In July this year, the Health Committee of the House of Commons1 published a 120-page, reasonably readable report entitled Patient Safety. It covers the issues surrounding patient safety in some depth; it is essentially a high-level stock take on how the National Health Service (NHS) is managing and performing in this discrete but critically important component of patient care. The key points from the summary in the report can be paired down as follows.

• Not all care is as safe as it could be; as many as 10% of admitted patients experience (mostly) avoidable harm.

• Nearly a decade ago, the government made it a priority to address patient safety across a whole system, with policy focusing on a unified mechanism for reporting and analysing incidents, underpinned by a new culture of NHS openness, centred on the National Reporting and Learning System (NRLS) and the National Patient Safety Agency. Although judging the overall effectiveness of patient safety policy is difficult because of the failure by the Department of Health to collect adequate data, there has been insufficient progress in making services safer.

Recommendations made by the Health Committee include the following:

• Data on the incidence of harm must be …