In the 1980s, Jan Carlzon helped turn around Scandinavian Air Services using the catchphrase ‘you can’t change something by 1000 times but you can change 1000s of things by 1%’. The current philosophy of making ‘marginal gains’ is the modern equivalent of this 1980s concept.

The more inefficiencies and minor errors there are at the base of the Bird triangle, the greater chance there is of a major error occurring. Then the more major errors there are, the greater the chance there is of a more serious error occurring.

Now that the Francis, Berwick and Kirkup reports are providing the high-level guidelines for a total change of working in the NHS, it is appropriate to describe how their thinking could apply at ground level.

Some personally acquired examples are quoted to explain what I mean: several examples of the Nil by Mouth being breached; a time-wasting episode involving a urine sample; phone calls not being made; errors of communication; poor-quality letters to patients; day-to-day errors; and finally, mislaid results.