STRATEGIC NOTES Nº5

There are issues that become so normalised they lose their strategic meaning. Safety in health systems is one of them. Few question its importance, but few truly approach it with the level of structural seriousness it demands. This is precisely the blind spot to be addressed here: safety as a central axis of governance and return, often neglected or trivialised in management models that continue to treat it as a regulatory obligation rather than as a factor of competitive, reputational and economic value.

Institutional insecurity quietly erodes flows, disrupts decisions, compromises teams and destabilises trust. But it goes further. International sources, such as the OECD and WHO, point to a growing financial and structural impact. Yet responses that embed safety as a core pillar of governance remain scarce.

OECD data (2022) confirm that around 13% of hospital budgets in member countries are consumed by avoidable failures, with losses exceeding 606 billion dollars per year in direct costs alone. When indirect impacts are included, such as additional hospital days, litigation, productivity loss and reputational damage, the global cost of insecurity surpasses one trillion dollars annually, with measurable consequences for economic growth (WHO, 2023).

These figures are well known. What remains largely unaddressed is the transformative potential of safety when integrated with vision. When treated as strategic architecture, safety becomes a lever for performance, a mechanism for trust and a reputational asset. Organisations that adopt it as a central axis, not as an accessory, achieve tangible returns. These include not only the prevention of adverse events but also team stabilisation, operational predictability, strengthened client relationships and enhanced institutional positioning.

Institutional models observed in the Middle East and London demonstrate the impact of integrating safety as an ongoing operational grammar. It becomes a transversal language that shapes decisions, prevents deviations and reinforces organisational cohesion.

In these high-complexity hospitals, safety was not treated as a secondary dimension. It was a structural principle embedded in the operational logic and decision-making architecture of the institution. It acted as a transversal integration criterion, a shared language across teams and an identity marker for the organisation. Any sign of relevant deviation triggered rigorous technical analysis, with multidisciplinary teams ready to map the event, identify causes, redesign flows and consolidate sustainable solutions. When errors occurred, they were addressed with method, clarity and institutional responsibility. There was no space for concealment or destructive exposure. Failures were treated as raw material for improvement. This approach did not promote permissiveness. It reinforced internal rigour, organisational cohesion and system reliability. Safety, in these contexts, was not a response to events. It was an architecture embedded in the institution’s daily functioning.

In the United States, the Medicare system saved 28 billion dollars over five years through structured safety policies (OECD, 2022). In the United Kingdom, the NHS spends around 14.7 billion pounds annually treating harm caused by avoidable failures, associated with over 800 deaths per year (The Guardian, 2024). These are not only human or ethical losses. They are budgetary losses with a direct impact on the sustainability of the system. This dimension of safety as return remains largely absent from many hospital management models.

There is also another, less quantified but equally critical factor: reputation. An unsafe system is not only more costly, it is also less reliable. A health system that fails in its most basic function — to protect — undermines the legitimacy of the institutions it encompasses. The reputational damage of an institution where safety is devalued goes far beyond media cycles. It erodes trust, drives clients away, demotivates professionals and undermines public credibility. When this becomes recurrent, the damage affects not only the organisation but the country as a whole.

Trust in a health system is a national asset. Countries that develop robust institutional safety frameworks attract investment, promote social trust and become more competitive in related sectors, from clinical research to health tourism. Institutional reputation is also economic value. And safety is reputation.

In Portugal, reports from IGAS and the Court of Auditors have already identified recurring failures. Yet the integration of safety as a strategic pillar remains incipient. Every day, new incidents with reputational impact emerge in the public sphere. They do not always stem from direct negligence but are often linked to hidden failures, near misses or silent operational deviations.

These are events that may not reach the level of critical error but reveal structural gaps in internal monitoring, formal debriefing, incident mapping and flow consolidation. Where there is no structure to identify, interpret and redesign, risk spreads invisibly.

This is where blind spots emerge. Failures go unread, pathways are not reviewed, and decisions accumulate without correction until rupture occurs.
More than an ethical concern, this is a strategic imperative.

Does Portugal currently have an organisational culture capable of treating error as institutional raw material with method, analysis and structural learning?
Are we truly interpreting error as an early warning with financial, operational and reputational implications, or merely silencing it on the surface?

Integrating safety as a strategic matter is not an ethical choice it is a governance imperative.