James Titcombe, patient safety specialist at Datix, says one word that comes up again and again in reports into adverse incidents is ‘culture.’

He argues that organisations that really want to improve patient safety need to develop a ‘just’ culture, in which there is open and honest disclosure, and professionals are not punished for human error.

The alternative, he warns, can be a culture of fear, in which incidents are not reported, investigated, or used as learning opportunities – and which can lead to even more harm for patients.

Titcombe also argues that organisations with good systems and processes need to share them with others; something that is being encouraged by NHS England, through the Five Year Forward View, and the Department of Health, through the new bodies it is setting up to encourage a learning culture in the NHS.

New technology, he adds, will play an important role in these developments, since it can help the healthcare community to identify risks, understand common problems, and implement, monitor and share effective solutions.

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