1/3 Reflections on relation of philosophical concepts to #Risk & #Patient #Safety. Ylönen, M., & Aven, T. (2023). A framework for understanding risk based on the concepts of ontology and epistemology. Journal of Risk Research, 26(6), 581–593. doi.org/10.1080/1366...

I have seen ➕impact of #LearningFromExcellence but am stuck by work of Staat & Gino showing that individual learning ⬆️ from own successes rather than failures, but we learn more from failures of others than their successes. Thoughts? psycnet.apa.org/record/2013-...

It strikes me that the number of narcissistic leaders in the world has been increasing. This is deeply concerning as the literature tells us they are likely to be led by their ego rather than rational logical thinking that remains sensitive to the adverse impacts of their actions.

SAVE 2025, virtual event 13/3/25 🎟 Registration Details: ✅ FREE for SESAM Members (Use code SESAM25Comp) ✅ FREE for attendees from LMICs (Use code SAVE25Comp) 💶 €7 all other non-members 🚀 Register now! www.trybooking.com/CZFIT 📩 For more info: [email protected] | 🌍 www.sesamsociety.org

Privilege to deliver introductory lecture of Bristol Med School integrated SafeTI Systems Curriculum in such a beautiful setting this morning. Arming these students over their first 3 years with knowledge and tools to deliver #Safe healthcare within a complex adaptive #Systems #preperationiskey

Her actions were the embodiment of integrity and courage - gray example for all

“When we know what is true, it’s incumbent upon us to speak the truth even when, especially when, it costs us” Rt Rev Mariann Budde @carlhorsley.bsky.social @kencatchpole.bsky.social @davidjgrant.bsky.social @janekohara.bsky.social @siriwiig.bsky.social @trishgreenhalgh.bsky.social

🎉 Join SESAM at #IMSH2025! We’re having a social gathering for all SESAM members and the wider simulation community who are in Orlando. 📅 Monday, 13th January ⏰ Starting at 9 PM 📍 Mia’s Italian Kitchen, 8717 International Drive, Orlando #SESAM #HealthcareSimulation

Masters level online programmes for those with interest in management/managerial responsibilities in healthcare & integrated care. Provides understanding of leadership, management, innovation, quality, safety, risk management, human factors & systems thinking. 👀👇🏽 www.bristol.ac.uk/study/postgr...

🧵1/8 Reflections on impact of listening to understand during conversations based on Difficult conversations by Stone et al & past experiences: Meaningful conversations require us to build rapport or a relationship with each other It is a fundamental human need to feel heard, understood & validated

Educational Research 🧵 1/3 Starting Ed Research journey? Love clarity of Maj-Britt Råholm statement: "Abduction is the first stage of inquiry within which hypotheses are invented; analysed and developed through deduction and verified through induction." 👇🏽 onlinelibrary.wiley.com/doi/10.1111/...

🧵1/5 Common misconception about Safety II: 1. It seeks to replace safety I. 2. Its focus is solely situations where things go right Though Safety II differs in that it seeks to understand both situations where things go right and wrong. Summary of key differences below👇🏼👇🏼👇🏼

🧵 1/4 Managing #change in the complex adaptive healthcare systems we work in can be challenging. As healthcare professionals we are trained to anticipate monitor and intuitively respond to a problem as soon as it is identified. - a "find & fix it" culture prevails

1/2 When attempting to analyse or make sense of events, most healthcare professionals choose the tools they use to do so based on organisational or personal preferences rather than having a framework in mind of the different components that may have contributed to the event.

🧵 1/2 The false belief that safety exists because “things have been done in a certain way” and it has not lead to a safety event in combination with the absence of trying to understanding why things went "right" leads to failure to identify adaptive actions that has maintained safety

In a world designed to grab our attention and overload us with information this is refreshing perspective by Maura Thomas “Your attention determines experiences you have & they in turn determine life you live. - control your attention to control your life” hbr.org/2018/03/to-c...

🧵 1/2 Ever wondered why people add emoji’s to their emails? Not surprising when we remember that large proportion of F2F verbal communication is in fact non verbal. The emoji’s are just attempt to add that element of communication to the serial monologue that is an email conversation.

🧵1/3 #Communication failures @❤️ of most healthcare adverse events Multiple structured communication tools have been developed to support communicator 2 communicate more effectively, but little time is spent teaching communicators to vary communication based on analysis of receiver.

🧵1/3 Complex systems are almost as fascinating as the human brain. A complex system’s resilience is determined by how effectively it recognises & processes information in order to reconfigure itself to accommodate change. #Systemsthinking #Safety

Great read highlighting risks of "Audit for Audits sake" #patientsafety Audit masquerade: How audits provide comfort rather than treatment for serious safety problems www.sciencedirect.com/science/arti...

“Psychologically safe environments help teams ⬇️ preventable mistakes & take on challenges without fear so they either succeed or walk away wiser when they don’t” A Edmondson

Great privilege to have contributed to this paper that is testament of evolution of #simulation from tool applied for education to organisational integration of tool that supports org learning & change focussed on the cont strive to deliver pt centred, high quality & safe care #simulation #safety

1/2 Love this Heraclitus quote: “No person ever steps in the same river twice. For it’s not the same river and they are not the same person.” Great metaphor for #resultant #outcomes in #complex #adaptive #systems #patientsafety #resilience

Resilience 🧵 I frequently see & hear reference to resilient systems so I thought I would summarise a core facts from Erik Hollnagel's work as a reminder for us all: 1. Resilience is functional not structural: A system cannot be resilient, but it has the potential for resilient performance.