Remembering to learn: the overlooked role of remembrance in safety improvement

Memory, and remembering the past, are fundamental to patient safety. One of the core objectives of safety improvement is to learn from the past in order to improve the future. This commitment to remember and to learn is central to the strategies that have shaped the evolution of patient safety such as 'An organisation with a memory',1 and underpins definitive academic research such as Bosk's 'Forgive and Remember'.2 Remembering the past to improve the future is institutionalised across healthcare in a variety of activities such as safety incident reporting, morbidity and mortality meetings, coroner investigations and public inquiries. Despite this, healthcare systems still suffer striking and acute episodes of forgetfulness3 that are deeply consequential: when harmful events are forgotten, they are likely to be repeated.

Given the central importance of memory in patient safety, it is surprising that one of the most long-standing...

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