Month: February 2016

Never events


There has been a lot of news about never events recently. Having been at the beginning when they were conceived I thought I would clarify a few things.  The idea at the start was to have no more than 8 ‘events’ – a list of things that happened during the delivery of  care that really shouldn’t.  Not simply a list of serious events but genuinely things that were felt could be eradicated if all the […]

2020 vision


There are some new clues that will help us see more clearly about what is happening with patient safety at a national level… The vision for 2020 via Mike Durkin via twitter is: Increase our understanding of what goes wrong in healthcare i.e. capture incidents and learn from investigations at a national level – these are via the new Patient Safety Incident Management System and the new Healthcare Safety Investigation Branch – ooh … two new […]

Safe safety conversations 


The next step in the Sign up to Safety team’s exploration into different methods to create ‘safe’ safety conversations happened last week.  We facilitated a conversation between a group of clinicians and a mixed group of policy makers and patients.  The subject was investigations. Primarily what does it feel like to be part of an investigation both from the staff and patient perspective.  We both want the same thing Was the conclusion at the end […]