An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS Chaired by the Chief Medical Officer.
An Organisation with a Memory set out to understand what was known about the scale and nature of serious failures in the United Kingdom’s National Health Service (NHS) system, examine how the NHS might learn from those failures, and recommend methods to minimize future failures. The analysis was informed by not only medical evidence but also the expertise and experience of other high-risk industries such as aviation. The findings and analysis have been used to modernize the United Kingdom’s process for understanding error by addressing a key set of goals to create unified reporting mechanisms, support an open learning culture, ensure that lessons learned are applied and changes made, and to more broadly embrace the systems approach to minimize error.
Donaldson L. London, UK: The Stationery Office, 2000.