Dr. Kathleen MacLellan:

Yes, the intent is that we are trying to create a safe space so that where there is a view that something has gone wrong, and at that stage we will not necessarily know why it has gone wrong, the health professional can feel comfortable in sitting down with the patient and saying to Mrs. X that he or she is very sorry something has happened here, the implications are whatever and this is how we will look after her and her care going forward. We are going to take this learning and see if there is something immediate in the system that we need to address. Is there something longer term that we need to promulgate, not just within the hospital or the organisation but across the whole health system?

I suppose it is trying to create an atmosphere where we turn things upside down, things are not covered up and instead of people feeling fearful in coming forward, they actually feel safe to sit down with their patients with their organisation supporting them to feel safe. We want to start opening the issues out. That is the international experience. When we start talking about patient safety incidents, measuring and knowing what is happening, we will make genuine moves to make the system safer.