Learning from failings in healthcare: A challenge for all healthcare systems

摘要

Reactions to significant and public failures in healthcare in the UK, and no doubt elsewhere in the world, trigger forensic inquiries. The aim, after finding out what went wrong, is to draw out lessons with the aim of ' it' never happening again. Each inquiry, whether small and internal or large and statutory, publishes a report with recommendations. These reports make difficult reading for anyone working in healthcare. For although the context and clinical details are never quite the same, they point to similar and familiar failures. The latest public failing in the UK has triggered not one but two inquiries and three reports: a report followed each inquiry with a third from an expert group, chaired by Professor Don Berwick, charged with taking the lessons from this latest failing and specifying what changes are needed to make the National Health Service (NHS) a safer health system. Will this third report, written to, and for, everyone in the NHS, make a lasting difference?