ABSTRACT
The year 2000 was a watershed moment in the history of patient safety policy development in the National Health Service (NHS) in England. The year saw the publication of the seminal patient safety policy document, An Organisation with a Memory with its underpinning concept of, 'Clinical Governance'. In reading Organisation with a Memory, it is useful to reflect on whether the NHS has moved significantly forward since 2000 in the intervening years in developing an ingrained patient safety culture. The issues and the conceptual tools, such as clinical governance, remain very pertinent today. The clinical governance was an excellent and simple quality organising concept and tool. Following Organisation with a Memory new guidance was issued in 2001 in the form of Building a safer NHS: Implementing Organisation with a Memory. This report set out the role of a new National Patient Safety Agency (NPSA) and determined what was to be the National Reporting and Learning System (NRLS).
