Why do surgeons seem reluctant to adopt a simple safety procedure that outsiders would regard as second nature? The question was recently posed by Sir Ian Kennedy, chair of the Healthcare Commission and best known for the inquiry he led into the deaths of 29 babies in the paediatric cardiac surgery unit at Bristol Royal Infirmary. That report, published in 2000, found that systematic failure and a culture of arrogance among doctors were the leading causes. His recent comments suggest that he doesn’t think much has changed.

“It comes as a shock that a group of professionals should be prepared to wait until something disastrous occurs before they agree to change their behaviour. It’s rather like a dangerous pilot being told: wait until you have your first crash,” he said.

Sir Ian’s comments at the first annual meeting of the Clinical Human Factors Group—an independent group of experts on factors that affect human performance from both inside and outside the healthcare professions (www.chfg.org)—in Harrogate in October are timely for once again the safety record of surgery is under scrutiny.

Last week, the health select committee began to question senior doctors and managers as part of its inquiry into patient safety. The investigation focuses on the issues identified by Kennedy: human error, poor clinical judgment, and systems failures rather than the better known problem of hospital infection.

The World Health Organization is also turning its attention to safety in the operating theatre. In June it warned of the growing risks of surgery in both the developing and developed world. Around 230 million operations are carried out every year—one for every 25 people in the world—giving rise to a million …