Reclaiming the systems approach to paediatric safety

Abstract

It is now 20 years since the publication of To Err is Human,1 the first major review of healthcare safety in the USA. In the UK, the publication Organisation with a Memory 2 in 2000 supported the view that patient safety required a wider system approach. Both documents reframed safety and error in healthcare as an organisational or system issue rather than one of individual error, whether of omission or of commission. Over the past 20 years, there has been major progress in the understanding of patient safety and the complexity of the systems involved in providing healthcare. In a recent review of the state of patient safety in 2018, Bates and Singh3 conclude that ‘Highly effective interventions have since been developed and adopted for hospital-acquired infections and medication safety, although the impact of these interventions varies because of their inconsistent implementation and practice’.