In the UK, the National Health Service (NHS) treats over one million people every day, but international estimates of serious and largely preventable error are around the 10% mark, at least for general hospital care.^1,2 The Chief Medical Officers’ report, “An Organisation with a Memory”,³ found that there was a lack of systems for reporting and analysing incidents, and a culture of blame that suppressed learning that is not conducive to developing and implementing safety solutions. The Department of Health’s response was to publish “Building a safer NHS for patients”,⁴ which set the policy context for a new body, the National Safety Agency (NPSA). A central objective of the NPSA was to develop a mandatory risk reporting system, which would enable the agency to analyse and integrate these and other sources of safety information to learn lessons and develop and disseminate solutions. An audit of all acute, mental health and ambulance trusts in the English NHS⁵ showed that progress was very variable across trusts on even some basic features of risk reporting. It showed there was little evidence of active measures to assess and address organisational culture issues. A critical report by the House of Commons Committee of Public Accounts² precipitated a change in focus at the NPSA, to include greater concentration on the development and dissemination of local safety solutions in NHS trusts.

The House of Commons Committee of Public Accounts’ report² recommended, in relation to the use of data from the National Reporting and Learning System, that “Learning lessons is most likely to come from the information on contributory factors and currently only a percentage of reports to the National Patient Safety Agency contain this information…”. In order for healthcare organisations to …