The importance of NHS patient safety lesson learning

Some degree of error is always going to be inevitable in healthcare delivery. Human beings are treating other human beings with often complex equipment in challenging healthcare environments. Nobody is infallible and we all make mistakes. The best we can hope to do is to try to effectively manage risk. To do so, we need to learn the lessons from past patient safety adverse events and to change clinical practices accordingly. We need to have a learning and reflective patient safety mindset.

One of the seven strategic objectives set out in the World Health Organization's (WHO) Global Patient Safety Action Plan 2021–2030 ambitiously states:

‘SO1: Make zero avoidable harm to patients a state of mind and a rule of engagement in the planning and delivery of health care everywhere.’

WHO 2021: viii

The mindset of zero harm is commendable and all health carers should try to maintain this. However, in practice, given the complex nature of healthcare delivery in the NHS with its dependence on fallible humans, it will not always be possible to achieve zero harm, but it is a good starting point. Adverse healthcare events will continue to occur despite the best efforts of all.