Kitchen Tables.. why?

Its Kitchen table week from next Monday!!!

How exciting is that.  Here are some quick key points for you to think about what you are trying to achieve.

‘Your kitchen table could help you……

  • Find out from your staff how your organisation could be better at listening
  • Bring people together from different parts of the organisation working on different things to share experiences and insight
  • Bring people together to share what they think works really well when they care for patients so that we can start to make the transition from Safety I to Safety II a reality
  • Reach out to people who may not normally be included in the conversation like porters and catering staff to find out what they know about keeping people safer
  • Talk to each other about how you think your corporate objectives relate to working safely
  • Take a moment to reflect together on what you are doing now in your safety work and what you wish for the future
  • Share ideas for steps you can all take that are free and don’t need permission but can make all the difference in building positive relationships and a strong safety culture; our website is full of them!
  • Reach those who find it difficult to take time to connect by going to them. Many of last year’s kitchen tables were really kitchen trolleys!

What matters is helping people feel welcomed, heard, listened to and understood.


Just Culture

I was recently told a story about a nurse.  He had given the wrong patient a drug which was supposed to be given to another patient.  He immediately knew that he had done this and instantly checked the patient, called 111 (this was in the community), informed the family, went with the patient to hospital and stayed with them for the next 16 hours or so.  Also at the same time informed his line manager and even referred himself to the Nursing and Midwifery Council.

If I was this person’s line manager I would clearly want to understand what happened but I would also console the nurse and ask him what I can do for him and applaud him for his actions following the error.  Instead the nurse is being disciplined.  That to me is not applying the Just Culture.

What do we mean by applying the Just Culture?

I recently shared an adapted definition of a just culture from the Skybrary website  at a presentation.  It was:  ‘A just culture is one in which people are not punished for actions omissions/decisions which are commensurate with their experience and training but where wilful and intentional actions are not tolerated’.

Definitions, and trying to bring clarity to a complicated subject, rightly leads to others saying things like ‘well there is a hell of a lot more to it than that!’.

Yes there is.

There are a number of different views on the Just Culture and a fair few myths and misconceptions.

David Marx describes how we should try to distinguish between different behaviours and respond appropriately and proportionately to these behaviours.  His books (Whack a mole and Dave’s Subs) try to help us understand the differences between error, (some refer to is as human error), risky behaviour, reckless behaviour, negligence and criminal intent or wilful acts.  He and others such as Prof James Reason would describe the big three as:

  1. Human error:  inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake
  2. Risky behaviour:  choices that increase risk, where risk is not recognised or is mistakenly believed to be justified – includes violations and negligence
  3. Reckless behaviour:  behavioural choice, intentional acts, conscious disregard to a substantial and unjustifiable risk

There are a number of toolkits, guides, decision trees that try to help with these distinctions. One of them is found at the Skybrary Just Culture Toolkit Just culture section.  Developed by Job Bruggen a safety manager at Air Traffic Control the Netherlands and Patrick Kools of GoGen – Beyond Rules.  A summary of the toolkit is below.

You might want to think of the nurses story at the beginning and ask where the case fits and what the response should have been.

Level – (the behaviour – the response)

  • Level 1 – Exceptionally skilled handling of a safety situation – recognise and reward exceptional behaviour as an important element of a just culture
  • Level 2 – A person suggests an improvement to the system – recognise and reward as a way to motivate others to do the same
  • Level 3 – People helped others to understand and operate the system better – sharing lessons learnt is a major milestone and significant contribution to safety, recognise and reward
  • Level 4 – Day to day good practice – working well on a day to day should not be trivialised, recognise and reward the desirable state to continue to motivate
  • Level 5 – Someone made an error (slips, lapses, omissions, commissions including wrong procedure applied), the actions are unintentional – there are some detailed notes here on what to do in response, I would sum up as understand and find out why, console and support
  • Level 6 – A rule or procedure was not followed – either the rule was not known or the rule was too ambiguous or complicated to understand properly – again there are some detailed notes here and again I would sum up as understand and find out why and coach the person about what they could do differently in the future
  • Level 7 – Although the person knew about the rule and the rule was in principle workable, he or she decided it was not applicable, this could have been to optimise the situation or to be helpful – again there are some detailed notes here and again I would sum up as understand and find out why and coach the person about what they could do differently in the future
  • Level 8 – Person knew the rule and person knew it was not followed but that suited him or her, they were acting recklessly – this needs to be dealt with promptly and may involve sanction although always apply the principle of first understanding and finding out why

