Publications policy and guidance

An organisation with a memory

Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer

Adverse health care events cannot be eliminated from complex modern health care but the recommendations of this expert group are designed to ensure that lessons from the past are used to reduce the risk to patients in the future. The cost of adverse events is increasing; there is also a distressing similarity present in some of them. With clinical governance comes an opportunity to focus upon this problem. The extent of the serious failures in healthcare is outlined but the reporting and information systems of the NHS give an incomplete picture. Very little research on reporting and information systems has been done in UK. Specific types of adverse events are seen to repeat themselves at intervals, thus demonstrating that lessons have not been learned. To make progress four key areas need to be addressed throughout the service; these are detailed in ten recommendations. Cites 69 references in chapter order.