Rethinking Patient Safety – Conclusion

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 Safety Campaign.

It is through our working together, exploring, experimenting, challenging each other and the status quo that we believe we can finally see what we might want to do or where we now should be focusing.

Our work together is helping us move into the era of profound simplicity.  Helping us think and act differently.   Helping us develop relationships that are truly enhancing our conversations.

Our profoundly simple approach is to build a culture of safety that is built upon helping people to talk to each other.  A vital ingredient of which is a culture of kindness.

We have one very simple premise; that if we get this right we will go a long way to transforming the safety for future patients and those that care for them.

The work continues.

The campaign will continue to share what we are learning.

Book number two is already on its way.

Thank you for reading so far.

Chapter 15 Facilitated Conversations

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.

This chapter describes how our work started with a method we call ‘trios’.  The process is simple yet has lead to unexpected results.  It is amazing what can happen when you provide a simple but profound format for people to really talk together as equals.

Trios are a way of exploring safety issues in a group of three people; a speaker, an active listener and an observers (Naylor et al 2016).

The chapter then describes how we then used what we learnt to experiment with other methods:

  • Quads
  • Fishbowl methods
  • Small group conversations
  • Large group conversations

It then describes the lessons learnt from all of these – lessons for those organising and participating.  These include:

  • Making sure that you are really well prepared (I know everyone always says that!)
  • That skilled facilitation can be the difference between success and failure
  • You need organisers and facilitators who work together to pay attention to detail all of the time; before an event, when greeting people, during the event and after it
  • If you ask people in a supportive setting to tell their story they will
  • People can be incredibly generous, imaginative and open hearted – if you get some willing, able and thoughtful people to listen you can help people really think about what they can do differently
  • One of the easiest human acts of listening to someone, simply listening, can also be the most healing

As a bit of a post script – the team are currently working on a handbook of all of the methods we have used so that people can download and use them in their own workplace


Naylor D, Woodward S, Garrett S, Boxer P (2016) What do we need to do to keep people safer? Journal of Social Work Practice – [online] Available via

Chapter 14 An evolving concept

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 go wrong if we don’t talk to each other more effectively and what happens when we are not listened to, or we fail to listen or we fail to learn.

This chapter describes the different methodologies:

  • the world café approach
  • huddles
  • briefing and debriefing

It also talks about what gets in the way of a good conversation such as status, gender, hierarchy, grandstanding, personal culture, bullying, incivility and a lack of respect.  For this blog I will focus on two of these:

Hierarchy is a significant issue in healthcare. There are rules and boundaries that exist in relation to conversations; we are not supposed to interrupt the boss, we are not supposed to question the expert surgeon or the senior nurse.  But for the safety of patients this can be extremely damaging.  While, a concerted effort has been made in healthcare to remove this risky behaviour we still hear of cases where someone failed to point out a particular risk that sadly led to the patient being harmed as a result.

Gender is another important aspect to focus on. We think we have an increasing equality of gender but it still falls short of ideal. This can have a profound effect on safety. Across the many cultures worldwide women find it really hard to speak out, often only giving an opinion if asked.  Gender and the impact on patient safety should be openly acknowledged rather than lurking beneath the surface. Women need encouragement and respect from both men and other women.

There is so much fear that speaking up will make the situation worse or be inappropriate or go unheard. All of us have a role to play.  We need to act as a cohesive group, working together for a common purpose.


The World Café; shaping our futures through conversations written by Brown and Isaacs in 2005.

Chapter 13 Enlightenment

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 and other high-risk industries and we too would be safe.

Confusing complexity arrived when the care provided didn’t seem to get any safer – so we threw a load of interventions at people – shouting ‘why are you not any safer’, ‘do as you are told’ ‘stop making mistakes.

Weick (2009) suggests that we have to progress through these stages and that time and experience helps us see that our initial simplifications are superficial, but also that some of those initial simplifications still hold true, although for different reasons than first thought.  These new simplifications help us make sense of the earlier confusion and are become profound simplicities or wisdom. Profound simplicity arises from a deeper knowledge and understanding of what is happening.

So profound simplicity is only achieved by working through the confused complexity and this needs to be lived.  For this to work experiential learning is vital. Without that people have no idea why the simplifications are profound, why they work, or what lessons there are.  Without this lived experience the borrowing is superficial and typically fails when implemented (Weick 2009).

So in patient safety it feels like we are moving into an era of profound simplicity, where we are starting to realise that there are some fundamental and seemingly simple aspects related to how we work in patient safety that we considered in the beginning that could make a profound difference to the safety of patient care.

Our profoundly simply ‘approach’ is our focus on helping people talk to each other.

This is our throughline; the strong thread throughout all the elements of our work.  A way of connecting everything together.

Our solution for change is conversations; allowing people the time to speak, listening with intent and asking the right questions.  This chapter and the following chapters describes our work to build on this approach in more detail.