Sidney Dekker suggests it is perhaps impossible to draw neat lines around behaviours and that there are blurred boundaries between them; that someone can be both erroneous and risky and what really is the difference between risky and reckless behaviour?  Who gets to draw the line?  He says that an organisation’s journey to a just culture will never be finished.

Justice is one of those categories about which even reasonable people may disagree. What is just to one is unjust to another.

Sidney Dekker suggests having a different mind-set and create a climate of honesty, care, fairness and a willingness to learn, with five key points.  This below is from his excellent editorial in Hindsight.

You might want to think of the nurses story at the beginning and ask whether his treatment is aligned with or misaligned from these points.

Don’t ask who is responsible ask what is responsible.  That people’s actions make sense once we understand the critical features of the world in which they work.  Targeting these features (the what) is an action that contains all the potential for learning, change and improvement.

Link knowledge of the ‘messy details’ with the creation of justice.  What he means here is if someone is going to ‘judge’ another’s actions then they should have all the relevant technical knowledge to do so.  Someone who knows what the work is like, the subtleties of what it takes to get the job done despite the organisation, the rules, the multiple constraints.  So ‘make sure you have the people involved in the aftermath of an incident who know the messy details, and who have credibility in the eyes of other practitioners’.

Explore the potential for ‘restorative justice’. Retributive justice focuses on errors or violations requiring retribution, restorative justice focuses on errors or violations requiring healing.  This acknowledges the multiple truths, each side of the story and point of view about what could have gone wrong and how it normally goes right.  It takes the view that people do not come to work to do a bad job. It fosters dialogue and relationships rather than fostering adversary and create breaks in relationships through sanction and punishment.

Go from backward to forward-looking accountability.  Backward-looking accountability is about blaming people for past events leading to sanction, removal or dismissal of people. This instils a sense of fear and doesn’t help learning, it only leads to reduce reporting and disclosure.  Instead forward-looking accountability sees individual actions as representing organisational, operational, technical, educational and other system issues. People are not a problem to control but a solution to harness.

Put secondary victim support in place.  The practitioners involved in an incident are often referred to as ‘secondary victims’.  This term is not liked by all.  Whatever term we use, Dekker suggests that there should be strong social and organisational support systems for these people.

How about talking about this subject in one of your Sign up to Safety Kitchen Tables?



David Marx.  Books – Whack a Mole and Dave’s Subs

Sidney Dekker.  Book – Just Culture – Balancing Safety and Accountability

Skybrary – website

Violations / risky behaviour

A key part of my job is to explore what it takes to create a safety culture.  I spend a lot of my time thoroughly enjoying reading research, opinion pieces, blogs and books on safety culture and just culture.

No aspect of either a safety culture or just culture is delightfully black or white, one thing or another.  There are blurred boundaries and nuances to every aspect of each.  Some aspects lend themselves to clearer boundaries such as error or criminal intent but its the middle that causes concern or confusion.  What to do with people who take risks or people who are considered reckless but not intentional?  What do we even mean by risky behaviour or reckless behaviour?

In safety II – the experts talk about (healthcare) workers having:

  • The ability for people to adjust what they do to match the conditions of work
  • The ability to succeed under expected and unexpected conditions alike
  • The ability to take actions to help create a state where as much as possible goes right

But in patient safety this behaviour is often described as violating best practice or violations or risky behaviour.  Is it really risky behaviour to do your very best, given the circumstances you are faced, to provide safe and effective care by adapting what you do and even adapting the written policies and procedures?  Even the words violating or violation have strong connotations of ‘disgraceful behaviour’; the tone is already set for those who are found to have not adhered to a set procedure.

