• adverse events;
  • healthcare system;
  • patient safety;
  • performance indicators.


We are unable to guarantee our patients that the care we provide will do no harm. Up to 16% of hospital admissions will be associated with an adverse event, approximately half of which are preventable. It is a clinical imperative that we must strive to improve patient safety by improving the systems in which we work, such that they support us in providing better and safer care. For this to occur, an environment must develop where clinicians feel safe to report and allow analysis of adverse events and near misses. The greatest inhibitor of a reporting culture is the prevailing legal climate with its associated blame culture. A new social contract is required whereby systems analysis will predominate over the previous presumption that individual clinicians must be held responsible for each and every adverse outcome. Individual responsibility should be reserved for events where it becomes evident during the course of systems analysis that an individual's behaviour is truly blameworthy.