Abstract
The National Patient Safety Agency aims to generate an open and fair culture in the NHS where errors and near misses are reported, studied and learnt from. Safety rests in the design of equipment, systems, procedures, buildings and corporate frameworks, together with awareness of the human factors behind slips, lapses, mistakes and violations and how to anticipate and control them. Cultural shift can only be achieved if staff are willing to report and learn from such events and from near misses. It is a long way from the current widespread climate of blame and cover-up, but the change has begun.
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