An organisation with a memory (June 2000)

Summary

This report examines the key factors at work in organisational failure and learning, a range of practical experience from other sectors and the present state of learning mechanisms in the NHS before drawing conclusions and making recommendations.

It's recommendations include the creation of a new national system for reporting and analysing adverse health care events, to make sure that key lessons are identified and learned, along with other measures to support work at local level to analyse events and learn the lessons when things go wrong.

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