Month: June 2017

Chapter 4 Systems approach to safety


All incentives should point in the same direction. In the end, culture will trump rules, standards and control strategies every single time, and achieving a vastly safer health service will depend far more on major cultural change than on a new regulatory regime – Don Berwick 2013 Healthcare is not one single system but a set of systems ranging from the ultra-safe to ultra-adaptive (Vincent and Amalberti 2016).  Neither is it one culture – but that […]

Chapter 3 A culture of learning


In the third chapter I explore ‘a culture of continuous learning’. I share two contrasting stories; one related to Johns Hopkins Hospital in Baltimore, US, and the other concerned with the care of Sam Morrish and his family in the NHS. The mystery that motivates most of us who work in patient safety is that why after more than two decade’s worth of energy and resources devoted to patient safety, progress has been so slow. The Johns […]