This report from the Chief Medical Officer and a range of safety experts defined and popularised the field of patient safety. Published in 2000, it continues to remain relevant and pertinent today.

The report explains how adverse events are caused in healthcare organisations, why these events can never be entirely eliminated, but how organisations and healthcare systems as a whole can understand and learn from safety incidents and act to reduce risks and improve safety.

The report provides a range of important and relevant references for further reading, many of which are definitive texts in the field of patient safety.