Will the future continue to repeat the past?
- Correspondence to: MsS J Woodward National Patient Safety Agency, 4–8 Maple Street, London, W1T 5HD; suzette.woodwardnpsa.nhs.uk
How organisations can learn from the experience of incidents to prevent future harm
Across different healthcare systems worldwide, published reports of inquiries into serious incidents urge that the lessons that emerge must be learnt and that such incidents should not happen again. But they do. The lessons, it seems, are rarely learnt and the perception is that health services are not trying hard enough—if at all.1,2 While it might appear straightforward, in reality not only are the reasons for the incident usually multifactorial, but implementing change is fraught with difficulties. This should not be taken as an excuse, but as a stimulus to understand why it is difficult to learn lessons and how the experience of incidents can be used by others to prevent future harm.
One of the fundamental barriers to learning lessons is the lack of a safety culture in health care. A difficult but essential aspect of health care is the need to accept that people, processes, and equipment in highly complex systems will fail. While the great majority of treatment is carried out effectively and safely, all organisations will at one time or another experience a …
