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First do no harm: The report of the Independent Medicines and Medical Devices Safety Review, Chaired by Baroness Cumberlege. 2020. (accessed 28 September 2022)

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The slow pace of developing an NHS patient safety culture

13 October 2022
Volume 31 · Issue 18


Lecturer in Law, Birmingham Law School, University of Birmingham, discusses some recent patient safety reports

History has not served the NHS well when it comes to developing an effective patient safety culture. Time and time again we read reports of the same patient safety errors being made. A constant problem has been that lessons from adverse healthcare events generally go unlearnt and that practice does not change sufficiently. I have said this many times in my columns over the years and it remains so today.

In terms of the history of NHS patient safety culture development, a good starting point is the seminal report, An Organisation with a Memory (Department of Health (DH), 2000). It set the scene and tone for contemporary patient safety reform and culture development, providing a good barometer of progress towards changes in patient safety. If we could say that the NHS had made great steps since the publication of this report (DH, 2000) towards developing an ingrained patient safety culture and errors are exceptional and uncommon, then we could say strong progress had been made. However, when the report is read, we can see this is not the case. Even though it was published over two decades ago, it is as relevant today as it was then. Many adverse patient safety trends noted in 2000 remain with us in 2022. The report expressed a sentiment that remains resoundingly true:

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