A relatively underdeveloped approach is one in which the organisation shows little interest in dealing with safety issues. If they are caught out by an incident, they will focus on moving on from it as quickly as they can, possibly by finding a scapegoat.

A slightly more developed approach is one in which the organisation does take safety a bit more seriously, but only in reaction to an incident. There is little thinking ahead to what could go wrong, unlike at the next stage.

The organisation has gained some knowledge about potential risks. However, its way of dealing with these is to rely on bureaucracy – procedures and audits. As long as the boxes are ticked, then the organisation is safe. This is fine, as far as it goes, but there is little thinking beyond the tick-boxes – how else could things go wrong, and what needs to be done about it?

Such questions are addressed by organisations at this proactive stage. They keep an open mind about patient safety issues, and are willing to learn and act on new insights.

Finally, are the organisations for whom patient safety is actually central to what they do, in the sense that they are never complacent about their awareness and management of risk, and they engage staff at all levels in efforts to improve safety.