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Continuous improvement of patient safety

The pursuit of safety is not for the timid. This Health Foundation report eloquently surveys the landscape of obstacles. But there are at least two inescapable facts that make improving safety especially difficult and frustrating. First, securing safety is a task that cannot be ‘finished’, ever. As Professor James Reason puts it: ‘Safety is a continually emerging property of a complex system.’ The threats to safety flow like an endless game on a football field, in which no two patterns and no two moments are ever the same. Linear thinking – the search for simple, single causes – is doomed. All modern approaches to achieving safety (or reliability, for that matter) require continual attention to adjustments, resilience, adaptation and local contexts.

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