Technical editor Kate Woodhead says NHS Trusts must continue to learn from patient safety incidents and work together to develop a standardised way of recognising, reporting and investigating when things go wrong.
Continuous emphasis on quality care and the development of standards with an evidence base is fundamental to the provision of safe, compassionate patient focused care. We can only advance practice and ensure that we continue to deliver the gold standard of care, if we learn from our mistakes. Ever since the recognition globally, that healthcare harms patients in considerable numbers, we have been seeking methods of reducing risk and harm. We know that around 10% of adverse incidents which happen to patients are preventable. Can we say that we work in hospitals or Trusts that have a culture of safety? Do we know that if the worst occurs, that lessons have been learned and that no further patients will be harmed in this way?
There are a variety of systems and frameworks in place to record adverse incidents and to enable examination of the detail. Is it confusing to have multiple possible means by which to record an incident?
Never events
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