Do you ever feel like we are missing something? Do you have moments when you are struck by a story or a fact that stops you in your tracks. I was recently reading the annual report from NHS Resolution as part of area of research. Having worked there and seen the exponential growth in litigation claims over the years it shouldn't have been quite the 'stop in tracks' moment that it was but nonetheless it did indeed turn out to be one.

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. I wrote a blog about the review, in the anticipation that it would be one of many commentaries on the subject, especially from the…

I read the review of patient safety by Dr Penny Dash . You can find it here: 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 high level key messages from my perspective. I will try to restrict myself to ten of them, I mean who wants six pages!

This has just arrived on my desk. I cannot wait to read it. and another I am in the middle of but loving...

Public accounts committee called the record sum ‘jaw-dropping’ and criticised inaction to reduce errors in a damning report

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 is biased in that it is often the easy to see, and the easy to report incidents.

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 Heinrich’s triangle – which states that likelihood of a fatality rises in line with the number of incidents – I am told has no basis in fact or research.  

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 first people to coin the term 'patient safety' in the 1970s.

The need for women to be accompanied by a man in public is blocking access to healthcare and contributing to soaring mortality rates, say experts

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 driving a familiar route.

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 come together for a short period of time and then disperse.  

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 of the engineers working on the shuttle Challenger 30 years ago – since the radio interview Bob has since died.  

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 are in the midst of an intensive care unit surrounded by pumps, wires and machines constantly flickering numbers and lights and you need to administer one drug in the patient’s vein and one drug in the patient’s nasogastric tube.  

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 individuals deviate from the prescribed work, often for genuine reasons.  

Exclusive: Departure follows meetings with Wes Streeting and unusual criticism from two Commons committees