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The aim of this review is to examine factors that may explain why other industries are considered ultrasafe while progress toward preventing adverse events in health care is not considered to have reached that level.

The paper is a narrative review.

Despite a decade of intense effort, the problem of patient harm in health care facilities remains a challenge. A recent study of ten hospitals in North Carolina, which have actively engaged in patient safety initiatives, reported rates of adverse events similar to those in the Institute of Medicine report, To Err Is Human in 1999. Seven key issues and their interaction are described.

This review focuses on broad issues that likely impede progress generally, not on individual project or individual hospital program success stories.

The authors believe the difficulty in making significant headway on the patient safety agenda is due in part to the fact that it was always going to be a long (indeed never ending) struggle – aviation for example took almost 60 years to become ultra‐safe – and in part to misunderstanding the nature of the dynamics that are involved in the generation of adverse events in risk critical industries. The paper reflects on the nature of the safety initiatives that health care has tended to focus on, but which have not sufficiently taken note of central concepts of safety science, as well as on features of the health care system itself that have impeded, in the authors' view, progress on enhancing patient safety.

This paper aims to explore the mediating effect of organizational support for innovation and moderating impact of supervisory support on how rewards shape employee creativity among rural healthcare employees, a group with few resources and considerable expectations.

Using a regression-based moderated path analysis, the authors tested the hypotheses with healthcare employee survey data from a large Southern rural hospital in the USA.

The empirical results suggest organizational support for innovation mediates the influence of rewards on employee creativity. In addition, the indirect effect of rewards on employee creativity via organizational support for innovation is moderated by supervisory support, such that the indirect effect is more pronounced at high levels of supervisory support than at low levels of supervisory support.

This study contributes to the organizational support and creativity literature by exploring the indirect relations of rewards on employee creativity through organizational support for innovation, and the moderating role of supervisory support in such relations.

An International Exhibition of Hygiene, Arts, Handicrafts, and Manufactures will be held in the Crystal Palace, Madrid, from September to November next, under the patronage of the Spanish Government. The participation of British exhibitors is particularly desired by the promoters, who state that the attendant expenses will be small. His Excellency the Spanish Minister of Commerce will be the Honorary President; the President of the Committee will be his Excellency the Duke of Tamames and Galisteo, Grandee of Spain, Senator, and ex‐Governor of Madrid. The American war on the one hand, and political changes on the other, have had the effect of seriously damaging the credit of Spain, and many exporters, in view of then existing difficulties, refused to trade until affairs became mere settled. To‐day, however, the Spanish Government are making every effort to restore the economical prosperity of their country. Markets have gained strength, commerce has quadrupled, imports have trebled, and exchange is greatly improved. Well‐advised manufacturers sell in quantity and at good prices, the demand being greater than the supply. Again, the immense natural richness of the Iberian Peninsula, which has not yet received the attention of enterprising and powerful capitalists in any proportion to its value, makes Spain one of those countries where industrial progress is the more certain. The decision to hold this exhibition is evidently a wise one, and considerable advantages may accrue to British manufacturers and merchants taking part therein. There appear to be ample guarantees to show that the undertaking may be supported with every confidence. We understand that all detailed particulars with reference to this important exhibition can be obtained from the Spanish representative in London, Mr. A. DONDERIS, Spanish Arts Exhibition, Compton House, 99A, Charing Cross Road, London, W.C.

The High Court judgments in the two appeal cases relating to the sale of cream containing boric acid will be read with considerable satisfaction by those who consider that the protection of the health of the people is a matter of greater importance than the protection of the interests of a trade. In one case the Westminster City Council appealed against the decision of a Metropolitan Police magistrate who had dismissed a summons taken out by the Council under the third Section of the Act of 1875 for the sale of “preserved cream” containing 23·8 grains of boric acid per pound, and in the other the vendors of a sample of “preserved cream” containing 19·7 grains of boric acid per pound, appealed against their conviction under the same Section of the Act by the Kensington justices. In the first case the appeal was allowed and the case was remitted to the magistrate with a direction to convict; and in the second the appeal was dismissed, the Divisional Court, consisting of Justices Ridley, Bray and Avory being unanimous in both cases.

