Do you ever feel like we are missing something? Do you have moments when you are struck by a story or a fact that stops you in your tracks.
I was recently reading the annual report from NHS Resolution as part of area of research. Having worked there and seen the exponential growth in litigation claims over the years it shouldn’t have been quite the ‘stop in tracks’ moment that it was but nonetheless it did indeed turn out to be one. This was the line “Almost £5 billion in compensation costs is currently incurred by the NHS in England each year for incidents that could be avoided”. The report goes on to say “against a background of constrained public finances, efforts to learn and act to prevent these incidents are crucial’. The national audit office review published in October 2025 concurs – saying by far the most important issue is reducing the incidence of clinical negligence and the harm caused to patients.
Why did it stop me in my tracks? not just because it is a huge amount of money that could be spent so much more effectively but I feel like I have forgotten that prevention should be one of our guiding principles in safety. In patient safety we spend most of our time dealing with the aftermath of events. Reporting incidents and investigations have become a huge industry. This has driven efforts and resources away from prevention.
How could we shift our efforts towards prevention and a more proactive approach to safety?
- Spend as much time on near misses, early warning signs and weak signals, as we do on patient safety incidents.
Set up mechanisms to learn about near misses and other early warning signs or weak signals. Weak signals are seemingly random or disconnected pieces of information that at first appears to be background noice but can be recognised as part of a significant pattern by connecting with with other pieces of information (Shoemaker and Day 2009). The are the small events that lie below our current thresholds for reporting and investigation. They include our habits, routines, adjustments, adaptions and common workarounds that most of the time lead to expected outcomes. How brilliant would this be if we could find a way of doing this in real time – to identify risks and hazards as they actually occur.
Using tools such as Exnovation and Video Reflectivity Ethnography to highlight these is such a wonderfully simple way to do this and could be incorporated into our everyday work. Exnovation is a way of looking at learning from things you already do which is mostly taken for granted. Prof Jessica Mesman at Maastricht University is a leading expert in this work. She says ‘workarounds are not the footnote to work but a key part of the plot’. The principle is to gain an outside perspective to see what we don’t see everyday and uses the tools of Video Reflectivity Ethnography (VRE) to do this. It is simply filming people while at work, you select an everyday task, such as a handover or a naso-gastric feed or a medication round and take a short film. You then sit down with the team to discuss the video. It can be done by the team or a researcher. She suggests that the video creates the ‘distance’ so it looks different and you see tings you don’t normally pay attention to. This generates a conversation about every day practice and then you can ask about near misses or signals that may tell you when this practice is impacted by certain factors and what those could be.
An example of the current work by Prof Mesman includes looking at interruptions and distractions – these happen all the time in ultra adaptive environments. They can be both good and bad but are mostly seen as bad. Using VRE you can study from the perspective of those interrupted and those that are doing the interruptions to find out why they happen, how they might sometimes need to happen and what could be done if it was considered should not have happened and so on.
2. Address the factors that lead to near misses and incidents / adverse events that are often forgotten. These include fatigue, hunger, dehydration, stress, anxiety, information overload, lack of information, poorly written policies, and team dynamics.
If we just look at team dynamics for example, we see the problems that are created by individuals within teams but also the problems created across teams, across professions or across care settings. We take little time to really think about the key factors across these different types of teams that can both break and enhance relationships and the way in which people talk and interact with each other. Erin Meyer focuses our attention in relation to people from different countries, their cultures and their impact on teams, in ‘The Culture Map’. However this can also be applied in a slightly different way using the key factors to map the culture of the different teams across healthcare.
3. Be more disruptive!
Hard to do but maybe we need to change the mindset we have in safety and to challenge some of our entrenched practices. Do we need to reshape expectations of what we can achieve with our current approach? What are the outdated solutions or interventions or processes? Who are the overlooked groups who are rarely heard from?
We need a movement of people who are willing to challenge the status quo to shake up existing practices, structures and systems. Intentionally challenge our established norms in safety.
In summary
Our current approach has always been reactive, responding mainly to when incidents or complaints or claims occur. This approach may resolve key problems but often misses the opportunity to prevent the harm before it happens and many studies have shown there were times when an incident or event (and some very high profile cases such as the Piper Alpha disaster and the Challenger explosion) was in fact preventable. To start to address prevention, we need need buy in right across healthcare from regulation to provision, to create a coordinated approach at every level and to be more innovative and novel, to not just tweak the system, but aim for fundamental change in our approach.
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PATIENT SAFETY NOW 