PROVIDING A REFRESHING VIEW OF SAFETY

More than just a checklist “The checklist was never about ticking boxes. It was always about creating a moment when a team comes together with a shared purpose.” I remember sitting at t…

I had the privilege of speaking to a large group of people who work in the NHS this week. I was asked to talk on the latest thinking on patient safety and what we have learnt over the last three de…

PROVIDING A REFRESHING VIEW OF SAFETY

Suzette Woodward I often get asked how can we measure whether we are safer today than we were yesterday. I suspect that this is often with the desire for me to provide a small number of clever meas…

For over a decade, the language and narrative of safety has been trying to embrace the concepts of a ‘new approach’, mainly called Safety I and Safety-II or Safety Differently. It has c…

Do you ever feel like we are missing something? Do you have moments when you are struck by a story or a fact that stops you in your tracks. I was recently reading the annual report from NHS Resolution as part of area of research. Having worked there and seen the exponential growth in litigation claims over the years it shouldn't have been quite the 'stop in tracks' moment that it was but nonetheless it did indeed turn out to be one.

In July, the review of patient safety by Dr Penny Dash was published. This was followed by an acceptance of all the recommendations made in the review by the government. Up until then I had not been party to what the findings had been or the recommendations so was somewhat surprised when I read it. I wrote a blog about the review, in the anticipation that it would be one of many commentaries on the subject, especially from the…

I read the review of patient safety by Dr Penny Dash . You can find it here: I made six pages of notes as I read it and have a few comments as you can imagine. I think the best thing for me to do at this stage is provide some high level key messages from my perspective. I will try to restrict myself to ten of them, I mean who wants six pages!

This has just arrived on my desk. I cannot wait to read it. and another I am in the middle of but loving...

Public accounts committee called the record sum ‘jaw-dropping’ and criticised inaction to reduce errors in a damning report

In reality we do not know what the true quantitive level of safety is. We dont know for sure how many things are going wrong and we definitely dont know how many things go right. I would argue we may never know. We cannot capture everything - that would be impossible. What we do capture is biased in that it is often the easy to see, and the easy to report incidents.

Following on from my blog titled "an organisation with a memory' it is worth us dipping in to things we have tried over the years. There are a number of tools and techniques that are used in the safety-I approach.  These include, Heinrich’s triangle, the swiss cheese model, ‘5 whys’ and root cause analysis. Heinrich’s triangle Heinrich’s triangle – which states that likelihood of a fatality rises in line with the number of incidents – I am told has no basis in fact or research.  

In many ways the year 2000 was the start of the safety movement as we know it today.  There are many safety scholars out there who will cite the work as far back as the late 1800s that helped our thinking in patient safety and the brilliance of our anaesthetic colleagues who were in fact the first people to coin the term 'patient safety' in the 1970s.

The need for women to be accompanied by a man in public is blocking access to healthcare and contributing to soaring mortality rates, say experts

Systems of thinking relates our approach to risk and decision making (Kahneman 2011). It is argued that there are two systems of thinking that people are engaged in through the course of their daily activities. System 1 - automatic, intuitive, effortless, nonanalytic System 2 - effortful, analytic, creative, deliberative Automatic thought processes come into play when we are driving a familiar route.

The way people work together is central to the safety of healthcare.   Behaviours of individuals at all levels can play a role in the lead up to incidents or in the prevention of incidents.  Teams are people who are used to working with one another, often the same people.  This is increasingly rare in healthcare where teams come together for a short period of time and then disperse.  

When we fail, we do three things: Personalisation – we think it is all our fault Pervasiveness – we think it is going to affect every bit of our lives Permanence – we think we are going to feel this bad forever In 2016 I came across a radio interview with Bob Ebeling.  Bob was one of the engineers working on the shuttle Challenger 30 years ago – since the radio interview Bob has since died.  

In safety today there is a view that error is somehow preventable and that when people make mistakes all we need to do is tell them to stop making mistakes and possibly sanction them if they do.  However, I know it is an obvious statement, but not everything we do will go right.   Imagine that you are in the midst of an intensive care unit surrounded by pumps, wires and machines constantly flickering numbers and lights and you need to administer one drug in the patient’s vein and one drug in the patient’s nasogastric tube.  

One of the ways we try to maintain safety in our everyday work is to do a workaround.   Workarounds in healthcare are common, sometimes planned, sometimes not, but in the vast majority of occasions well meaning.   Often a workaround is a method for overcoming a problem or limitation in a way of working.  A workaround is where individuals deviate from the prescribed work, often for genuine reasons.  

Exclusive: Departure follows meetings with Wes Streeting and unusual criticism from two Commons committees

Like the soldiers they battle to save, combat medics in Ukraine are under constant attack. Three years after the invasion, one NHS doctor bears witness

Don Norman wrote the Design of Everyday things in 1988. It is a brilliant book which is underrated in the area of safety. If you do work in safety I would encourage you to read it. A little taster. Don was once asked by a computer company to evaluate a new keyboard.  He spent the day learning to use it and trying it out on various problems.  

Safety culture remains a key concept in occupational safety management. In the North American construction industry, regulators are growing increasing…

Work as imagined is what we imagine work is like or what we imagine the work could look like.  The ‘we’ is often policy makers, standard settings, guideline developers, regulators and commissioners.  It also includes us. The term work as imagined can also apply to policies themselves. When we first set out the intention of a policy we are in fact setting out how we imagine what a policy will achieve.

Safety-I is defined by Professor Hollnagel as a state where as few things as possible go wrong (Hollnagel 2014).  In order to achieve this 'state' our aim is to try to prevent things from going wrong. Being proactive and prevent harm or injury is at the very heart of risk management and safety. However, the way we do this is to ask ourselves the following questions:

Directly linked to this way of thinking about safety is the view that what people do can be prescribed in some way; policies, procedural documents, guidelines, standards and so on. This view asserts that all the people need to do is adhere to them and care will be delivered in the right way, by the right people and safely. There is often a huge difference between how the developers of these polices think and how the work is actually carried out.  

Do you need help? As a recognised expert in patient safety, I bring a wealth of experience and insight to every organisation I partner with. Whether it’s guiding leadership teams, providing keynote…

Wherever you work in healthcare and whatever role you have you will be wanting to ensure the safety of the patients in your care. You will want to find ways of building safety within your work. However, healthcare is an uncertain world and the difference between safe care and unsafe care can be decided in minutes. Over the last two decades and more we have tried hard to prevent things from going wrong, to detect them quickly if they do, to limit the harm as much as possible and to learn for the future.

Do you need help? As a recognised expert in patient safety, I bring a wealth of experience and insight to every organisation I partner with. Whether it’s guiding leadership teams, providing keynote speeches, or helping you create a culture of safety, my approach is built on evidence-based practices tailored to your unique needs. Proven Expertise: With years of experience in senior leadership roles, including as a Board member of both the National Patient Safety Agency, NHS Resolution and having the privilege of leading the national Sign up to Safety Campaign, I understand the complexities of healthcare systems and how to embed sustainable safety practices.

YouTube video by Job Brüggen

Human factors and ergonomics in healthcare is an important discipline that considers both the physical and mental characteristics of healthcare workers, as well as the complex interactions within whic...