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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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Do you need help? As a recognised expert in patient safety, I bring a wealth of experience and insight to every organisation I partner with. Whether it’s guiding leadership teams, providing keynote speeches, or helping you create a culture of safety, my approach is built on evidence-based practices tailored to your unique needs. Here’s how…
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It was an absolute honour and joy to deliver the James Reason Lecture in 2016 at the Patient Safety Congress on what was the 68th Birthday of the NHS. Prof Reason was my supervisor for my doctorate and a source of inspiration for over the last 25 years. I will never forget the words; ‘Dr…
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People “tend to overestimate their ability to function flawlessly under adverse condition, such as under the pressures of time, fatigue or high anxiety” and “We must re-examine all that we do and redesign our many and complex systems to make them less vulnerable to human error” Two quotes from an editorial in the BMJ from 18…
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I have mentioned (many times) the excellent series that the BMJ Quality and Safety journal published titled: ‘The problem with…’. The journal published one on incident reporting; the problem with incident reporting written by Carl Macrae, who provides an outstanding addition to the debate that the problem with incident reporting is that reporting and reporting systems are…
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As humans we are filled with biases. The way we perceive people, make judgements about what we see rather than what we know. The things that are within us even though we are not totally aware that they exist. There are a number of biases that impact on patient safety. You can simple search via…
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PATIENT SAFETY NOW 