Month: July 2017

Rethinking Patient Safety – Conclusion

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The book has made the case for going back to basics for revising the very foundations of risk and patient safety. The end of the book is therefore also the beginning of the next stage of our work in patient safety. I have had the privilege of working in the NHS for over 35 years and worked with the most wonderful people.  None more so than the team who have worked on the Sign up to […]

Chapter 15 Facilitated Conversations

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There is nothing more potent than being in the presence of someone who just wants to listen to you. 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 David Naylor 2015 This chapter describes the work of Sign up to Safety in learning about the factors and methods that can help people talk to each other. […]

Chapter 14 An evolving concept

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Chapter 14 builds on our theory and experiences that at the heart of a safety culture is the ability to talk to each other. A good conversation is where the person is given the time to speak, someone listens, and importantly hears so that they can respond. Helping people talk to each other could shift the direction of patient safety forever. There are so many examples (that are described throughout the book) that show how badly things can […]

Chapter 13 Enlightenment

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William Schutlz argued in 1979 that understanding progresses through three stages; superficial simplicity confused complexity profound simplicity Profound simplicity is achieved when people doubt the completeness of their assumptions, and through experimenting with a wider variety of possibilities may realise that out of that confusion may come a fuller understanding of what they face (Weick 2009). The superficial simplicity in risk and patient safety included the notion that all we needed to do was imitate aviation […]

Chapter 12 Sign up to Safety

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Chapter 12 describes the start up of the patient safety campaign Sign up to Safety. Launched in 2014 it was set up to help the NHS in England reduce avoidable harm.  We instantly knew we wanted to do something different.  We did not want to be ‘yet another top down initiative’, we also did not want to focus in the same way patient safety campaigns have focused before; harm topic by topic.  What we want to […]

Chapter 11 The next fifteen years and beyond

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Two things triggered the book. First, was the nagging feeling that we should be rethinking our approach to patient safety and second, was something I heard in a webinar I was listening to on May 27, 2015.  Kaveh Shojania said that incident reporting ‘is the single biggest waste of time in the last fifteen years’ and ‘the most mistranslated intervention from aviation’ (Shojania 2015).  This started my thinking on whether not only was this statement […]

Chapter 10 Implementation the way forward

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It takes, on average, 17 years to turn 14% of original research findings into practice  Suzette Woodward, 2008 The recognition of the failure of our approach at the NPSA – in simply disseminating guidance and expecting people to know about it, read it, adopt it and embed it into everyday practice – led to me pursuing a doctorate in patient safety implementation. I studied the factors which can help and hinder effective implementation.  I spoke to […]

Chapter 9 The implementation challenge

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The approach of relying on passive diffusion of information to inform health professionals about safer practices, is doomed to failure in a global environment in which well over two million articles on clinical issues are published annually This was a quote from my doctoral thesis in 2008 and still applies today. I am biased but to me implementation is the most important thing we need to get right; more important than improvement and more important […]

Chapter 8 The impact on frontline workers

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I will be more careful in the future is not a solution to improving patient safety. Chapter 8 describes the impact on frontline workers when things go wrong. A few years after my own personal experience of error, I carried out a retrospective investigation in order to finally understand why it happened.  I now know that rather than being solely down to individual performance that there were a number of small moments or incidents during my […]

Chapter 7 Relegated to the back office

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Air Accidents Investigation Branch inspectors, usually airline pilots, are regarded in the industry as credible and trustworthy: it is a role that is seen by many as the pinnacle of their career Professor Graham Braithwaite of Cranfield University (PASC 2015) This is what is so very badly needed – for the role of an incident investigator in the NHS to be seen by all as at the pinnacle of their career.  What this does is […]