Patient Safety
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For over a decade, the language and narrative of safety has been trying to embrace the concepts of a ‘new approach’, mainly called Safety I and Safety-II or Safety Differently. It has circulated through healthcare conferences, academic journals, and policy discussions. Influential thinkers such as Erik Hollnagel, Sidney Dekker, Stephen Shorrock and Jeffrey Braithwaite (and…
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In July, the review of patient safety by Dr Penny Dash was published. This was followed by an acceptance of all the recommendations made in the review by the government. Up until then I had not been party to what the findings had been or the recommendations so was somewhat surprised when I read it.…
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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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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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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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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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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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I have just uploaded a post related to a just culture. That was describing the culture that is for the vast vast majority of incidents and staff. I purposefully left it at that because I didn’t want it confused with this post which is asking some difficult questions that I don’t know the answer to.…
PATIENT SAFETY NOW 