More food for thought

Patient Safety is a complex science.  It is still a relatively young field, with just fifteen years since an Organisation with a Memory in human terms it is still a teenager!

The National Patient Safety Foundation (NPSF) in the US have now released their report; Free from Harm: Accelerating Patient Safety Improvement Fifteen years after To Err is Human – you can access this via  The group responsible for this report were headed up by Don Berwick and Kaveh Shojania on behalf of the NPSF.  The report identifies 8 recommendations:

  1. Ensure that leaders establish and sustain a safety culture
  2. Create centralised and coordinated oversight of patient safety
  3. Create a common set of safety metrics that reflect meaningful outcomes
  4. Increase funding for research in patient safety and implementation science
  5. Address safety across the entire care continuum
  6. Support the health care workforce
  7. Partner with patients and families for the safest care
  8. Ensure that technology is safe and optimised to improve patient safety

The content resonates with our work in Sign up to Safety and our views on what is needed over the next fifteen years.

Quality versus patient safety

The current approach is to focus on quality and effectiveness rather than the safety of patient care.  This approach is diverting attention from the unique and specific aspects of patient safety that require addressing, it is also diverting research and resources away from safety improvement.  The report stresses the importance of recognition that a safety science exists.

Focus on one harm at a time or total systems approach?

Over the last fifteen years patient safety has focused on reducing or eliminating specific harms such as falls or pressure ulcers or infections.  I can take some of the responsibility for this as our strategy at the National Patient Safety Agency (NPSA) certainly added to this approach.  However, activity related to patient safety requires a shift from this reactive approach (one which focuses on one harm at a time) and move to supporting a total systems approach. It requires focusing on design the systems, the environment, the equipment together with procurement for safety rather than simply trying to change minds and behaviour.

National coordination

Interestingly they recommend a new body for the US to act as a focal point for safety and to develop a national strategy (where have I heard that before).  Our view at Sign up to Safety is that leadership can be provided in a number of different ways; the campaign being one of them.

The difficult art of implementation

Implementation science formed the basis of my doctorate – a science I did not know existed until I started studying the gap between theory and practice.  Safety science investigates safety and the contributory factors and underlying causes of error and harm.  Implementation science supports patient safety science by focusing on the delivery of policy, recommendations, research, and theory so that it is adopted, spread and embedded into everyday practice.

Caring for those that care

The report stresses the importance of supporting the ‘dedicated’ workforce. We could not agree more.  Lets move away from the polarised view that clinicians don’t care when things go wrong and do their best to hide or cover up.  Lets ensure we bring joy and meaning to those that work in healthcare.  Lets also provide practical help for those really struggling to get through each day.

Enjoy reading the full report and let me know what you think.

Reference:  National Patient Safety Foundation (NPSF); Free from Harm: Accelerating Patient Safety Improvement Fifteen years after To Err is Human –  accessed via

Guest Blog David Naylor (2)

I will learn from this (well maybe…) – David Naylor

The emphasis on learning has never been greater in public services. It can sound like a stock response after something has gone wrong (we are sorry; we have learnt important lessons…). When I listen to the complexity of the issues leading up to the mistake I wonder how they could have learnt so fast because in my experience any serious learning is a bit of a slog.

We have placed learning at the core of the Sign up to Safety campaign’s five pledges; they are all about learning. The need to continually learn from one’s own experience; to help others to learn from theirs, and apply this ‘know how’ to keep people safer. The sort of learning we need to do to make things safer requires us to act decisively and question the ground we stand on as we do this. As a consequence it is entirely reasonable to expect that we will put up some degree of resistance to this sort of learning.

 Arguing with a colleague

About a year ago I had a row with a colleague. I fundamentally disagreed with an assumption he was making about the scope of work we were undertaking. Things got heated and he complained that I was too argumentative, too blunt and too rude. What I remember was my absolute refusal to hear his point of view; caught up in my sense of being willfully misunderstood and just plain right.

Eventually, we staggered towards a shared understanding of what had gone on and how the row was both personal and at the heart of the issue we were struggling with. What I remember most vividly was my reluctance to listen, to entertain alternative ideas about what may have been going on. I stuck to my righteous position, I was resilient but not in a good way.

The problem with being smart

Yet we should not feel too bad if we resist learning. According to Chris Argyris (1991) the smarter you are the harder you will find it to learn. Being seen as smart means you are the person to go to to get things done. This is a hugely important capability and should be rewarded. Some problems just need fixing (we need this monitoring kit; this drug label is confusing please change it). We recognize the problem and we have a fix for it. We implement well established behavioural patterns based on what has worked in the past. We do not take much notice of context. If the solution works here it will work over there. If our fix does not have the desired effects we just ‘do’ the fix better. This is what Argyris calls ‘single loop’ learning.

