In 2000, then-chief medical officer Professor Sir Liam Donaldson published a seminal report, ‘An Organisation with a Memory.’ This urged the NHS to learn from other safety-critical sectors and to modernise its approach to learning from failure.
One of its specific recommendations was a call for better systems for reporting and analysis of when things go wrong, which led to the establishment of national reporting and alert systems. Yet successive reports have suggested that, as a whole, the NHS is still poor at learning from error, and that an open reporting culture has yet to take root.
The present government has recently announced additional measures to support an open learning culture in the NHS, including a ‘national freedom to speak up guardian’ and a Healthcare Safety Investigation Branch.
However, James Titcombe, a patient safety specialist at Datix, argues that more needs to be done to improve the quality of local investigations and to embed a safety culture into local organisations. New technology, he adds, can help organisations to get this right.
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