Weick KE (2009) Making Sense of the Organisation; the impermanent organisation Chichester: Wiley (John Wiley and Sons Ltd)


Chapter 12 Sign up to Safety

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 do was to create the conditions for safer care; the culture, behaviours, attitudes and values that are so very important as the foundation for everything else.

The lessons we have learnt apply to anyone.  Leaders of organisations, leaders of projects, team members and people who work in change.  They apply to any care setting – wherever care is provided they are relevant.

  • It is important to help people but not simply ‘tell them this is what you must do’
  • That if you trust people they can do some spectacular things
  • That social movements cant be ‘engineered’ or ‘created’ – they emerge if you provide the right principles
  • Campaigning is a much underused method for change in patient safety
  • Don’t say one thing and then do the other – i.e. be genuine and mean what you say
  • Listen more than you talk
  • Use words and language differently – to thank, to reward, to appreciate and to be kind

The campaign used the Ganz model of leadership (Ganz 2009)….

The difference between leadership as a position, and leadership as a practice

Ganz says (2010) that we act from habit, we don’t choose, we just follow the routine and that when the routines break down and no one tells us what to do we start to make real choices about our lives, communities and futures. We have found that by not telling people what to do we have in fact energized them.  We have surprised them and some have told us they found this really exhilarating.

To build trust and engagement the campaign created a brand that was synonymous with kindness, caring and compassion. In today’s stressful and challenging healthcare environment the last thing people needed was another stick.  We have shown that kindness works; thanking people, valuing them and being thoughtful of all around us are vital to creating the right culture for safety and are leadership traits that we both embody and promote. The question we get asked most often is ‘how can we turn the NHS and all who work in it into an organisation that cares about them?

We believe that we can do this by listening to one another again. 

Listening to another human being starts to create a relationship, starts to help us understand them more. The reason why we believe this so fervently is that ‘not listening’ or ‘not being heard’ or ‘not being able to speak out’ has led to harm on numerous occasions.  Listening means we hear someone else’s point of view rather than forcing our own on to others.  Listening means that we recognise that we are not better than anyone else but that we are just different and that we all add value.  We move away from our judgments and assumptions towards curiosity.  This means we start to learn more about what could be safer, what could or should be changed.


Ganz M (2010) Leading Change in Handbook of Leadership Theory and Practice Eds. N Nohria, R Khurana Boston: Harvard Business Press ISBN 13: 978-1-4221-6158-6

Chapter 11 The next fifteen years and beyond

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 correct but also whether there were any other aspects of patient safety that this line could be attributed to.

What else had been a waste of time over the last fifteen years?

When I was listening to the webinar with Kaveh Shojania (2015) he also mentioned that he was co-chairing, with Don Berwick, a review on behalf of the National Patient Safety Foundation (NPSF) (2015) in the US. I looked this up.  This review group wanted to galvanise the field to move forward over the next fifteen years with a unified view of the future of patient safety to create a world where patients and those who care for them are free from avoidable harm.

So what have we learnt from the last fifteen years?

In March 2000, the British Medical Journal produced a whole issue devoted to Reducing Error Improving Safety.  I still have my much thumbed through copy today.  This was the moment that I genuinely thought we would truly transform the safety of patient care.  A journal devoted to patient safety was extremely rare at the time.

The editor Richard Smith stated in his editorial that it is essential that doctors, patients and politicians worldwide grasp the scale of the problem and in their article, ‘Safe healthcare: are we up to it?’, Lucian Leape and Don Berwick (2000) wrote about the ‘error prevention movement’.  In a prophetic statement, they said,

making more fundamental and lasting changes that will have a major impact on patient safety is much more difficult that simply installing new technologies’

They told us that there are no ‘quick fixes’ and that it was important to redesign our many and complex systems to make them less vulnerable to human error.

Significantly Leape and Berwick (2000) talked about how it was important to focus on culture as much as technical aspects of safety and to focus on the working conditions of staff and on how humans interact with one another.  Leape and Berwick wrote this as a powerful ‘call to action’ to mobilise people to make safety a priority.

This call to action asked us to promise patients and the public that they will not be harmed by the care that is supposed to help them; ‘we own them nothing less and that debt is now due’ (Leape and Berwick 2000).

For the following sixteen years these two leaders have repeated this mantra; they have said it in multiple different ways but at the heart of all their work is the desire to stop patients from being unnecessarily harmed.  If you read the call to action by Leape and Berwick back in 2000, you can feel the urgency in their words, you can feel the frustration but you can also feel the hope.

What did we do with that hope?