However, violation (or risky behaviour) comes in many forms…

  • Erroneous  – an individual did not understand the policy or was not aware of it.  Given the amount of stuff people have to be aware of in this information rich world together with the limited time and pressures in today’s healthcare – its a wonder anyone has time to read a policy or procedure
  • Routine — when the policy or procedure is routinely bypassed or ‘worked around’ – this is the stuff that human factors experts talk about in terms of ‘work as imagined versus work as done’
  • Situational  – usually related to the on-going and insidious circumstances, situation, environment or resources including time, effort, money and people – all of which impact or can make it difficult to take the right steps
  • Exceptional – extreme circumstances which result in the clinician making a purposeful choice to bypass the normal procedure (linked to situational)
  • Optimising —when in fact there is a better way of doing things i.e. people on the ground know better or the policy is out of date, unworkable (linked to routine)

Ken Catchpole (1) sums it all up for me when he wrote in the BMJ Quality and Safety Journal, ‘violations and non-adherence are common, not always conscious, not always planned, are frequently well meaning, and in many cases allow the system to run smoothly’.

However, importantly, as Rene Amalberti (2) states, a resilient system requires flexibility to help it become safer, efficient and adaptive to changing circumstances.

It is therefore important to understand why this happens first before simply judging people and disproportionally blaming people when they are considered to have violated a policy or procedure.


(1) Catchpole, K.  BMJ Qual Saf 2013;22:705-709 doi:10.1136/bmjqs-2012-001604

(2) Amalberti, R, Vincent C, Auroy, Y et al BMJ Qual Saf Health Care 2006;15:i66-i71 doi:10.1136/qshc.2005.015982

Six tips for implementation

Recently I have been asked to help provide advice on implementation for a few patient safety projects which made me revisit my previous research in 2008.  Its always interesting to review the knowledge you had at the time and compare with the knowledge you now have.   Mixing the two here are six tips for implementation that might help:

1. Demonstrate that the change is better than status quo

This remains highly relevant.  If all is ok then why change? We can be a bit like that with even our personal stuff.  If the fridge freezer works why change, even though I know there are some amazing super new fridge freezers on the market! So the change has to either replace something that isn’t working or have clear and tangible benefits on the existing way of doing things.

2. Try and make the change as easy as possible to do

This is a bit of a conundrum.  I think it does need to be easy but at the same time, doing something difficult well is incredibly rewarding.  I think the main thing is not to over complicate it.  So don’t produce the 100 page manual that is a nightmare to understand or follow or create something that requires on-going and intense hours of training.  The behavioural insights world has a lot to offer in this respect.



3. Adapt the change to local conditions – use the 80/20 rule



I have slightly changed my thinking on this.  I used to think that organisations or people need to completely adapt something to make it theirs and to own it.  This way they would be invested in it and want it to work more.  However, too much adapting means that simple interventions across the country or similar documentation for things like prescribing are all a bit different as you go round the country.  This is sort of ok if no one moves but with a workforce that is highly transitory then this becomes an issue.  The key is to standardise what you can, stay true to the core of what ever it is you are adopting and then only adapt say 20% of it to fit with your environment. And maybe think again when you want to change the name of something – I came across a team who had decided to call huddles ‘cuddles’ – confused the hell out of everyone who worked there!

4. See who you can get on board to help ‘champion’

If you respect and like someone you pay attention to what they say and what they do.  This is a human trait.  So if someone you like and respect at work thinks the ‘change’ would be a good thing to try and the added bonus is that they have actually done it themselves then you are more likely to do the same.  This is what people refer to as peer to peer influence or the use of opinion leaders or role models.

5. Carefully use intrinsic and extrinsic motivators

Intrinsic motivation is defined as performing an action or behaviour because you enjoy the activity itself. It is an internal form of motivation. People strive towards a goal for personal satisfaction or accomplishment.  The inspiration for acting on intrinsic motivation can be found in the action.  Whereas acting on extrinsic motivation is done for the sake of some external outcome or pressure, itself.  Extrinsic motivation can be another person, or some outside demand, obligation, or even reward that requires the achievement of a particular goal. Think carefully about these when you are developing your implementation plans.

