1. Paradigm Shift

What you see depends on what you’re conditioned to see:

We’ve grown up in healthcare seeing education, policy writing and checklists as the most powerful tools for improvement.

Those in the most influential positions are often academically gifted and tend to reinforce this behaviour. Education has served them proud, it has enabled them to excel. They may believe if others are as well educated many of the issues will be resolved.

Resultantly in the top down structures of healthcare education and policy writing is where the energy is invested.

Unfortunately human factors engineering teaches us that these people focussed interventions are relatively ineffective when it comes to improving safety.


While education and training are important, if healthcare safety is to improve we need a paradigm shift cultivating system focussed interventions. The aviation industry underwent this paradigm shift many years ago leading to massive improvements in safety.

Forcing functions, at the top of the hierarchy, prevent staff from committing the error – in effect designing the error out.

Patient Safe have focussed on several hazards and are striving to implement the forcing functions to prevent them. See:
Central lines which open to air
APL valves which trap open
Indistinct pourable chlorhexidine
Valveless intravenous fluid bags

Our hospitals are teaming with thousands of hazards. Used in the correct way they won’t cause a problem – however they’re not designed to take into account the human in the room. Despite teaching and policies they continue to be used incorrectly and patients suffer as a result.

We’ve focused on a few to help highlight the problem. The longer these hazards remain in place the more obvious it is healthcare safety desperately needs this paradigm shift.

Change won’t happen overnight – perhaps it will occur through  tens of thousands of steps.

All healthcare staff have it within them to recognise and focus on a specific hazard, take a position of leadership, gather a team around them and work tirelessly until the hazard is removed.

Healthcare safety needs a ‘team of teams’.

One Comment

  1. Andrew Ottaway

    We need a system that will enable us to better-understand human-factors, by determining just how human-factors impacts workplace activities. We need information on the reality of the workplace; what works and what doesn’t, the ‘near-misses’ that go under-reported, the stresses that affect both staff and patients that lead to mistakes being made. What would be more effective for gathering that vital information than giving everyone – staff, patients, and patients families – who witness at first-hand workplace activity the opportunity to share their testimony without the fear of censure or sanction?

    Other sectors where the safety of the public is paramount have been using systems of confidential occurrence reporting and analysis in human-factors research for decades, so why is it so difficult to have a similar process in our health- and social-care system? Even more difficult to understand when you learn that surgical teams across the public and private sectors operate a very effective confidential reporting system.

    An independent, charity-run confidential occurrence reporting and analysis program is a simple, inexpensive solution to a pressing problem; how do we improve our knowledge of human-factors, and its impact on everyone concerned?

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