Public inquiries, patient safety and the implementation gap

Abstract

A decade on from the Francis report, avoidable patient harm continues to occur and we have continued to see new inquiries and reviews into serious patient safety scandals. A failure to listen to patients or learn from previous investigations, a corrosive blame culture, a lack of effective leadership and an unresponsive regulatory framework are alarming and often reported themes that we review here.

Keywords: Patient Safety Learning; Patient safety; blame culture; healthcare safety investigations; implementation; patient harm; safety management.