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This paper explores what it might take to narrow the implementation gap between the evidence base and advice about what keeps people safe and the actual practice close to the patient and client. We describe what we have learnt about facilitating conversations with clinicians about times when their practice ‘fell short’ and how attention to the framing assumptions embedded in these stories can tell us more about what it takes to keep people safer.

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.

It is now well recognised that incidents in healthcare systems are a serious problem which requires urgent attention. This paper outlines the work of the National Patient Safety Agency (NPSA), presents an overview of the 7 key steps required to achieve a safer organisation. The first 3 steps introduce the concepts, methods, research and practical tools in relation to developing a safety culture (step 1), establishing a strong focus on patient safety throughout the organisation (step 2) and integrating risk management systems (step 3). The following steps describe national and local reporting requirements (steps 4), patient and public involvement in safety (step 5), the root cause analysis approach to incident investigation (step 6) and transferring lessons to solutions (step 7). Every day more than a million people are treated safely and successfully in the NHS. However the advances in technology and knowledge in recent decades have created an immensely multifaceted healthcare system. Patient safety is such an important concept that taking this agenda forward might seem daunting in any area of the NHS. It is vital that healthcare staff can progress towards delivering this safety agenda. The 7 steps provides a guide to help them achieve this.

A total of 63 parents whose children underwent urological surgery at a tertiary referral specialist paediatric hospital were surveyed at three times points: immediately after signing consent; two to three days after surgery (at discharge); and by telephone two to three weeks after discharge. The survey was to assess parents’ perceptions of the consent process and parental recall of information given about the surgical procedure and risks. Results demonstrated that despite the majority of parents being satisfied with the consent process, operation, aftercare and the subsequent health of their child, their recall of risk information was poor, with 60 per cent of parents unable to recall any explained risks of the operation. This study pre‐dated the introduction of the national consent policies and forms, but provides evidence which supports the need for this consistent approach across the NHS which emphasises the effective communication of risks and benefits in relation to proposed treatment.

Clinical governance: a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. ‘Learning and applying the lessons’ when things have gone wrong is one means to improve service quality, but the current process for investigating homicides committed by mental health service users has been subject to criticism due to the length of time they can take (up to six years), expense (up to £3 million), their sometimes adversarial nature that can have a negative impact on staff, and often inadequate attention to the needs of the families of both the victims and the perpetrators. The same recommendations are repeated across inquiries with little evidence that lessons have been learnt across the mental health community. Certain organisational and cultural factors can increase the risk of incidents happening (Department of Health, 2000). Root cause analysis (RCA) is a technique for undertaking a systematic investigation that looks beyond the individuals concerned and seeks to understand the underlying causes and the organisational context in which the incident happened. Retrospective and multidisciplinary in approach, it is designed to identify the sequence of events, working back from the incident. To ascertain the suitability of RCA for use in mental health incidents, the National Patient Safety Agency (NPSA) evaluated a number of homicide inquires where RCA had been deployed. This found that RCA was generally well received: the focus on the system rather than the individual was welcomed; the process was considered less threatening than panel inquires and therefore conducive to more honest responses; and the skills, sensitivity and expertise of those conducting the inquiry were considered paramount. It was concluded that RCA was indeed appropriate for use in homicide inquiries. Draft guidance is awaiting final approval and NPSA is producing an information pack for local services to help foster a more uniform approach to independent inquires. In addition NPSA will conduct annual thematic reviews of inquiry reports to ensure that lessons that have implications across the service are both understood and acted upon. This article outlines the basic components of the root cause analysis process which are more fully described in the NPSA’s guidance Seven Steps to Patient Safety (www.npsa.nhs.uk/sevensteps).

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