Healthcare Safety Investigation Branch – First Report

The Healthcare Safety Investigation Branch has published its first report .  The investigation was triggered by a failure to correctly check hip prostheses for a 62 year old man, Mr John Hampton.

The report is excellent and with this the Healthcare Safety Investigation Branch have set the bar high for the quality of their work.

It is one of the best investigation reports I have ever read.  It is clear, detailed and easy to read and beautifully describes the multiple factors (human, system and cultural) that can lead to an error.  The following are a few things that really hit home for me.

The patient:

From what I can read it appears that the investigators developed a good relationship with the patient and that he was involved in the investigation.  There is a particularly moving point about the on-going effects for Mr Hampton on himself and his family.   Not only will they have a crucial piece of the jigsaw they should be involved , informed and supported throughout.  This should be the minimum.

All investigations should involve the patient and or their family  – they should never be a silent participant of their own story.

Standards, guidelines, policies and procedures:

The report shows that standards, guidelines and procedures are not full proof tools for error prevention.  As Jim Reason says ‘there are not enough trees in the rainforest to write a set of procedures that will guarantee freedom from harm’.  The issue is not that you have a standard but whether people know about it, whether it is easy to read and understand, whether it is short enough to help you make the correct steps but not long enough to drown you in detail.

Standards are worthless if they are not implementable.

Labelling and packaging:

We are reminded of the continuing problems with labelling and packaging (highlighted some time ago by the National Patient Safety Agency (NPSA) in its outstanding ‘design for patient safety’ series).   I urge you to read The Design of Everyday Things if you are interested in this subject.

This has been debated for far too long now and it is crucial that manufacturers use the support of human factors experts, designers and behavioural insight experts to design their products to minimise the errors that can be made with things like poor packaging and labelling.

Understanding human factors:

It is so heartening to see that the report has a wealth of human factors thinking and knowledge thread throughout. Crucially the investigation demonstrates the importance of understanding the environmental conditions, individual and team factors.  For example recognising the role that fatigue plays in performance.   There is a fascinating discourse on team work and relationships and the different error rates between familiar and unfamiliar teams.  There is also an insight to understanding more about our mind-set in relation to error; for example the consultant could recall being brought the wrong size before but not the wrong manufacturer so it ‘was not, therefore, an error experience had taught him to be alert to’.  There are so many things that are applicable for all healthcare, for example the issue of noise in section 5.3 and 5.7, and our cognitive biases in section 5.6.

We simply don’t pay enough attention to human factors in the way we design our systems, structures, and organisational processes.

Barriers to error:

The investigation clearly highlights the fallibility of human memory and the importance of the different types and effective use of memory aids and the importance of reading out loud all the details needed and/or independent checks.  Love the comment ‘what’s on the box may not be what’s in your head’ – which tells us all about the strange things our brain can do to convince us that we see things that are not there or don’t see things that are.

The ‘solution’ we are always searching for is the complete inability to make a mistake, ‘designing out the chances of error’ through effective barriers that get in the way of making an error (checklists, verification processes).  These are really rare and if we think we have found them we may have to think again.  Us humans are very clever at thinking of different ways we can get round things that don’t fit naturally with what we are trying to achieve.

As it says in the report ‘team checking processes already in place have not reduced the number of wrong prosthesis incidents, suggesting that more of the same is not the solution’ and ‘double checking requires that one fallible person monitors the work of another imperfect person’. 

Therefore if you are designing barriers, just as for manufacturers, involve human factors experts, designers and behavioural insight experts.

There may never be a neat answer:

There is also a key point that we don’t talk about often enough, ‘the nurse could not understand why she had gone to different cupboards that contained prostheses from different manufacturers’ – ‘the consultant…. could not recall the details of the prosthesis verification during the operation as there was nothing out of the ordinary about it’.  I can think of numerous incidents I investigated when the people involved had no idea why they did what they did.  They could not offer a nice neat explanation.  They could not recall even the steps they took.

There is still a particular pressure to desperately search for a root cause, to find an answer.  We seem to find it impossible to say ‘we simply don’t know’.  Not knowing too often is misinterpreted as ‘covering up’, or ‘hiding something’.

It is therefore great that in this report it clearly states ‘it cannot be known precisely what checks were undertaken or at what point the process failed’  Hopefully this will give other investigators the courage to say this too.  It does not mean that we cannot learn enough in order to make recommendations as this report has done so well.

Carrying out investigations:

The report also recognises the complexities of carrying out investigations, for example noting how the interviews took place six weeks after the incident and that ‘memory recall at this timeframe may be affected by many factors and so have limited accuracy’.  It would be interesting to know whether most incident investigations involve interviews some time after the incident and how much of the truth we are actually finding out because of this.

