Month: October 2015

Safety conversations 

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Getting beneath the surface Tuesday 27 October 2015 was a fairly momentous day for me. The Sign up to Safety campaign has a small but very select team of specialists; in campaigning, in patient safety, in large scale change and importantly in learning. Everyone in the team makes a unique individual contribution to the whole.  One of our team (guest blogger) David Naylor – has significantly contributed to our approach to learning. He is helping us think […]

A culture of continual learning

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I know things move on. I know that we can’t live in the past. However when our past holds valuable gems which can help us with our future then I am all for reminding people where we have been. Patient Safety – a brief history of our time December is our focused month on the pledge, continually learn – so to get us all ready for this I thought I would create a brief history of patient […]

Guest Blog – David Naylor

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Dr David Naylor I am part of the Sign Up to Safety campaign team with the responsibility for helping people leading safety improvement work to share their learning. I currently work at The King’s Fund as a senior consultant. My doctoral research was into how people found their voice to speak up and to be ‘constructively awkward’. That is, how to say things that people may not want to hear and survive.  I have trained […]

The problem with….incident reporting

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I have mentioned before the excellent series that the BMJ Quality and Safety journal is publishing titled: ‘The problem with…’. The journal recently published one on incident reporting; the problem with incident reporting written by Carl Macrae, who provides an outstanding addition to the debate that the problem with incident reporting is that reporting and reporting systems are often misunderstood, misapplied and have left us all with confused and contradictory approaches which have seriously limited their potential impact. […]

Communication the 80% factor

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Ara Darzi is quoted as saying 80% of adverse events are caused by poor communication. Now I am not sure of the exact stats but having read a fair few incident reports and investigations as well as studied the national reporting and learning data and joint commission (US) reports communication is most definitely a major causal factor for harmful events.  Understanding the problem is key to finding the solution.  TIPS: Analyse just a few of […]

Through the looking glass

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Socrates said that a life un-examined is not worth living. In our re(think) patient safety work which includes ‘getting beneath the surface’ we want to examine patient safety and truly understand how systematic certain mistakes are, how we repeat them again and again and how we could avoid some of them.  And. We really want to understand why certain things are not implemented and others are.  We need to consider our past actions, things that […]

Put safety first (gender issues)

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We talk a lot about the ability or inability to speak out as crucial for a safety culture. However we rarely talk about this in terms of gender. We think we have an increasing equality but it still falls short of ideal. This can have a profound effect on safety.  Across the many cultures world wide women find it really hard to speak out. Often only giving an opinion if asked.  I don’t have a […]