Month: March 2020

Understanding the middle

Leave a comment

Imagine a range which has at one end the status quo i.e. the way in which we continue to do the same thing time and time and time again (I’m talking safety wise, incident reporting, incident investigations, focus on error, harm and failure etc) and at the other end is ‘change’ or ‘innovation’ or ‘improvement’ whatever you want to call it (I’m talking QI project, doing change projects etc).  Now I am not for one […]

New ways for new times

comments 2

The tools and methods for safety I seem clumsy and out of sync with the world we find ourselves in. Incident reporting and root cause analysis have long been both the methods of choice and the wrong way to learn. Over the next few months let’s explore better methods for learning. Let’s use this time to design a much better way to help people work safely that is based on safety II principles. 1. Learning […]

Safety II and Covid-19


Julia Unwin says the time is for us to notice what is happening now in order to learn from it for the future. The study of how people and systems are able to succeed within complex adaptive systems and constant changing dynamics is really important right now.  Complexity forces us to consider the dynamic properties of healthcare and the way in which it is constantly changing and its unpredictability. In order to make sense of […]

You are doing something very special


For those of you who think you are doing nothing by staying at home. By doing so you are supporting everyone else, you are not putting yourself and others at unnecessary risk.  You are doing something very special. For those of you who are working from home for all sorts of reasons.  You are doing something very special.  For those of you who are hearing stories from your friends and colleagues about what it is […]