The only way to truly understand what can be done differently is to study how work is normally done including the actions and habits that have become common place ( Steven Shorrock ).  I particularly like the way in which staff went to observe work in other operating theatres and in another country to see what normal practice was elsewhere.  We all know about the effect observation can have on behaviours but they were clever in that they stated they were observing ‘general theatre practice’.

What I like most about this is the way it demonstrates variation and that this incident was not the problem of one person, one team or even one organisation.

What’s missing:

The two things missing for me:

  1. The different slant that looking at all of this through a ‘safety II’ lens may bring.  I think it goes some way to try to explain the every day, what happens in the organisation of review but also what happens elsewhere.  It alludes to what works well elsewhere and what could be replicated but this could be a little stronger for me
  2. The cultural issues – was it an environment where people could speak up?  I appreciate that the fact the team were ‘like a family’ and its potential inhibitory factor was bought up but what about the issues of hierarchy or gender or status that may have inhibited people from challenging (even if this was not part of the factors that led up to the error)? Even if there wasn’t a problem it might have been worth discussing more

What to do with this report:

  • Read it! and then read it again – it has so many really great learning points throughout
  • Give it to your staff to read and use the report as a tool in itself to start the conversation for briefings and debriefings in theatres (it is applicable elsewhere too)
  • Use this to show the importance of accessing human factors experts where you can – not only in understanding how things work, how things could be safer and what you can do differently but also in your investigations
  • The way the report is written is a lovely ‘good practice’ example for all local investigators to learn from

Link to the report also found here:

Norman D (2013) The Design of Everyday Things. London: The MIT Press


Joy and happiness

There is a lot of talk these days about creating ‘joy at work’.

Why this growing interest in the study of joy ? What is the difference between joy and happiness? What does it have to do with helping people work safely (patient safety)?

We all talk about happiness and mostly know it when we experience it, but we lack a coherent definition.  Searching the definition of joy the dictionary states ‘a feeling of great pleasure and happiness‘ but when searching for the definition of happiness the dictionary states ‘the state of being happy’.  In fact, the source of the word happiness is the Icelandic word ‘happ‘ which means luck or chance.  What I do know is that during my career I have been very lucky.  Training to be a nurse and the subsequent years working in the NHS has offered me multiple opportunities to experience fulfilment, joy and happiness.

To help us understand more the Institute for Healthcare Improvement (IHI) have created a Framework for improving joy in work (Perlo 2017).  The framework provides four steps for leaders:

  1. Ask staff what matters to them
  2. Identify unique impediments to joy in work in the local context
  3. Commit to a systems approach to making joy in work a shared responsibility at all levels of the organisation
  4. Use improvement science to test approaches to improving joy in work in your organisation

Our friends at Kaleidoscope held a day focusing on joy in the NHS earlier in the year (see earlier blog) and have just published their paper which builds on that event together with the associated excellent webinars.  These can be found at: .  The report is titled Beyond Burnout (Kaleidoscope 2018) and at the end it provides fives ways to bring joy right away:

  • Eat together – make dedicated time for colleagues even just five minutes to share a cup of tea or your lunch
  • Say thank you – create a culture of positivity at the workplace by normalising thank you and you will start to hear them back
  • Seek laughter – laughter brings joy, share jokes and allow yourself to have a laugh even during a tough day (it is ok to feel joy even when things are hard)
  • Learn new things – learn things about your work, your patients and each other, discovering something new is invigorating and joyful
  • Support flexibility – do your best not to micromanage your colleagues, let their creativity and joy flourish but be available for advice and direction if needed

Psychologists have found that happy people live secure in the knowledge that the activities that bring them enjoyment in the present will also lead to a fulfilling future, rather than enjoying something now that may make them unhappy later.  While we cant be happy all of the time, we can work on becoming happier.  For example, one of the exercises Emmons and McCullough suggest is to keep a ‘daily gratitude journal’, writing down at least five things for which you are grateful every day.  They suggest that doing this regularly can help you appreciate the positives in your life.

Joy comes from so many places; enjoying what you do, liking the team you work with, having pride in your job and your organisation, and your own health and wellbeing. Often joy comes from small moments in the day.  As with so many things at the heart of this are relationships.  Healthcare employees who experience joy in their work and other positive emotion such as contentment may well thrive and build better relationships.  These relationships can be enhanced by the way we talk to each other in a positive and respectful way, our own joy, even the way we smile and show kindness.

Things that get in the way of joy include bullying, racism, sexism, the blame culture and incivility.  There is a need to acknowledge the current problem with incivility, when people are short or rude, which is sadly common in healthcare.   Incivility impacts on people’s cognition, their happiness and quality of work (Riskin et al 2015, Porath et al 2013).  It takes its toll on productivity, morale and relationships. See –  To shift from incivility to a kinder culture everyone needs to counter the rudeness by role modelling the right behaviour, reward good behaviour and deal with bad behaviour (Porath et al 2013).

