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Nurses are at the forefront of patient safety and are constantly reviewing their practice to improve care delivery. When things go wrong in health care the consequences can be distressing for patients and staff. Lessons need to be learned and acted on to minimise the likelihood of reoccurrence. The 'root cause analysis' approach provides nurses and other healthcare staff with a consistent and structured methodology to investigate incidents. It enables staff to identify where systems are failing and where improvements in patient care and safety can be made.

In the past few weeks, I have had the privilege of attending a series of seminars exploring the themes emerging from the Mid Staffordshire Public Inquiry to date. They are highly relevant to nurses and to the future of nursing. They have explored system and professional regulation, organizational culture, board leadership, information systems, nurse training, patient experience and commissioning.

Primary cutaneous T- and B-cell lymphomas are a heterogeneous group of diseases with varied clinical presentations and prognosis. The use of new molecular, histological, and clinical criteria has improved their recognition. Cutaneous B-cell and T-cell lymphomas are seldom found together in the same patient. Here we report a rare case of mycosis fungoides variant of a cutaneous T-cell lymphoma (CTCL) which later developed Epstein-Barr virus (EBV) associated cutaneous B-cell lymphoproliferative disorder. The patient initially presented with generalized erythroderma, extensive plaques, and axillary lymphadenopathy. Histopathology and immunophenotyping of her tumor from the right breast nodule revealed a T-cell lymphoma consistent with mycosis fungoides. She was initially treated with pentostatin, followed by topical mechlorethamine and topical steroids. After progression of her mycosis fungoides with worsening diffuse skin lesions on this regimen, her treatments were changed to oral bexarotene with an initial partial response followed by stable disease. Three years from her initial presentation, she developed ulcerated cauliflower-like nodules on her forehead. Biopsy of these lesions revealed EBV-positive large- and medium-sized pleomorphic B-cells consistent with EBV-driven B-cell lymphoproliferative disorder. She was treated with topical acyclovir cream on the involved skin areas while continuing with oral bexarotene for mycosis fungoides. Skin lesions gradually diminished and totally disappeared after four weeks of topical acyclovir treatment. Bexarotene treatment was continued for another year until the mycosis fungoides progressed and became wide spread causing her death four and a half years after the initial diagnosis. The coexistence of two cutaneous non-Hodgkin lymphomas of different lineage in the same patient and the complete clinical response of EBV-related B-cell cutaneous component to topical acyclovir makes this rare case particularly interesting.

The third paper in our series describes the National Patient Safety Agency's approach to investigation, root-cause analysis and significant event audit. When should an investigation be high level and when should it be low level? What does this mean, and how can lessons be translated into safety solutions in local areas? Central initiatives such as patient-safety alerts are also examined.

Patient safety incidents are a major problem in the health service and it is acknowledged that blaming and reprimanding staff for actual or potential mistakes does not encourage an open and safe culture in which to work. In the first paper in a three-part series the National Patient Safety Agency's seven key to steps to achieving patient safety are discussed.

‘You don't need to work around a hospital for long to realise that there are loads of opportunities for things to go wrong. And you only have to listen to a story from a patient or actually be a patient to understand that it doesn't take much to make things an awful lot better and safe’. Participant, Patient Safety First, 2010