Review of patient safety - update.

Opinion piece: Patient Safety Review by Dr Penny Dash 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…

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

Harvard president receives standing ovation during commencement.

This will fuel calls to restrict access to justice. But what should be a priority is preventing harm in the first place, improving the response to incidents, and offering truly authentic apologies.

As with a lot of patient safety stuff, there is a danger of making safety II thinking and implementation far more complicated than it needs to be. No wonder we have not achieved as much as we hoped.

Safety II thinking - should we try to embed across healthcare?

Decades of learning 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…

Fortunate enough to work with a great group of colleagues & discuss how to create #psychologicalsafety in the perioperative environment. ➡️ journals.lww.com/co-anesthesi... #ptsafety #medsky #nurseky #psychsafety @tomgeraghty.bsky.social @curiousbecks.bsky.social @amycedmondson.bsky.social

An organisation with a memory 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…

Thinking again of the women of Afghanistan - such desperate, awful straits www.theguardian.com/global-devel...

22 weeks apart.

Automaticity 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 -…

Teams 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…

Today we repaired 14 hernias. Started on time, finished on time. Even stopped briefly for lunch. One operating theatre, no expensive technology. Last list for a while as all extra sessions to reduce waiting lists have been stopped for now due to lack of money. #nhs #waitinglists

Personalisation 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…

Human error and zero harm 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…

In an extraordinary display of public support, heads of state, heads of government, and foreign ministers from all over Europe and Canada are posting in support of Ukraine in response to the Oval Office meeting with Trump, Zelenskyy, and Vance.

Workarounds – good or bad? 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…

NHS England’s next CEO faces immense challenges trying to improve care after the last 15 years. But caring for the carers is vital. The NHS *is* its staff, its people. The discretionary effort. The quiet acts of kindness. Rebuilding morale is imperative. www.theguardian.com/society/2025...

You're probably reeling, like me, from Trump's onslaught on Ukraine & from the horrifying spectacle of two superpowers trying to carve up a sovereign country. Please, I beg you, use your voice. Write to your MP. Express your views on social media. Share this piece. Act. Thank you. #SlavaUkraini 🇺🇦

And these are the mass graves, in a forest outside Izium, where occupying Russian forces dumped the bodies of the civilians they murdered. 445 bodies were retrieved by the Ukrainian troops who liberated Izium. To witness this scene, in a European country in 2025, shook me to my core.

These are the makeshift memorials to some of the children who died.

This is my dear friend Andrii, a neurosurgeon from Kyiv. We're standing outside a block of flats in Izium hit by a Russian missile. All five storeys collapsed onto the basement below, where hundreds of residents had sought shelter. 54 people, including children, were killed.

This is Jenya, the anaesthetist who helped stabilise Mykola. In Bakhmut last year, he treated between 6,000 & 7000 casualties, including children. “Something died inside me. Too much horror. I stopped being able to feel,” he said. "It is hard to keep on, but we will because we have no choice."

We need facts as never before. 3 years after Putin invaded Ukraine, I spent 24 hours with combat medics on the Ukrainian frontline. Their courage, compassion, dedication & skill are astounding. Please read & please never stop standing up for Ukraine. 🇺🇦 www.theguardian.com/world/2025/f...

Ability to disclose 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…

Great article on “safety culture” with relevance to healthcare. Despite decades of discussion and constant calls to improve it, are we clear in what it is and what it means? TLDR: is it time to abandon the concept of “safety culture”. Probably. www.sciencedirect.com/science/arti...

This email from a senior medical consultant hit me hard. How can we establish #PsychologicalSafety when it's never been there for so many of us? 💔 #OperateWithRespect

Work as imagined and more 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…

What is safety I? 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…

Can we prescribe daily work? 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…

Patient Safety Now – summary of my book 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…

Bravery, compassion and strength. God bless this woman.

I have a few new followers - welcome - so thought I would let you know who I am and what I do

People in Control❓ Last week I did a talk for LVNL (the Dutch air navigation service provider) for one of their safety days. The talk was entitled ‘People in Control? Work-as-Imagined and Work-as-Done’. youtu.be/fanYF8cXNYU?...

A short journal editorial on Human Factors and Ergonomics, adapted for hospital medicine readers, by Dr Craig Bailey, me and Dr Kevin Fong @drkevinfong.bsky.social www.magonlinelibrary.com/doi/full/10.... 🧵

RCAs are problematic because they are used to assure consumers that we "will learn from this harm in order to prevent it happening again". But the system in which the harm occurred has moved on before the RCA even starts. It is just a very expensive (and symbolic) mea culpa from the organisation.

The James Reason Lecture 2016 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… http://suzettewoodward.org/2024/12/01/the-james-reason-lecture-2016/

I am seeing lots of comments about RCA. That is was/is a good tool just used badly and that PSIRF should include it in the repertoire of methods. What do you all think?

Really like this framing of Psychological safety by Timothy Clark. Need to start with inclusion, then learner then contributor then challenger. We need to get to challenger level to enable innovation & to enable all to feel able to speak up / challenge / have a different opinion…

Welcome 😊

Loving this new paper on complexity in medicine, using pediatrics as the worked example. Too many medical authors (and the MRC) run fast and loose with the terms 'complexity' and 'complex interventions'. They should read this paper. #medsky #academicsky #philsci 🧪 www.nature.com/articles/s41...

The James Reason Lecture 2016 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… http://suzettewoodward.org/2024/12/01/the-james-reason-lecture-2016/

Our conclusion after 6 years working across the healthcare system #safety

Totally agree

A positive culture in the NHS 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… http://suzettewoodward.org/2024/11/23/a-positive-culture-in-the-nhs-copy/