Introduction

‘Do no harm’ is an enduring principle of medicine, yet people continue to be harmed in the process of being ‘cared for’. Before the 1990s, there was very little understanding that poor quality might be inherent in the structures and processes of the healthcare system.1 Now, as a result of considerable research investment, a great deal is known about, for example, hospital-acquired infection, surgical error, medication error, and the systems and processes that predispose practitioners towards error. Nevertheless, what it means to ‘care’ and how this might carry threats to safety has recently been exemplified by events at Mid Staffordshire NHS Foundation Trust in the UK. Here, there were consistently higher than average mortality rates and poor standards of care in which patients’ most basic needs were routinely overlooked; personal hygiene, nutrition and hydration were not maintained, and patients were treated without compassion or respect for their dignity.2 3 Describing a pervasive culture of indifference to suffering and tolerance of poor standards of care, the public inquiry explicitly aligned a culture of staff disregard for patients’ dignity with threats to patient safety and drew attention to the value of compassion, kindness and respect for dignity.3 The emphasis the ‘culture’ of healthcare work received as a result of events such as these further stimulated efforts to understand and, where necessary, change healthcare cultures.

So although the scope of what is now considered to fall within the remit of ‘safety’ research has expanded to include concepts like culture, still things fall out of view. It has been suggested that the current emphasis of patient safety initiatives on ‘technical errors’ such as surgical mishaps and medication errors means that other harms are overlooked and that ‘emotional distress’ should be considered a legitimate harm on the grounds that it is ‘unwise to …