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“Reducing unintentional harm to patients in NHS hospitals is a central tenet in the management of healthcare quality and risk. Two factors are crucial to this: the establishment of a culture in which incidents can be reported easily, honestly and without fear of blame; and the ability to ensure that lessons learned from these incidents are successfully promulgated to NHS staff both locally and nationally. What today’s report shows is that the Department of Health and the NHS have made some progress in both of these areas – but not enough.
“There needs to be significantly faster progress at the national level in ensuring effective evaluation of numbers, types and causes of incidents. And lessons and solutions must be better evaluated and shared by all organisations with a role in keeping patients safe.”

Sir John Bourn


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