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Update on patient safety
  1. Simon P Kelly
  1. Correspondence to Simon P Kelly, Royal Bolton Hospital NHS Foundation Trust, Minerva Road, Bolton BL4 OJR, UK

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It is recognised that adverse events or ‘incidents’ frequently occur in hospital care. The importance of improving patient safety in surgical care is thus widely recognised as a key global public-health issue. Thus, the WHO's ‘Safe Surgery Saves Lives’ (http://www.who.int/patientsafety/safesurgery/en/index.html) initiative aims to improve patient safety in surgical practice. The preferred term is a ‘patient safety incident’ (PSI), which is defined as ‘any unintended or unexpected incident which could have or did lead to harm.’

Patient safety incident-reporting systems aim to identify problems in the delivery of healthcare and provide an opportunity for organisations to learn from errors in order to improve patient safety. They can build an understanding at a local level or at a national level or international level.1

The process of reviewing incidents is central to incident-reporting systems. It involves gathering information about ‘what happened’ to understand ‘why it happened.’ By definition, such learning is a reactive and reflective process. Clearly, this is an essential step prior to developing solutions to prevent errors recurring. Procedures for reviewing incidents vary between hospitals and departments.

The National Patient Safety …

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