ganey PSO Senior Director Heather Reed at: hreed@pressganey.com.