Patient safety, law, leadership, conclusion

This final chapter by Steve Gulati and Marc Stauch provides a conclusory overview by drawing together some of the key themes discussed in earlier chapters and presenting some recommendations as to how patient safety initiatives should be conceptualised and taken forward in the future. As the authors suggest, besides a focus on technical aspects of risk-mitigation, for such initiatives to bear fruit, there needs to be a transformation of the overall culture of health care provision, so that core ethical values of transparency, compassion and respect become integral to daily practice. In this regard, the chapters together offer a holistic perspective on the myriad patient safety issues that stem from a failure to pay sufficient attention to the voices of ‘fellow actors’ in the system. As different chapters illustrate, this may take either an external form – in which the concerns and interests of certain (groups of) patients are undervalued – or an internal one – in which the same occurs within the relevant health care team. In both cases, a key aim must be to promote a respectful (non-discriminatory or -stigmatising) care environment, where uninhibited communication thrives, and information, essential to avoid – or learn from – safety mishaps is not overlooked.