Since that year, terms like patient safety, root cause analysis, systems approach to safety, safety culture and just culture have become commonplace.   Across the globe people have designed, developed and disseminated all sorts of interventions, initiatives and guidance.  The language of patient safety has become embedded in that of policymakers, academics, healthcare workers and the media.    Individual countries have set up national bodies, national databases to collect incidents, and there has been international guidance such as the WHO surgical checklist referred to earlier and other global campaigns such as improving hand hygiene and cleanliness.

Every year the collection of research and books on patient safety and all its component parts grows larger and larger.   Patient safety has expanded to include other areas of study that can impact on the safety of patient care including; human factors, ergonomics, behavioural insights, improvement science, LEAN methodology, resilience engineering and high reliability organisations.

Those that work in patient safety have significantly raised awareness and understating of patient safety and as we have seen some aspects of harm have reduced.


We have yet to build a safety culture that is embedded into every day practice, every day actions and every individual’s mind-set.  Patients are still being harmed by the same things that were happening in the year 2000.

The reason why have I chosen to reference this particular journal published in the year 2000, and less so on the thousands of articles that have been published since, is that every single article could have been written today and be describing the exact same situations we still find ourselves in and have the exact same meaning for the reader.

While it feels like so much has happened since the articles were written, at the same time it feels like nothing has happened since. To read these articles sixteen years on is extremely sobering.

This chapter provides the bridge between the last fifteen years and the next where hopefully we can narrow the implementation gap between the ideal and the real.

And where….

  • Patient safety and a safety culture are a way of being
  • People take the time to embed good practice so that it is sustained
  • Implementation is valued as much as improvement and innovation
  • We have tackled patient safety differently and have been bold enough to stop the things that are not working and started again



Leape LL, Berwick DM (2000) Safe healthcare: are we up to it? BMJ Qual Saf 320: 725-726

National Patient Safety Foundation (2015) Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. National Patient Safety Foundation, Boston, MA; 2015 [online] available via

Chapter 10 Implementation the way forward

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 loads of frontline staff and as this was a professional doctorate produced a kit for people to use to help them implement.  Professional doctorates are the same as PhDs but instead of stopping at a thesis – the professional doctorate has to add a practical output of your learning to help people use what you have learnt.  So not just showing what you know but helping people use that knowledge.  In itself the professional doctorate mirrors what we should be doing in implementing research or theory into practice and action.

What did I find out?

There is not enough attention paid on how to execute, how to implement in relation to patient safety and now enough written about how implementation occurs, and under what conditions it is favourable.

There is a growing science of implementation; which is the study of methods to promote the systematic uptake of research findings and other evidence based practices into routine practice (Eccles and Mittman 2006).

Implementation requires thoughtful action, it requires expertise and effort and there is no easy way of doing it.

Each stage, dissemination, adoption, embedding, spread and sustainability requires special thought.

There are many factors or principles that can be used in order to maximize the chances that the good idea being finally sustained.

Very few get it right; effective implementation of knowledge, research and information into healthcare practice remains for many an unconquered challenge.

Implementation is a slow and haphazard process.   To my surprise implementation research has found that it takes, on average, 17 years to turn 14% of original research findings into practice.  And even when implemented in some way we fall at the final hurdle; there is a sustainability failure rate of up to 70% of organisational change (Elwyn et al. 2007).

Implementation requires dedicated resources, funding and time and a shift away from the short term approach. It is a fantasy to think that an idea can be implemented through to sustained change in just three to five years. This is in part because implementation requires a culture shift; a culture whereby the embedded idea it still used even when politics, or policies or people change.  Understanding the simple reality that implementation takes times is important but we can also aim to reduce the time from the average of 17 years.

How do we help people to notice the things they need, when they may only have five minutes in their day to sit down and look beyond their daily activity?

There are a number of influencing factors that can both help and hinder effective implementation.  The book describes the list of factors (too long to mention here) I found which affect the success of adoption and implementation which include:

  • Demonstrate visibly with numbers, feelings, experiences that the change is better than status quo
  • Make it as easy and as intuitive as possible
  • Improve the quality of the guidance associated with the idea or solution ; do not produce a 100 page manual
  • Reduce reliance on hours of training
    • and so on….

Key references:

Diffusion of Innovations in Health Service Organisations; A systematic literature review by Trisha Greenhalgh, Glenn Robert, Paul Bate, Fraser Macfarlane and Olivia Kyriakidou published in 2005.  This book is of major significance for anyone responsible for implementation.  As Sir Liam Donaldson said in his foreword, it genuinely breaks new ground in conceptualizing and mapping a vase intellectual terrain in a way that provides insight and adds practical value.  This book is a towering work of remarkable scholarship.  I could not have put it better myself.

Eccles M, Mittman B (2006) Welcome to Implementation Science Implementation Science 1:1 DOI: 10.1186/1748-5908-1-1 Available at:

Elwyn G, Taubert M, Kowalczuk J (2007) Sticky knowledge: A model for investigating implementation in healthcare contexts: A Debate. Implementation Science. 2: 44.