In discussing the subject of bread, or indeed any subject, one is of course confronted by the initial difficulty of definition. Nothing is harder than to define any concrete thing, no matter how common and well‐known it may be. This is not surprising when we remember that no one has ever succeeded in defining a definition. Perhaps the best attempt to do so is Pascal's, in the “Port Royal Logic,” and it is easy to drive a coach and six through the rules which he lays down for definitions to conform to. The only things that can be strictly defined are mathematical abstractions, such as a circle, which are formed on natural objects by pruning away their multitudinous properties till only two or three which can be expressed by a short and indisputable definition are left.

In a previous article we have called attention to the danger of eating tinned and bottled vegetables which have been coloured by the addition of salts of copper and we have urged upon the public that no such preparations should be purchased without an adequate guarantee that they are free from copper compounds. Copper poisoning, however, is not the only danger to which consumers of preserved foods are liable. Judging from the reports of cases of irritant poisoning which appear with somewhat alarming frequency in the daily press, and from the information which we have been at pains to obtain, there can be no question that the occurrence of a large number of these cases is to be attributed to the ingestion of tinned foods which has been improperly prepared or kept. It is not to be supposed that the numerous cases of illness which have been ascribed to the use of tinned foods were all cases of metallic poisoning brought about by the action of the contents of the tins upon the metal and solder of the latter. The evidence available does not show that a majority of the cases could be put down to this cause alone; but it must be admitted that the evidence is in most instances of an unsatisfactory and inconclusive character. It has become a somewhat too common custom to put forward the view that so‐called “ptomaine” poisoning is the cause of the mischief; and this upon very insufficient evidence. While there is no doubt that the presence in tinned goods of some poisonous products of decomposition or organic change very frequently gives rise to dangerous illness, so little is known of the chemical nature and of the physiological effects of “ptomaines” that to obtain conclusive evidence is in all cases most difficult, and in many, if not in most, quite impossible. A study of the subject leads to the conclusion that both ptomaine poisoning and metallic poisoning—also of an obscure kind—have, either separately or in conjunction, produced the effects from time to time reported. In view of the many outbreaks of illness, and especially, of course, of the deaths which have been attributed to the eating of bad tinned foods it is of the utmost importance that some more stringent control than that which can be said to exist at present should be exercised over the preparation and sale of tinned goods. In Holland some two or three years ago, in consequence partly of the fact that, after eating tinned food, about seventy soldiers were attacked by severe illness at the Dutch manœuvres, the attention of the Government was drawn to the matter by Drs. VAN HAMEL ROOS and HARMENS, who advocated the use of enamel for coating tins. It appears that an enamel of special manufacture is now extensively used in Holland by the manfacturers of the better qualities of tinned food, and that the use of such enamelled tins is insisted upon for naval and military stores. This is a course which might with great advantage be followed in this country. While absolute safety may not be attainable, adequate steps should be taken to prevent the use of damaged, inferior or improper materials, to enforce cleanliness, and to ensure the adoption of some better system of canning.

Sixty‐two samples of medicines and drugs taken from supplies for the Colonies were examined as to conformity with the specification. Four samples of foods were also submitted as to their purity and suitability for export to hot climates.

