The NHS is a long way from the aviation industry when it comes to safety and you have hit the nail on the head with this blog. A solution for the NHS will not be found until two two conditions are first met. For simplicity I have come up with two formula. Fist: WAD=WAI, and second: QI=CI. There is a great deal of change required for the NHS to meet these two conditions, far too much to show here. WAD is Work as Done. WAI is Work as Imagined. QI is Quality Improvement as interpreted by the NHS, and CI is Continuous Improvement. Once these two conditions are met then the NHS can start to implement three, universally recognised systems. These are Process Management System (PMS), Quality Management System (QMS) and finally a Safety Management System (SMS). Clinicians', on there own, will not achieve this, they need to seek help from outside the NHS.