OBJECTIVE: To assess trends in the perception of quality and safety between 2009 and 2013 in the European Union (EU). DESIGN: We analysed data from waves 72.2 and 80.2 of the Eurobarometer survey. Multilevel logistic regression models adjusted for sociodemographic factors and country-level health expenditure were fitted to assess changes between 2009 and 2013 in each of the assessed outcomes. SETTING: Twenty-seven EU member states. PARTICIPANTS: A total of n = 26 663 (2009) and n = 26 917 (2013) individuals aged ≥15 years. MAIN OUTCOME MEASURES: Outcomes included the perception of being harmed in hospital and non-hospital care; rating of the overall quality of the healthcare system; and personal or family experience of adverse events. RESULTS: Respondents in 2013 were more likely to think that it was likely to be harmed in hospital (Odds Ratio [OR] = 1.09; 95% Confidence Interval [CI]: 1.05-1.13; P < 0.001) and non-hospital care (OR = 1.11; 95% CI: 1.07-1.15; P < 0.001), compared to 2009. However, they were more likely to rate the quality of their country's healthcare system as good (OR = 1.26; 95% CI: 1.21-1.32; P < 0.001) and no significant change over time was identified in reported experience of adverse events (OR = 1.00; 95% CI: 0.95-1.05; P = 0.929). Lower health expenditure and decrease in health expenditure between the two waves were associated with worse outcomes in overall quality and perceptions of harm. There was significant variation between and within countries in all indicators. CONCLUSIONS: The public's perception of safety in European healthcare systems declined in recent years, which highlights that there are safety issues that could be addressed.