6. Major on reward and recognition

Linked to intrinsic and extrinsic motivators is that of reward and recognition.  If people are recognised for their actions, thanked and valued for their contribution to safer care they will feel great. Others will see that they feel great and want to feel that way too.  This can mean anything from shining a light on someone’s achievement to sharing their work in a journal or a blog, to giving people awards.  But a ‘thank you’ goes a very long way.


Before I go… just a few things that get in the way of success:

  • Relying on training as the way to get people to change
  • Simply sending out stuff – dissemination of alerts or guidance with no support expecting people to notice
  • Punishment for poor compliance
  • Devising the wrong solution that doesn’t actually address the particular problem that needs addressing
  • The sheer number of ‘top down’ articles, policy documents, guidance, interventions  published daily – coming from all different directions including within your own organisation– trying to figure out which are the ones to pay attention to and which are the ones to ignore

As I have said before …. if we do ‘one thing’ it is for the ‘problem of implementation’ to be owned by the guidance developers, solution designers and researchers.  The people tasked with developing something for others to use or to action. This means when planning it all out, spend as much time on implementation as innovation and improvement.

All of this could increase the chances of sustained change.

Kitchen Tables

In the 1960s my Uncle was a scientific officer at the Radar Research Establishment in Malvern. There were a number of divisions within the establishment who had a tendency to stick together in their different groups.  My uncle decided that every day the different groups should be invited to come together for coffee and conversation.  They had one main rule which was to ban any conversation which concerned things beginning with C.  This was to rule out computing, which was their main work related activity and therefore encourage people to broaden the conversations to help learn more from and about each other.

He would pose questions that may have been triggered by the latest New Scientist or the latest news but more often than not they were stimulated by some obscure question or fact. For example one time they talked about Puccini’s opera Turandot.  The opera was unfinished at the time of Puccini’s death in 1924, and was completed by Franco Alfano in 1926. The question posed was; ‘should an opera lover walk out at the point that Puccini stopped and before Alfano started or stay to the end?’  This to my uncle was a bit of fun but he was fascinated in how it stimulated conversation and improved the conversational skills between divisions.

My uncle is not the only person to think about helping people talk to each other.

For example, a lot of people have used conversational methods such as ‘The World Café’. One such example is that of Bob Veazie, a senior engineer at Hewlett-Packard.  Bob’s role was to improve organisational performance.  He experienced a World Café event where he realised that the boxes in his traditional hierarchical organisation chart would be better depicted as webs of conversations.  That managing these conversations might not be the best way to achieve results.  He described how every day his teams were engaged in conversations about different questions.  He sensed the power and potential for networks of conversations and how the connections among them could produce real value.  He wondered if conversations and personal relationships are at the heart of our work.  He questioned his role as the leader and whether he was contributing to or taking energy away from this natural process.  He questioned why we are using the intelligence of just a few people when we could gain the intelligence of hundreds or thousands of people.

When Bob became the safety leader for Hewlett-Packard’s inkjet operations he was eventually responsible for fifty thousand employees at five sites around the world. When he started there was a high accident rate.  This varied from country to country; in Oregon US 6.2% of the workforce was being harmed each year, 4.1% in Puerto Rico and 2.5% in Ireland.  The initial attempt to address this was to implement a programme called STOP, which is where people give each other feedback about how they are doing against a list of predetermined risks.  Feedback from the test group was that the discussions related to someone else’s list, not their own ideas about what their own risks really were.  He says ‘we started with someone else’s answer rather than a question that should have evoked people’s own curiosity and creativity’.  The second attempt was to pull together a small group of full time internal safety experts, called safety change agents.  The safety change agents defined the set of risks for the whole organisation.  As Bob says this was the second mistake.  He felt that by doing the work internally, they were consistent with the principles of the World Café; that the wisdom lies with the people themselves.  In reality they had created a small group that functioned like outside experts, removing the responsibility from others.

