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 from what we usually do well to understand why it failed in this rare instance
2. Asking why decisions were made without making a judgement in order to understand thought processes and the situation or context the people faced. Supporting people when it didn’t go as expected.
3. Use huddles and debriefs for real time learning – is there always a need for an incident form to be completed or an investigation or a focus on failure when we could instead put our energies into getting the conditions right, building connections and holding conversations. Take five (see previous post).
4. Most things can be solved by talking to each other.
5. Be kind. You know that’s always going to be on my list!!
Thinking of you all. 💓
Patient Safety Now 
Wise words as always suze. It would great that we change the imperative to collecting what worked well in real time and sharing this rather then the unending collection of errors. The real time sharing of intelligence in the ITU community at present is such a great example. Learning how to harness that desire is key for me.
Totally agree. If you have any ideas how we can make this a reality I’d love to talk.