The cyclical nature of patient safety

Repetition of error is a strong and striking feature of patient safety in the NHS. The fact that the same errors are often repeated by health professionals and that lessons from past adverse events appear to go unlearnt is most concerning. NHS maternity care and Never Events are particular contemporary instances of this problem but the same problems can be seen in other clinical care areas and can be traced back well over two decades, to the seminal publication, An Organisation with a Memory (Department of Health, 2000). Effecting positive change and improvement in NHS patient safety is easier said than done.

We need to move away from the rhetoric of saying that we know and understand the nature of the patient safety problems in the NHS, that we are taking steps to deal with the issues and that matters are improving. It is possible to say that when you have demonstrable proof and measurement of improvement and we have this in some clinical areas but in many we do not. Looking at reports from the Care Quality Commission (CQC) a different, real-time picture of patient safety can emerge.