Dinting Pumpkins

Yes. Great paper. A companion paper is needed to consider how ill-suited the coronial process is for investigating unexpected patient deaths. The hindsight bias and invention of linear processes undermine the whole process, and can sometimes traumatise the bereaved family.

en.m.wikipedia.org/wiki/Ludwig_...

'Rationing' healthcare spending through any explicit means is taboo but the indirect effects of chasing n=1 outcomes are glossed over. Meanwhile consumer expectations are sky-high and some corners of patient safety still promise zero harm.

📌

Such an eloquent and informed piece.. thanks for sharing. Loved, "the endless promises of more for less..." para. I would add zero harm in as the other 'promise' that has become a liability, and at worst it can be weaponised in the clinical incident management space, esp if media involved.

In a variation of this conversation... When people ask my 15 year old what they'd like to do after school, and she isn't sure, I tell her not to worry because I'm 49 and I'm still not sure what I want to do 'when I grow up' 😉

Also, the more I read, the more I reckon pt safety has more in common with construction than aviation. Obvs different in that we are trying to protect pts rather than workers, but goal conflicts, production pressure and multidisciplinary complexity/chaos sounds v familiar.

Great analysis of this paper from Drew and Dave. They go stronger than 'probably' 😉
pca.st/episode/0999...

It is particularly bruising that they took the time to cross out the final sentence of encouragement. Ouch!

The paper isn't healthcare related but an excellent call to arms to stop talking about safety culture. It is a term that has stopped being useful and it is sucking time and energy away from things that can actually be effectively researched and improved.

pca.st/episode/0999...

I honestly thought someone had stuck googly eyes on that! A-la...

Thanks for highlighting this issue. I've always found it odd that healthcare aspires to zero harm, but has a training ethos of "see one, do one, teach one". In Hollnagel's Efficiency Thotoughness Trade Off, healthcare has always chosen Efficiency but then seems shocked at some of the outcomes.

Ha!...You must be a real Aussie now if you're using Bundy Rum!

Yep, "walking iris"....Stunning tropical iris from Central and South America..... It gets its common name from the habit of rooting from the tips of fallen flower stems, thereby 'walking' its way across your garden borders.

I use this to start my presentation on why most patient safety interventions don't work. Such a powerful (and relatable!) image.