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Final Report > Recommendations > The safety of care

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The safety of care

  1. We support and endorse the broad framework of recommendations advocated in the report `An Organisation with a Memory' by the Chief Medical Officer's expert group on learning from adverse events in the NHS. The National Patient Safety Agency proposed as a consequence of that report should, like all other such bodies which contribute to the regulation of the safety and quality of healthcare, be independent of the NHS and the DoH.
  2. Every effort should be made to create in the NHS an open and non-punitive environment in which it is safe to report and admit sentinel events. [3]
  3. Major studies should, as a matter of priority, be carried out to investigate the extent and type of sentinel events in the NHS to establish a baseline against which improvements can be made and measured.


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[3] A sentinel event is defined as `any unexplained occurrence involving death or serious physical or psychological injury, or the risk thereof'