By learning free lessons from near misses

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An Organisation with a Memory, the newly released report from England's chief medical officer on learning from adverse events in the NHS,1 joins recent high profile policy statements from the United States 2 3 and Australia 4 that acknowledge an epidemic of underreported preventable injuries due to medical management. This report should not, however, be seen as a one off response to preventable patient catastrophes—although recent celebrated cases in Britain, such as the Bristol paediatric cardiac surgery story, have provided a driving force for change. Instead, An Organisation with a Memory should be understood in the larger context of a 10 year modernisation strategy to continuously and measurably improve the quality of health care. If it is understood in this way, and the government is willing to invest in the necessary systems, training, and research, then it will prove a real force for change.

Most care in the NHS is of high clinical standard, but the chief medical officer's report suggests that as many as 850 000 serious adverse health care events might occur in the NHS hospital sector each year at a cost of over £2bn. Half of these …