Past cases provide basis to improve patient safety education and training

To provide safe and good quality health care nurses and doctors need to reflect on past cases where adverse events have occurred and to learn lessons. Trend analysis should take place, which should inform policy, and the information obtained cascaded down the management chain to frontline staff. It is imperative that this happens, but the all-too-familiar story in the NHS is that it does not to the extent that it should. Many safety lessons from past adverse healthcare events go unlearnt.

This should not happen: lesson learning is a fundamental prerequisite to developing an NHS patient safety culture.

One way to reflect on errors is to look at closed legal claims and examine the causes of litigation. This is a valuable exercise, as it enables a wealth of important detail to be obtained. Solicitors and barristers who act for patients and NHS trusts often post case summaries on their websites and some also post regular blogs on legal issues.