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Care Quality Commission. Opening the door to change NHS safety culture and the need for transformation. 2018. (accessed 14 June 2023)

Department of Health. An organisation with a memory. Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer. 2000. (accessed 14 June 2023)

Reading the signals: Maternity and neonatal services in East Kent – the report of the independent investigation. 2022. (accessed 14 June 2023)

NHS England. Provisional Never Events 2022/23 data: 1 April 2022 and 31 March 2023. 2023. (accessed 14 June 2023)

The cyclical nature of patient safety

22 June 2023
Volume 32 · Issue 12


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

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.

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