The third attempt was to ask, what are the few key questions that would improve safety results if we were to ask them to people already in conversations about their daily work? What they chose to do was pose key safety questions to the people in the already existing but invisible ‘café’ – the web of relationships – so that they could integrate the questions into conversations they were already having.  Bob and his team began by meeting with people where they normally gathered, in staff meetings, worker assemblies and on the shop floor.  First they shared the local facilities safety record with them.  They showed these people the visual from the world café which shows how one person can then influence a small group, who can then influence a number of groups which can lead to large scale impact.  This shows the powerful pattern of the world café in action.  It helped employees realise that to make a shift, rather than use predetermined training programmes that focused only on solutions.  It demonstrated that they were trusted to hold conversations, develop relationships and mutual intelligence as a way of dealing with critical safety questions.

The first question Bob and his team explored was; if you were to get hurt, how would that happen?’ People began answering the question with risks that they identified from their own work situations. The second question was; do you want to manage these risks before people get hurt or after?’  Of course they all said, ‘before’.  The final question was; ‘what do you want to do about it?’  Bob’s team had invited them into a meaningful conversation called ‘I don’t want to get hurt at work’.  They talked together about different methodologies, and their own ideas for managing risk.  Then they were asked to try out the answers, keep asking the questions and revisit the answers as they learnt more.

Bob used the World Café as a guide to help his safety effort and articulated this as an on-going ‘Safety Café’, a network of conversations across the company connected by key questions. The internal safety experts he had employed were used as the hosts.  Bob and his team travelled across the world sharing the stories, bringing together people from across the product lines to learn with and from each other.  Bob says that as they were leading the safety effort, they were simultaneously learning about how conversations are a core method that really works to enhance performance.  The results of these efforts; the accident rate reduced in Oregon from 6.2% to 1.2%, Puerto Rico went from 4.1% to 0.2%.  The company as a whole was able to reduce the overall accident rate by approximately 33%.

So, thanks to my uncle we have one example of an informal get together to help create relationships with people you wouldn’t necessarily meet or spend time with and thanks to Bob we have another example which is a more structured approach to build knowledge through conversations.

The Sign up to Safety campaign is encouraging conversations to help people work safely and combining these two approaches; bringing people together from different groups to talk to one another but also to focus around what we can all do to help people work safely.

We have called it a ‘kitchen table’ because we wanted to evoke the times when you sit round a table with your family or friends and tell them about your day. We imagine different people from across the organisation or practice coming together to have a conversation about safety.  We don’t want people to over-think it so we suggest that it is not planned like a meeting,  doesn’t need an agenda or minutes taken.  The host could stimulate the conversation with questions and some key insights could be captured as single words or key messages on a scribble sheet in the middle of the table.

It doesn’t have to be as obscure as Puccini’s opera but if that is what it takes to create relationships then why not?! What would be even more wonderful is if the kitchen table then stimulated a network of conversations in the same way Bob achieved for Hewlett-Packard. Imagine that network not only across an organisation but across the country simulated by key questions about how we can help people work safely. This is what we are trying to achieve by our second national kitchen table week starting on 19 March 2018.

We would love it if the conversations were linked to three key topics;

  • Firstly about how everyone across the NHS could implement ‘safety II’ i.e. a way of looking at what works as well as what doesn’t
  • Secondly about how we can instil ‘joy at work’ by building on the initiatives such as ‘learning from excellence’, #kind2018 and saying thank you to the people you work with
  • Thirdly how we can keep building this way of developing relationships and having conversations so that they become part of the everyday fabric of the NHS

If you want to know more about the kitchen table week all you have to do is head to our website or twitter account @signuptosafety. You will see what people did last year and you can see what people are planning for this year.  Any questions can be asked via

In memory of Dr Philip Woodward DSc – 6.10.1919 to 30.01.2018


Sign up to Safety update

At Sign up to Safety we are constantly reviewing what we have done and what we want to do in the future.  We have assessed the data, looked at what works and what doesn’t, and talked to loads of people who have been involved in our journey over the last 3 years.