Simple fixes are resilient and thus make us reluctant to give them up. Hence Maslow’s (1966) comment that if your only tool is a hammer, everything looks like a nail. We tend to see the world through our preferred solutions, which are in part derived from our professional background. To get beyond simple fixes we have to take a step to the side and identify, question and evaluate the assumptions behind our preferred behavioural and perceptual patterns. We need to pay attention to any gaps between our intention to fix things and what actually happens. This is what Argyris calls ‘double loop’ learning.

Double loop learning at work – it’s harder than it sounds

When I worked in a mental health service, during the closure of long term hospitals and the reprovision of services to the community, my colleague and I were asked to lead the patient participation strategy. Our response to the challenge of ‘engage people more’ was to design a training programme, which we thought would help service users to be more skillful.

When we presented our ideas to the advocacy group it was forcibly drawn to our attention that we were trying to shape the very voices we said we wanted to hear. It took an hour for us to realise our error. We had made several assumptions.  Our ‘fix’ for a lack of engagement was to do what we knew how to do; that is to lead a training programme. We assumed that service users were ‘history free’ in that they would not bring their experiences into the room or be alert to any issues of power and control that permeate mental health services.

The feedback, which was forceful and well-argued jolted us out of our comfortable way of thinking and behaving. We spent time trying to surface the underpinning assumptions that had been largely silent in our planning and presentation. We thought about why a disability group would be quite so angry with us. We thought about our assumption that we should be in charge. This was the beginnings of double loop learning. It was insufficient to review and tweak our programme; we needed to expose, evaluate and change the assumptions that were framing how we were making sense of our task of engagement in this evolving mental health service.

What we noticed was that this was hard work. We felt what Schein (2004) calls ‘learning anxiety’. We worried about looking stupid and ignorant. We were embarrassed by our failure to win the public support of service users in a high profile project. We were ready to resist the new data that had emerged and yet we did not. We were lucky, our managers were interested in what had happened and did not interpret the failure as personal to us but as gap in our collective thinking and reprovision strategy. They noticed that our focus on getting service users trained hid in plain sight the bigger challenge; helping service managers hear and act upon what was likely to be said.

What I think helps people learn

In my work in the Kings Fund and as part of the campaign team I have spent a lot of time learning and trying to help others learn. What follows are six ways of behaving and thinking if you want to help yourself and others learn.

  1. Just learn to listen
    • There is nothing more potent than being in the presence of someone who just wants to listen to you. That is, someone who is both open minded and open hearted; someone who does not get restless for you to find a solution or for you to take up their preferred solution.
  2. Resist the pressure to make or collude with a simple personal explanation of a failure
    • In the context of a just culture this is really important. Most people need no encouragement to feel responsible for what they have or have not done. Self-centred explanations consign important insights about how things actually work in practice to the personal, where it is hard to bring collective know how to trying to understand why it is hard to get things done.
  3. If the context is complex, expect and try to accept ‘falling short’ is integral to trying to change things
    • To keep people safer in this context requires action to be taken on incomplete understanding of what is going on, there will be unintended consequences to even the best laid plans. This is not bad planning but just how it is. Some of what is really going on only emerges as you get involved. It cannot be anticipated, despite what some people, who cling to a simplistic notion of context, will tell you.
  4. Be a manager who thinks hard about how to authorise people to work across the wider system
    • People who care about keeping people safer, understand that they have to engage a wider group of people who directly and indirectly contribute to the context of care. Why would you stop them doing this.
  5. The way to kill double loop learning stone dead is to require people to define as they begin what it is they will learn, it’s relevance, how long it will take and what they will do with their learning
    • It is in the nature of reflective based learning that there is a moment as one steps away from a preferred way of thinking and acting, that real uncertainty is felt. This uncertainty is the prelude to new ideas and insights tend to trickle into consciousness.
  6. Be a manager who talks about your assumptions and ideas
    • It is hard to justify pressure on others to learn at depth if you are not willing to try it yourself.

Finally, the really interesting people are the ones who make you think; who are curious and who are just interesting to be around. Beware of people carrying just a hammer. They have their place but it’s an insufficient tool box if that is all they have got.


Argyris, C. 1991. ‘Teaching smart people to learn’. Harvard Business Review. vol. 69(3), no. May – June, pp. 99-109.

Maslow, A. (1966) The psychology of science. Chapel Hill, Maurice Bassett

Schein, E. (2004) Organizational culture and leadership (3rd Ed). San Francisco, Jossey-Bass.