Learning the lessons from patient safety incidents

Nobody is perfect and we all make mistakes. In health care some degree of error is inevitable. Care is a multifaceted process often involving complex procedures, treatment regimens and equipment. We are dealing with human interaction and the exercise of human skill and judgment. The best we can hope to do is to try to minimise the risk of error occurring, to be risk aware, to learn from the patient safety errors of past and to change practices. These are the fundamental prerequisites for developing an ingrained patient safety culture in the NHS.

There is no shortage of reports showing patient safety incidents from a variety of national organisations such as the Care Quality Commission (CQC) and NHS Resolution, and international organisations such as the World Health Organiztion (WHO). The difficulty for the nurse and doctor is to keep track of all this information in challenging working environments—and to work out which is the most authoritative and relevant information.