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I read the review of patient safety by Dr Penny Dash [published in July 2025]. You can find it here: https://assets.publishing.service.gov.uk/media/686bd5d52cfe301b5fb6780c/dhsc-review-of_patient-safety-across-the-health-and-care-landscape.pdf I made six pages of notes as I read it and have a few comments as you can imagine. I think the best thing for me to do at this stage is provide some…
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This has just arrived on my desk. I cannot wait to read it. and another I am in the middle of but loving…
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In reality we do not know what the true quantitive level of safety is. We dont know for sure how many things are going wrong and we definitely dont know how many things go right. I would argue we may never know. We cannot capture everything – that would be impossible. What we do capture…
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Following on from my blog titled “an organisation with a memory’ it is worth us dipping in to things we have tried over the years. There are a number of tools and techniques that are used in the safety-I approach. These include, Heinrich’s triangle, the swiss cheese model, ‘5 whys’ and root cause analysis. Heinrich’s triangle…
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In many ways the year 2000 was the start of the safety movement as we know it today. There are many safety scholars out there who will cite the work as far back as the late 1800s that helped our thinking in patient safety and the brilliance of our anaesthetic colleagues who were in fact the…
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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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PATIENT SAFETY NOW 