Last year the BMJ reported medical error as the third greatest cause of death in healthcare. Does the design of error reporting systems render them powerless to change this? Current systems are designed using a command structure: Command structures have been present for hundreds of years and were used with […]

One day, some time in the future, a nurse or doctor will notice something – a piece of equipment, the way a drug is packaged, a problem with a system – and she will (metaphorically) pull a cord to sound an alarm. The siren that sounds will be a pleasant […]

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 […]

The patient declined rapidly, the arrest call went out, staff rushed into the operating room. Some helped obtain intravenous access, others drew up adrenaline, and the arrest trolley was brought in. As the patient’s cardiac output disappeared the anaesthetist asked for someone to commence cardiac compressions then turned to put […]

Every system is perfectly designed to get the results it achieves. Medical error has been reported as the third greatest cause of hospital death. Despite interventions to overcome this there has been no improvement in medical error rates. Healthcare is perfectly designed for error to be the third greatest cause […]