In order for a more positive approach to safety to flourish we have studied the psychology of positive emotions, drawing from Barbara Fredrickson’s Broaden and Build theory (Fredrickson 2013). The Broaden and Build theory of positive emotions suggests that positive emotions i.e. enjoyment, happiness and joy, all broaden one’s awareness and encourage new insights, thoughts and actions.

Over time, this broadened behavioural range builds personal skills and resources. This is in contrast to negative emotions, which prompt narrow, immediate survival ‘fight or flight’ behaviours (Fredrickson 2004). Frederickson stresses the importance of positive and authentic feedback to instil pride in the workforce, and the benefits to both the person giving and receiving of saying a simple thank you.

Positive emotions are therefore considered a key component in happiness and wellbeing and perhaps even prevent burnout.  It could also help to promote both a positive safety culture and improved patient safety which are both dependent upon good relationships and the ability for people to speak up, listen to each other and learn from each other.

In a positive safety culture workers are seen as the solution rather than the problem. If we change our approach in patient safety, to draw explicit attention to the positive rather than simply look for the negative or even at the absence of the negative, we may in turn help people feel happiness and joy and also develop new insights and ideas.

It is a joyful time that these emerging concepts and theories; positive emotions, positive deviance, appreciative inquiry, safety II, joy at work and learning from excellence are all starting to gain serious traction within the safety world.


Bushe, G R (2013) The appreciative inquiry model. In E.H. Kessler, (ed.) Encyclopedia of Management Theory, (Volume 1, pp. 41-44), Sage Publications, 2013

Cawsey, M.J, Ross, M, Ghafoor, A, Plunkett, A, Singh (2017) Implementation of Learning from Excellence initiative in a neonatal intensive care unit ADC Fetal & Neonatal

Emmons RA and McCullough ME (2004) The Psychology of Gratitude, Oxford University Press

Fredrickson, B (2013) Positive Emotions Broaden and Build. In Advances in Experimental Social Psychology, Vol 47 Elsevier

Hollnagel, E, Braithwaite, J, Wears, R L (2013) Resilient Health Care. Ashgate Publishing Limited

Kaleidoscope Healthcare (2018) Beyond Burnout found at:

Perlo, J, Balik B, Swensen S, Kabcenell A, Landsman J FD (2017) IHI Framework for Improving Joy in Work. Cambridge Massachusetts found at

Porath, C, Pearson, C (2013) The price of incivility. Harvard Business Review, Jan-Feb; 91 (1-2): 114-21, 146

Riskin, A, Erez A, Foulk, T A, Kugelman, A, Gover, A, Shoris, I, Riskin, K S, Bamberger, P A (2015) The impact of rudeness on medical team performance: a randomized trial. Pediatrics, Vol 136; issue 3



Risky Behaviour

Design a bad system and it will lead to an increased rate of human error and an increased rate of at risk or risky behaviour

David Marx

What do we mean by risky behaviour?

Risky behaviour is a choice that comes with risks.  It could be a deviation from a rule or procedure, it could be that it is easier to deviate from the required behaviour.  Some refer to this kind of behaviour as violation or simply cutting corners.

Humans make mistakes and they drift into risky behaviours, it is part of being human.  Throughout our day to day lives we take risks, some of us more than others.  We can be placed into various camps; the risk averse, the risk takers, the risk lovers.

The deviation could drift over time towards the risky behaviour becoming simply habit or the new norm and may eventually become such that the level of risk and the new behaviour is accepted.

David Marx suggests that error, risky behaviour and reckless behaviour all have their own defined meanings.  That they are labels that can guide our actions and guide decisions in relation to individual performance and actions.  Being able to differentiate them is important in order to determine what might be done with system design and how we might understand the individuals behaviour within that system.

Is all risky behaviour bad?

Not necessarily.

  • Is it risky behaviour for people to adjust what they do to match the conditions of work or the patients they are caring for
  • Is it risky behaviour to interpret policies and procedures to make them work
  • Is it risky behaviour for people to change what they do so that they succeed under unexpected conditions

What do we do about risky behaviour?

Behind every error and every risky behaviour there is an explanation.  When you see people exhibiting risky behaviour then one step would be to ask them about it, try to understand why they are behaving in that way and provide them with a form of coaching, a conversation about the risk they are taking and whether they see it as a risk to either themselves, their colleagues or their patients.

For healthcare in particular it is imperative that we move away from the punitive approach to risky behaviour and to create a learning culture so that individuals are encouraged to talk about what they are doing and why.  We need to understand that what some may see as risky behaviour for others it may be providing the most optimum service for patients in their care.

Ref: David Marx in Dave’s Subs: a novel about workplace accountability