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Final Report > Chapter 26: The Safety of Care

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Chapter 26: The Safety of Care

Messages from Bristol


The components of safe care

Pressure for change

Past and present approaches to clinical safety

Creating a culture of safety

The extent of adverse events and near misses - the urgent need to establish a baseline

A national reporting system

Reporting sentinel events: the barriers to openness

Overcoming the barriers to openness

Replacement of clinical negligence litigation

Reporting systems

Making reporting as easy as possible

Incentives to report


Acting on reports

Learning from what is already working in the NHS

Learning from other industries and other healthcare systems

Designing safer systems, buildings, equipment and pharmaceuticals

Incorporating a concern for safety into systems and policies

Patients are entitled to receive care which is safe and which exposes them to as little harm as possible.

`... we understand you do not come to work to make errors and we want to minimise the risk that you will do so.' [1]


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[1] James Bagian, engineer and former astronaut, head, US National Center for Patient Safety, Veteran's Adminstration