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Systems of thinking relates our approach to risk and decision making (Kahneman 2011). It is argued that there are two systems of thinking that people are engaged in through the course of their daily activities. System 1 – automatic, intuitive, effortless, nonanalytic System 2 – effortful, analytic, creative, deliberative Automatic thought processes come into play when we are…
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The way people work together is central to the safety of healthcare. Behaviours of individuals at all levels can play a role in the lead up to incidents or in the prevention of incidents. Teams are people who are used to working with one another, often the same people. This is increasingly rare in healthcare where teams…
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When we fail, we do three things: Personalisation – we think it is all our fault Pervasiveness – we think it is going to affect every bit of our lives Permanence – we think we are going to feel this bad forever In 2016 I came across a radio interview with Bob Ebeling. Bob was one…
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In safety today there is a view that error is somehow preventable and that when people make mistakes all we need to do is tell them to stop making mistakes and possibly sanction them if they do. However, I know it is an obvious statement, but not everything we do will go right. Imagine that you…
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One of the ways we try to maintain safety in our everyday work is to do a workaround. Workarounds in healthcare are common, sometimes planned, sometimes not, but in the vast majority of occasions well meaning. Often a workaround is a method for overcoming a problem or limitation in a way of working. A workaround is where…
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Don Norman wrote the Design of Everyday things in 1988. It is a brilliant book which is underrated in the area of safety. If you do work in safety I would encourage you to read it. A little taster. Don was once asked by a computer company to evaluate a new keyboard. He spent the day…
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Work as imagined is what we imagine work is like or what we imagine the work could look like. The ‘we’ is often policy makers, standard settings, guideline developers, regulators and commissioners. It also includes us. The term work as imagined can also apply to policies themselves. When we first set out the intention of a policy…
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Safety-I is defined by Professor Hollnagel as a state where as few things as possible go wrong (Hollnagel 2014). In order to achieve this ‘state’ our aim is to try to prevent things from going wrong. Being proactive and prevent harm or injury is at the very heart of risk management and safety. However, the way we…
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Directly linked to this way of thinking about safety is the view that what people do can be prescribed in some way; policies, procedural documents, guidelines, standards and so on. This view asserts that all the people need to do is adhere to them and care will be delivered in the right way, by the right…
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Wherever you work in healthcare and whatever role you have you will be wanting to ensure the safety of the patients in your care. You will want to find ways of building safety within your work. However, healthcare is an uncertain world and the difference between safe care and unsafe care can be decided in minutes. Over the…
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PATIENT SAFETY NOW 