The scale of harm from health care has been documented for over 150 years, but only in the last decade has there been any sustained interest in systematically examining safety issues. The principal theme of the first major report on safety in the NHS, An organisation with a memory,¹ was that health care in general, and the NHS in particular, was extraordinarily poor at learning from mistakes and disasters. One of the most striking instances of this failure was that, between 1985 and 2000, there had been at least 13 documented instances of death from the spinal injection of cytotoxic drugs in the NHS. The circumstances were remarkably similar in all cases; warnings on labels and reports in the medical literature had been insufficient to avert this series of tragedies. We now know events of this kind are far from rare. Studies in several countries have generally found that about 8–12% of patients suffer some kind of adverse outcome from their health care.^2–5 Many of these are slight, but a proportion are serious or even fatal.

Appreciating this background is key to understanding the role of the National Patient Safety Agency (NPSA), which in effect functions as the “safety memory” of the NHS. NPSA is a Special Health Authority created to allow learning from patient safety incidents occurring in the NHS through coordinated efforts of all those involved in health care.⁶ Reports of incidents and near misses are collected from staff at local level and entered into the NPSA’s national reporting and learning system for analysis and subsequent development of appropriate solutions. This can be in the form of clinical recommendations or practice alerts which are distributed to all relevant healthcare personnel. …