We have found that not everyone is aware of how we have significantly evolved from the early days of Sign up to Safety in 2014.  We started out with a fairly traditional aim and approach; help the NHS reduce avoidable harm and save lives through the implementation of a set of safety interventions set out in safety improvement plans.  Now this is a really laudable aim but it was also a very busy playing field with all sorts of national and regional bodies and initiatives trying to do the same thing.

So we worked out where the gaps were; culture, relationship building, networking, kindness, positivity, supporting the learning from excellence initiatives and implementing safety II and we started to relentlessly focus on these gaps.  The thread throughout all of these is our throughline; helping people talk to each other.

So who are we now?

We are a Department of Health and Social Care commissioned team (and not as is often thought part of NHS England).  We help the NHS reduce avoidable harm and save lives by focusing on the following three key objectives.

Our three key objectives for 2018/19

  1. Build on the work of the Sign up to Safety campaign since 2014 and continue to focus on behaviours, attitudes and values that are vital for a safety culture via the mechanism of helping people talk to each other
  2. Support our current membership to build a safety culture, help people work safely and implement a new approach to safety (safety II) and build new membership, particularly in primary care
  3. Support two national priorities (the just culture and implementation of the revised NHS Resolution organisational strategy) with our work on safety culture

How are we doing this?

We started by thinking all we needed was to develop a ‘pack’ that would be a sort of ‘how to guide’ and then quickly realised it needed to be much less a guide and more a conversation in itself.  We wanted to create interactions with our members so that they could find out ideas, connect with others, and feel energised by the new knowledge and thinking.

We were helped by some trusty members who gave us their wise and honest advice. They reflected what we already knew, that asking people to talk to each other is a profoundly simple solution and that people find it difficult to accept simple solutions. What we started to do was almost apologetically turn something simple into something more complex.  To make us feel proactive we tried to turn what we know into a tool or technique or pack. We even started calling it a conversation pack and the methods as ‘Safety Conversations’.  What were we thinking?!

Calling them ‘Safety Conversations’ can be (and has been) misinterpreted and boom another trend is started.

We have enough checklists, policies and procedures to help people work safely.  There is already the confusion around the difference between huddles,  briefings, debriefings, handovers, and Schwartz rounds.  We even added to this list with our ‘kitchen tables’.  Why would we add to this with a ‘new’ thing called Safety Conversations?

So we have chosen not to do this.  Instead we have…

  • Designed a new website which will bring all of our thinking together with ways in which people can interact with us and the new ideas.  It is in the final stages of design but we wanted you to know that it is nearly there
  • Developed videos for you to download and share in your organisation
  • Recorded podcasts for you to listen to about what others are doing
  • Curated the latest thinking on safety and divided them up into 1min, 3 min, 5 min, 10 min, 20 min, 30 min segments depending upon how much time you have
  • Launched #kind2018 – our key hashtag for 2018 to help people share their stories about kindness and being kind to others which includes people saying thank you to each other
  • Designed a ‘Matchmaking‘ initiative being launched this February
  • Continued with sharing our approach to holding conversations about safety through ‘kitchen table’ events and encouraging another national kitchen table week from 19 March
  • Redesigned our newsletters which are issued every other Wednesday which are applicable to everyone no matter where you work
  • Written and commissioned blogs which will continue throughout the year, including the real experiences of our members who are making this a reality where they work

We hope that you will find our new site easy and all of these things, practical and accessible and help you have the conversations you need.

We would love it if the focus of your conversations over the coming year on many of the previous blogs here…such as those on safety I to safety II and helping people work safely.  That you too concentrate on culture, relationship building, networking, kindness, positivity, learning from excellence, and implementing safety II in order to help them work safely.

We truly hope that these conversations will open up new ideas and insights, and enable you to help people to put forward their perspectives, help them be heard without being interrupted or ignored, feeling that their voice can make a difference.

And lastly, try out our ideas, explore the different ways and then if you can share with us what you have learnt and experienced. We would love to show off your work.

