Prior to the emergence of the patientsafety movement as a distinct science, itwas assumed that the safety of patientswas an outcome of good professionalacumen, and that if healthcare providerscould individually perform well then theirpatients would remain safe at all times.It is now 20 years since the publicationof To Err is Human,1 the first majorreview of healthcare safety in the USA.In the UK, the publication Organisationwith a Memory2 in 2000 supportedthe view that patient safety required awider system approach. Both documentsreframed safety and error in healthcare asan organisational or system issue ratherthan one of individual error, whether ofomission or of commission. Over the past20 years, there has been major progressin the understanding of patient safety andthe complexity of the systems involved inproviding healthcare. In a recent review ofthe state of patient safety in 2018, Batesand Singh3 conclude that ‘Highly effectiveinterventions have since been developedand adopted for hospital-acquiredinfections and medication safety, althoughthe impact of these interventions variesbecause of their inconsistent implementationand practice’.
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