With an estimated 850,000 incidents and errors occurring every year across the NHS, reducing medical errors and improving patient safety are critical issues in healthcare today. The costs in human tragedy and suffering to patients, with a third of adverse incidents leading to disability or death; the effects on healthcare staff involved; and the financial costs mean there has never been a greater need to improve patient safety and the patient environment.

In June 2000, the Government accepted all recommendations made in the report of an expert group, led by Dr Liam Donaldson, Chief Medical Officer, called An Organisation with a Memory. The report acknowledged that there has been little systematic learning from adverse events and service failure in the NHS in the past and drew attention to the scale of the problem of potentially avoidable events that result in unintended harm to patients.

An Organisation with a Memory proposed solutions based on developing a culture of openness, reporting and safety consciousness within NHS organisations. It proposed the introduction of a new national system for identifying adverse events and near misses in healthcare to gather information on causes and to learn and act to reduce risk and prevent similar events occurring in future.

Whilst awaiting the national reporting system the PCT has established an incident reporting system and investigates each report. Additionally the Trust collates a summary to identify trends for further review.