We really look forward to hearing from you.


Working Safely

It turns out that if you change how people talk, that changes how they think’

Lena Boroditsky, Professor of Psychology, Stanford University

Over the last twenty years the subject of patient safety has grown and we have achieved a number of changes in terms of raising awareness of the issues and quantifying the problem.  However we all know that this is not quite working as we imagined.

As has been mentioned by us in previous blogs we are big fans of the work of Erik Hollnagel and his colleagues and their thoughts in relation to Safety I and Safety II.

To remind you…

Safety-I is where safety is defined as a condition where the number of adverse outcomes (accidents, incidents, near misses) is as low as possible

Safety-II is the ability to succeed under expected and unexpected conditions alike, so that the number of intended and acceptable outcomes (in other words everyday activities) is as high as possible

With this definition, safety (and patient safety) changes from studying why things go wrong to studying why things go right. Hollnagel suggests that means studying and understanding everyday activities which are ‘actual events’ that show how a system functions.  The purpose is no longer to ‘avoid that things go wrong’ but instead ‘ensure that things go right’.

Hollnagel challenges us to think about our definitions and language when talking about ‘safety’, that we should move away from these titles or easily boxed in headings to talking about ‘working safely’.  We could not agree more.  This completely changes the mind-set.  It moves Patient Safety from a thing one person does or a workshop or a strategy to about everything we do, every action we take and every decision we make.

Helping people work safely means we help them adjust what they do to match the conditions of actual work, help them learn to identify and overcome the flaws in the system, and help them interpret and apply policies and procedures to match those conditions.

So in that respect ‘Patient Safety’– should be redefined as ‘working safely’ and should be defined as:

working safely (in relation to patient care) is ensuring that that the number of intended and acceptable outcomes is as high as possible and people adjusting what they do to match the conditions of actual work, learning to identify and overcome the flaws in the system, and interpreting and applying policies and procedures to match those conditions

Those that work in patient safety should study what is working, rather than what doesn’t and should study how people work, individually and collectively and how the organisation functions when things are going well.


There are a few things we can do to help people work safely.

Connect people up to work together

We need to connect up the people who are working separately on particular problems in isolation. When people and their isolated projects come together learning increases and instead of improving one process at a time they improve aspects of care (and problems) that thread throughout all of these different harms.

We have tended to focus on problems in isolation, one harm at a time, and our efforts have been simplistic and myopic. If we are to save more lives and significantly reduce patient harm, we need to adopt a holistic, systematic approach that extends across cultural, technological and procedural boundaries – one that is based on the evidence of what works”

Professor the Lord Ara Darzi

Working on harms in isolation can have the risk of creating competition in a way that people don’t know which ‘interest’ or area of harm deserves more or less effort, time and resource.  These competing interests create competing prioritisation and confusion.

Instead organisations could hold ‘cross harm’ conversations where people talk about the common set of causal or contributory factors. These conversations could help discover new ways of sharing information, or designing new pathways to pick up issues more quickly, what could be standardised and what cant.

Stop assuming that healthcare fits into a neat linear model

Erik Hollnagel suggests that simple linear accident models were appropriate for the work environments of the 1920s (when they were first conceived) but not for the current work environments. Also that ‘composite’ liner models such as the ‘swiss cheese’ model by Jim Reason from the 1980s also worked for a different operating model than today.

The reality is that working in healthcare is muddled and unpredictable.  However, Liz Wiggins and Harriet Hunter talk about organisations as…

complex responsive processes with the focus on local, unpredictable interactions between people

They assert that there are multiple, non-linear relationships and interactions between people that are taking place all of the time.  That what is really happening is different from what people think ought to be happening.

Working safely is not a nice neat linear, step by step process that is underpinned by nice neat linear protocols or procedures.  That would be reliant on everyone agreeing with what is needed, that it is known by all and achievable and that nothing unexpected will happen along the way.

Zero harm is impossible

We have to accept that a system can never be ‘safe’ it can only be as safe as possible. Too often, people work in systems that are not well designed or not designed to help people work safely.  What we can do is drive down error and design systems to minimise its effect as much as we can.

