Patient safety and clinical negligence: the importance of reflection

Hindsight is a wonderful thing, but it must be handled carefully. It is all too easy to say: if we would have done this and that, then the adverse healthcare event would never have happened. In the many cases that I have seen reported, there is often no simple, singular cause that explains all. I have discussed in previous columns the vexed issue of causation in clinical negligence and how it is often the most difficult of issues to resolve in a case. The same thinking applies equally to broader crises. Problems are often more complicated than they seem at first sight. It is important to look back to see what happened and to reflect on how things could possibly have worked out differently, to identify remedial steps, solutions, and any future problems.

In this column I will be discussing the recently published rapid review report from the World Health Organization (WHO) (2022) on the worldwide implications of the COVID-19 pandemic for patient safety. Meanwhile, NHS Resolution (2022a) has produced a report on clinical negligence claims relating to anti-infective medication.