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Twenty-five years ago the field of patient safety, apart from a number of early pioneers, did not exist and the lack of research and attention to medical accidents could reasonably be described as negligent (Vincent 1989). There is now widespread acceptance and awareness of the problem of medical harm and, in the last decade, considerable efforts have been made to improve the safety of healthcare. Progress has however been slower than originally anticipated and the earlier optimism has been replaced by a more realistic longer-term perspective. There has undoubtedly been substantial progress but we believe that future progress, particularly in the wider healthcare system, will require a broader vision of patient safety. In this chapter we briefly review progress on patient safety and consider the principal future challenges as we see them.

In this chapter we first attempt to persuade (or remind) the reader that much healthcare departs from the care envisaged by standards and guidelines. We appreciate that standards and guidelines need considerable interpretation and adaptation for patients with multiple conditions (Tinetti et al. 2004) and that even the simplest conditions require consideration of personal preferences and other factors. However we are concerned primarily with the basic fact that the care provided to patients often does not reach the standard that professionals intend to deliver and which professional consensus would regard as reasonable and achievable. Clinical processes and systems are often unreliable and in fact many patients are harmed by the healthcare intended to help them. All this is to some degree obvious to anyone who works at the frontline or studies healthcare deeply. One of the questions we address in this book is how to manage the gap between the ‘real and the ideal’ and how best to manage the risks to patients.

In the previous chapter we set out five levels of care with the levels being defined according to how closely they met expected standards of care. We argued that the care delivered to patients frequently departs from expected standards and that this has important implications for the management of safety. Most safety improvement strategies aim to improve the reliability of care and move more closely to optimal care. We suggest that these strategies need be complemented by strategies that are more concerned with detecting and responding to risk and which assume that care will often be delivered in difficult working conditions.

Consider these reflections on patient harm written by Carolyn Canfield whose husband’s care was very poorly managed at the end of his life. This is a description of harm written from the patient’s side and in several respects it is strikingly different from the accounts of incidents and adverse events described by healthcare professionals. Three things in particular stand out:

Every high-risk industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. Such industries employ many other methods for assessing safety but the identification and analysis of serious incidents and adverse events continues to be a critical stimulus and guide for safety improvement. Analyses of safety issues always require review of a range of information and recommendations should generally not be made on the basis of a single event. Nevertheless, an effective overall safety strategy must in part be founded on an understanding of untoward events, their frequency, severity, causes and contributory factors. In this chapter we consider how these analyses might need to be extended in the light of the arguments presented in the preceding chapters.

Imagine that you are the leader of a healthcare unit or organisation. You are concerned about safety but you have (as always) limited time and resources. You plan a programme lasting 1 year initially and perhaps extending to 5 years.

We have developed a series of ideas and proposals in the book which together laid the foundations for five safety strategies described in Chap. . We believe that thinking of safety strategies in this way has three major advantages: first, we can enlarge the range of safety strategies and interventions available to us; secondly we can customise the blend of strategies to different contexts and third the high level architecture of safety strategies may help us think more strategically about safety both day to day and on a long term basis

Patient safety has evolved and developed in the context of hospital care. The understanding we have of the epidemiology of error and harm, the causes and contributory factors and the potential solutions are almost entirely hospital based. Safety in home care is likely to require different concepts, approaches and solutions. Safety in this context has however been barely addressed and yet care provided in the home will soon become the most important context for healthcare delivery.

Patient safety is a young discipline that emerged from medico-legal concerns associated with the risk of occurrence of specific and easily identifiable adverse events that were mostly associated with hospital care. In primary care however patients are managed over long periods of time and the safety issues that arise are likely to be of a very different character. We have earlier suggested that we should recast patient safety as the management of risk over time; this perspective may be better adapted to the longer time scales of primary care.

The developments described in the previous chapters are required because our present vision of safety is not adequate for the challenges we face. Our arguments for these developments rest on analyses of the nature of safety in healthcare as it is delivered today. However, as is well known, healthcare is changing rapidly and there are many new opportunities, pressures and challenges. We believe that these coming changes will have further implications for how safety is understood and practiced which will increase the urgency and importance of the transition to a broader vision.