Month: December 2015

More food for thought


Patient Safety is a complex science.  It is still a relatively young field, with just fifteen years since an Organisation with a Memory in human terms it is still a teenager! The National Patient Safety Foundation (NPSF) in the US have now released their report; Free from Harm: Accelerating Patient Safety Improvement Fifteen years after To Err is Human – you can access this via  The group responsible for this report were headed up […]

Guest Blog David Naylor (2)


I will learn from this (well maybe…) – David Naylor The emphasis on learning has never been greater in public services. It can sound like a stock response after something has gone wrong (we are sorry; we have learnt important lessons…). When I listen to the complexity of the issues leading up to the mistake I wonder how they could have learnt so fast because in my experience any serious learning is a bit of […]