Narrow the gap between ‘work as imagined and work as done’

There is an assumption that everything we do can be written down in procedures and guidelines and people will simply follow them.  Wiggins and Hunter suggest:

the key to a relational approach to change is paying attention to what is actually happening in practice as a result of people working with each other, rather than being enslaved to beliefs about what you think ought to happen and what is inscribed in the protocol

This is also the view of those who believe in Safety II concepts and the science of Human Factors.  Steven Shorrock and others talk eloquently about the issues associated with ‘work as imagined as opposed to work as done’.  Steve is the Editor of a fantastic resource titled the Hindsight Magazine which devoted a whole journal to the subject (Hindsight 25).

Sidney Dekker says:

“Sure, we can imagine work in a particular way. We can believe that people will use the technologies we provide them in the way they were intended. Or that they will apply the procedure every time it is applicable. Or that the checklist will be used.

These assumptions (hopes, dreams, imaginings), are of course at quite a distance from how that work actually gets done on the front line, at the sharp end. Work gets done because of people’s effective informal understandings, their interpretations, their innovations and improvisations outside those rules”

Extreme adherence to the plan or directives or rules can be problematic. The way work is imagined by policy makers, board members, leaders, managers and planners is the way they want it to be done not necessarily how it can be done. What these people need to do is:

“Pay attention to what is really happening, rather than what you think ought to be happening; be facilitative and focus on working with people, rather than ‘doing to’ them and see relationships as the source of insight, creativity and energy”

Liz Wiggins and Harriet Hunter (2016)

Sidney Dekker goes on to say;

To learn how work is actually done – as opposed to how we think it is done – our leaders need to take their time. They need to use their ears more than their mouths. They need to ask us what we need; not tell us what to do. Ultimately, to understand how work actually gets done, they need an open mind, and a big heart

At Sign up to Safety we would add:

In order to learn how work is actually done go and talk to people, sit down with them and listen with intent, listen to understand. Then think about what you can do to help people with their reality

Talking and listening to staff on the frontline provides a rich source of intelligence of what works well, especially those that move around the system frequently such as doctors in training.

This work helps people to become consciously competent. If you notice what you can do you can also explore the gaps between your intentions to keep people safer and what can happen in some situations.

It also works both ways.  Often frontline staff say things like ‘the people at the top don’t understand what we do’ ‘I don’t understand why they cant just fix things’.  So the frontline ‘imagine’ a world where leaders, board members and so on that is not quite as it is ‘done’.

The conversation that will help narrow this gap has to be two way.

What can we all do differently?

  • Change the language
  • Shift ‘patient safety’ from one persons job to everyone’s job
  • Create a consensus of what we mean by a just culture and consistently embed it
  • Learn from when we get it right and replicate good practice
  • Re-design systems and mind-sets across every part of the NHS differently that help the human adapt and adjust their performance safely.  This means across your organisation – finance, procurement, operations, clinical areas and so on to think about working safely as part of what they do – creating an enabling environment to help people work safely
  • Stop doing stuff (prioritise and focus the top down interventions, directives, targets and alerts)
  • Focus on the cross system factors that thread through the individual ‘harms’ such as observation, the factors that lead to deterioration, communication and design
  • Spend as much time on implementation as we do on innovation and improvement
  • Be kind to each other
  • Help people interact and develop relationships through talking to each other and listening


  • Erik Hollnagel and Rene Amalberti, (2001) The Emperor’s New Clothes or whatever happened to human error? In: 4th International Workshop on Human Error, Safety and System Development, June 11-12, Linkoping, Sweden (keynote)
  • Hindsight Journal – via
  • Erik Hollnagel, (2010) Safer Complex Industrial Environments. CRC Press, Boca Raton, FL
  • EUROCONTROL (2013) From Safety-I to Safety-II: A White Paper.
  • Erik Hollnagel, (2012) A Tale of Two Safeties – via
  • Erik Hollnagel, (2013) Is safety a subject for science? Safety Science; Elsevier Ltd