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Healthcare is complicated, too complicated for any one person to actuallyown or control the processes of diagnosis and care. Patients come into our

hospitals for care, and for their benefit and safety we all need to look upon

ourselves as part of the system of care. Risks are all around, but often we

fail to see them as our workplace environment becomes more or lessbackground noise. Complacency is our enemy and therefore each patients

enemy.

Caring for patients is fraught with danger. !very time we stand at the

bedside we bring benefits but also risks. Problems with our systems of careand personal lapses from a range of human factors often result in harm,

preventable harm. Healthcare is all about partnership, patients and

healthcare professionals partnering to achieve desired outcomes. "t is all

about trust and obligation.

Patient complaints may or may not be well#grounded, but what really matters

is why, in the comple$ity of what we call modern healthcare, clinician#patientcommunication has failed to satisfy the needs and wants of individuals whore%uire understanding and care. &his is particularly the case when sharing

uncomfortable or troubling news with patients and care givers. 'dmittedly

some patients, especially those with more limited capacity to understand the

multifaceted issues relating to their illnesses, may harbor unrealistice$pectations( and this may contribute to miscommunication. )ut more often

than not, patients simply want to get better, and when complaints arise it is

because of an imbalance between e$planation and understanding.

*ell, 'retha certainly deserved respect, as we all do. !veryone has inherentworth and dignity and in healthcare we can potentially bring real value to our

patients +. every one of them

'ccessing %uality healthcare and e$ercising individual options for care arebasic human rights. "nformation sharing, honesty and openness are elements

of the informed consent process that facilitate the provision of safe care and

serve to decrease litigation risks. &he failure to get this process right leads to

misunderstandings, unrealistic e$pectations, potential adverse outcomes andrisks of litigation. *e need to get this right

&here is a conundrum in patient safety incident classification that arises

because of conflicting opinions regarding -ust what is or is not an incident

&he primary reason for adverse event reporting is to identify learningopportunities and preventive strategies so that ultimately we can avoid, or

moderate the impact of, incidents. "ncidents have causes, often preventable,

and these can be detected through structured processes of analysis. Causes

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