![]() The need for sound ‘clinical’ risk management is further reinforced through the clinical governance agenda. This is a fundamental requirement set out in both the DH Risk Management System standard (6), developed to meet the requirements of the NHS controls assurance project, and the Clinical Negligence Scheme for Trusts (CNST) risk management standards (7). Engaging in proactive risk management activity, in addition to the reactive process of incident management, will enable the identification of many things that could go wrong as part of a systematic approach to risk assessment. It is not sufficient for organisations and individuals involved in provision of NHS care to learn and improve only from things that go wrong. The aim is to reduce the risk of harm to future NHS patients through improving patient safety and quality of care. This document builds on the work that has been carried out to-date and sets out the key requirements for local organisations to manage, report, analyse and learn from adverse patient incidents. The report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary (5) adds further impetus to the drive to improve the safety and quality of care. This is supported by the recent work of Neale et al, who have established from retrospective medical record reviews that at least one in twenty NHS patients suffers preventable harm (4). The Department of Health (DH) publications An Organisation with a Memory (2) and Building a Safer NHS for Patients (3) identified the significant opportunities that exist to reduce unintended harm to patients arising during NHS care. In relation to doctors and patients, this is a fundamental pledge made by the Government, the medical professions, and the NHS in A Commitment to Quality, A Quest for Excellence, published on 27 June 2001 (1). When they do, the response should not be one of blame and retribution, but of learning, a drive to reduce risk for future patients, and concern for staff who may suffer as a consequence. In a service as large and complex as the NHS, things will sometimes go wrong.
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