SAFER HOSPITALS
at which point harm – including fatalities – may occur. If hazards could be identified at the inception of
the project, appropriate mitigation strategies could be incorporated into the design from the outset. This would greatly increase the likelihood that the project would be successful – completed on time, within budget, and, most importantly, safe for its occupants. Therefore, the key to a successful project is identifying
all relevant risks at the earliest stage and incorporating the necessary mitigation measures into the design. The challenge then becomes: how can these hazards be anticipated?
The failure to learn systematically “Detecting and accurately recording errors is a fundamental step in learning from experience.” An Organisation with a Memory
In 2000, the NHS published a report titled An Organisation with a Memory.4
It was produced by a team
of experts chaired by the then Chief Medical Officer, Sir Liam Donaldson. The central premise of the report was clear: detecting and recording errors is fundamental to improvement. Despite this, there is currently no national repository capturing failures related to the healthcare built environment across NHS projects. There is no standardised mechanism for: n Recording water or wastewater system failures in new hospital builds.
n Sharing commissioning failures. n Logging ventilation compliance deficiencies. n Disseminating lessons learned across estates teams, infection prevention specialists, and design teams.
As a result, each project effectively learns in isolation, and design flaws may be repeated across multiple projects. Given that the NHS operates as a national system, it is uniquely positioned to achieve exceptional organisational learning. Instead, valuable experiential knowledge is often lost once individual projects conclude. If learning is to be maximised, the airline industry provides a useful model through its application of the
Heinrich ratio. According to this principle, for every 330 incidents, there are: n 300 near misses with no injury. n 29 incidents causing minor injuries. n 1 major accident.
The airline industry systematically collects and analyses near-miss data – the 300 incidents with no injury – because these represent valuable opportunities for learning. By acting on these ‘free lessons’, major accidents can often be prevented. By contrast, the construction industry often responds only to major incidents, and even then, it is uncertain whether meaningful lessons are translated into practice. Eight years after the publication of the Hackitt Report (discussed below), many stakeholders had still failed to implement its recommendations, ultimately requiring legislation to enforce change.
Grenfell and the Hackitt Report – the way forward In 2017, seventy-two people died in the fire at Grenfell Tower. The subsequent report into the tragedy, chaired by
For every 330 accidents, there are 300 near misses, 29 minor injuries and one major injury/ accident. Learning from the 300 near misses makes the airline industry the safest form of transport. Contrast this with the construction industry where any learning to protect occupants of new buildings is based on major incidents making the press.
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April 2026 Health Estate Journal 37
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