The recent epidemic of food poisoning at Nelson, Lancashire, is an event which is unfortunately not unknown in this country, especially in summer time. It has been said that at least two hundred people have been affected more or less seriously, and that there have been four deaths from acute gastro enteritis. Cases of suspected food poisoning are now in many places compulsorily notifiable to the local authority by medical practitioners to whose notice such cases may have been brought in the course of their practice. As far as we know such notification was not made compulsory before the year 1924, when Wakefield obtained powers under a Corporation Act to do so. A large number of places since that time have followed the lead of Wakefield. Thus among watering places, Cleethorpes, Bridlington, Brighton and Bournemouth; among manufacturing centres, Sheffield, Stoke‐on‐Trent, Bradford, Blackburn, Oldbury, Smethwick, Cardiff and Rochdale have powers of compulsory notification.—Cheap, rapid, and frequent means of road and rail transport has in these days resulted in an enormously increased influx of holiday makers from the manufacturing centres into seaside towns during the summer. Here, then, is a floating population amounting to several thousands. They are at a place that has been freely and emphatically advertised as a health resort. The have come for a “change” in every sense of the word. It is high summer. The weather is hot. The holiday spirit in the air. A very natural result is for people to eat more fruit, ice cream, and fancy dishes than they would ordinarily do. Assume through some mischance there are one or two cases of food poisoning. These are now automatically reported to the local authority, which at once institutes investigations, tries to trace the evil to its source, and check it from spreading. A serious outbreak is a damning catastrophe for the place, and may adversely affect its future for years to come. In manufacturing centres the need for action on the part of the local authority is still more urgent. The danger is perennial. It may easily reach the dimensions of an epidemic in a poor and crowded district. The people are there from necessity not from choice, and there they would have to stay even if the place were swept by cholera. In the County of London notification is compulsory under the London County Council (General Powers) Act, 1932, Pt. II., s.7, which says : “ Every registered medical practitioner, if he suspects that a person is suffering from food poisoning shall notify the Medical Officer of Health for the district.” This section it is pointed out, was drawn up on the lines of the Sheffield Corporation Act, 1928, s.190, one of the main Corporation Acts that insist on notification. There seems indeed to be a growing belief that compulsory notification of food poisoning is desirable in the interests of public health. Processed foods are particularly liable to become sources of infection. Thus the Act just quoted, Pt. II. s.5, states that premises used for the sale or manufacture of ice cream; or for the preparation or manufacture of sausages or potted, pressed, pickled, or preserved meat, fish or other food must be registered with the Sanitary Authority of the district. Under the same section registration may be refused or registration may be cancelled. Many towns have similar regulations. This section of the London County Act is founded on the Exeter Corporation Act, 1928, s.111. The fact that the London County Council have adopted these two regulations that had already been “ tried out ” in two important cities of such widely different interests as Sheffield and Exeter is a good illustration of how closely associated all municipal bodies are in matters connected with public health. Medical Officers of Health and Public Analysts are officers of the Ministry of Health, and the Ministry itself is a clearing house for general information, investigation, and the co‐ordination of statistics. The sanitary authority of, and the medical practitioners in, any given district discharge not only admittedly most important but, as it seems to us, complementary duties. Each has knowledge not possessed by the other. Diagnosis in cases of suspected food poisoning is by no means easy. Time is not on the doctor's side so that the sooner the sanitary authority is notified the better are the chances of being able to trace the trouble to its source and to deal with it— assuming, of course, that it did not originate in some piece of purely domestic carelessness or ignorance. The information acquired may be slight, or even negative in any given case, but in the aggregate a fund of knowledge must accumulate that cannot fail in the long run to be of value. In many cases of suspected food poisoning further investigation has shown that they are not due to food poisoning at all. For instance, in one borough nine cases reported were found to be due to “ dietetic indiscretion ”; in another twenty reported cases were only forms of more or less acute digestive disturbance of the ordinary kind; in another it was found that daffodil bulbs had been eaten in mistake for onions. Other instances could be given. Facts like these would seem to support the argument that compulsory notification is unnecessary, but it is surely better that twenty suppositious cases should be reported than that the circumstances of one real case should escape investigation. In other cases the cause may remain unknown, but as to the seriousness of the matter there can be no doubt. In a recent outbreak in a home for “unwanted” children out of thirty‐nine infants in one dormitory twenty‐seven were attacked, and twenty died in from two to four days from some obscure form of gastro enteritis. Bacteriological examination of excreta and vomit yielded negative results. The high rate of mortality was attributed to the poor physical condition of the children when they were admitted to the institution in which they died. The case is admittedly an extreme one. Another was reported of exactly the opposite character. Twelve cases of undoubted food poisoning were reported, but these were of so slight a character that no action was taken in regard to the circumstances. In general, however, there is no room for giving the benefit of the doubt. The error—even if it may be so called—of reporting what turns out to be a case of indigestion instead of one of food poisoning is an error on the right side. A question arose recently in the House of Commons as to whether it was necessary to retain an Act on the Statute Book when there had been no prosecutions under the Act. It will be remembered that the Solicitor‐General replied that the mere fact that the Act was on the Statute Book had a very salutary effect. As far as it may be possible to draw an analogy it seems that even better reasons exist not only for retaining, but for extending, compulsory notification of cases of suspected food poisoning. Registration and inspection of premises, plant, storage conditions, and the food itself in places where food is prepared and sold is now a general practice in all centres of population. How necessary this is a glance at the Law Reports of this journal will show. The state of the places mentioned in the records of the prosecution was often such as to ensure them being potential centres of food poisoning. Had it not been for the vigilance of the respective sanitary authorities they would have become actively and permanently so. Such prosecutions are comparatively rare having regard to the large number of food shops in existence, but it would certainly be a backward step to cease to register and to inspect.