Poetry Month April 2013: Workplace Safety Poems

Safety? Poetry? You must be mad, I can hear you thinking. But no, there is such a thing and such a poet. Don Merrell specialises in writing poems about safety in the workplace.  Poetry has the advantage of appealing to the emotions. Safety at work is not only about check-lists  board papers, risk assessments and significant incident reviews. It's a mindset - and mindsets are about beliefs and values - which in turn are emotional factors.

I CHOSE TO LOOK THE OTHER WAY (Don Merrell)

I could have saved a life that day,
But I chose to look the other way.
It wasn’t that I didn’t care;
I had the time, and I was there.

But I didn’t want to seem a fool,
Or argue over a safety rule.
I knew he’d done the job before;
If I spoke up he might get sore.

The chances didn’t seem that bad;
I’d done the same, he knew I had.
So I shook my head and walked by;
He knew the risks as well as I.

He took the chance, I closed an eye;
And with that act, I let him die.
I could have saved a life that day,
But I chose to look the other way.

Now every time I see his wife,
I know I should have saved his life.
That guilt is something I must bear;
But isn’t’ something you need to share.

If you see a risk that others take
That puts their health or life at stake,
The question asked or thing you say;
Could help them live another day.

If you see a risk and walk away,
Then hope you never have to say,
“I could have saved a life that day,
But I chose to look the other way.”

How do I use this poem in the workplace?

Safety has an emotional angle and a poem like this allows a small group to discuss issues that might otherwise not be tabled in regular mtgs. I use this only in small groups so there is time and respect for listening to how it makes people feel. Do they have an example of when they "looked away". How did they feel? What might happen if they don't "look away".

Often patient safety is set up to be a systems issue - and it is. But it is also about individual mindsets and beliefs. This poem brings the individual to the fore and helps people understand their role in ensuring a safe process and workplace.

The issues are, of course, not about the poem, but about the workplace and what might be done to improve safety for all.

Book Review: Overtreated by Shannon Brownlee

The subtiutle of this book is "Why too much medicine is making us sicker and poorer". This book was quite shocking. I know there is a lot of what goes on in healthcare that is unnecessary yet to find a huge amount of detail and information in one place really put the issue into perspective. It is focused mainly on the USA though there are many parallels with other health systems.

Throughout the book, the author provides stories and examples to illustrate the data and statistics that without the stories would appear cold and less shocking.

As I read through the book, particularly in the early chapters I found myself going "I know him/her"! Shannon Brownlee hooks a fair amount of the debate onto the actions of some of the current health leaders in the USA (you might like to read the book to see if you are mentioned...!) There is an excellent chapter on the VA Healthcare systems, how it has improved and in many cases how it is an example of how healthcare in the USA could look and feel.

Chapters include:

• Too much medicine: complelling arguments as to why population based healthcare would be a real improvement
• The most dangerous place: beware the hospital and what might happen
• Your local hospital: how uncoordinated care and overtreatment results in poor outcomes
• Broken hearts: how the latest fad takes root, based on economics
• The desperate cure: an argument for evidence based care if there ever was one
• The limits of seeing: an expose on the limits to radiology tests
• The persuaders: mmm who is influencing whom, and why?
• Money, drugs and lies: why not to believe everything published in journals
• The doctor isn't in: all about managed care
• When less is more: some ideas to cope with over-capacity and overtreatment in the USA

This book is a must for every health care improver who believes their own project is making a difference... The strategic and tactical issues raised in it really provide a new perspective.

Paper: Strategies for sustaining a quality improvement collaborative and its patient safety gains

Int J Qual Health Care. 2012 Jun 4. [Epub ahead of print]
Strategies for sustaining a quality improvement collaborative and its patient safety gains.Parand A, Benn J, Burnett S, Pinto A, Vincent C.

In their words, the conclusions are

"This study has presented what principle programme coordinators across 20 NHS organizations considered to be the key strategies to sustain their own improvement programme and its successes, during the supported phase of the programme and 1 year on. Recommendations are to consider these practical strategies in order to improve chances of maintaining changes and continuing a quality improvement programme beyond the formal cessation of the intervention."

I'm not sure what this means other than 'watch and wait' and 'learn' - which is fine.

Book Review: Sway; the irresistable pull of irrational behaviour by Brafman & Brafman

Irrational behavour? Me? Never!

The Brafman brothers write a compelling story of how irrational our behaviour is in a variety of circumstances. While most of the book is well evidenced they bring each of the issues alive with stories that make sense - perhaps too much sense.

I'm getting a bit tired of the constant use of the airline industry as a safety example. So it was with interest I read through the case study on the crash at Tenerife which was one of the largest loss of life incidents. The authors demonstrate how the perception of loss played an important part in the creation of the incident.

Next up is a football team in the US which managed to beat all the major players but relinquishing their commitment to the predominant method of play. The story here is about how our commitment to a certain way limits our opportunities for growth and advancement. The authors show how loss and commitment add together to become a powerful irrational pull.

The chapter on value attribution is quite scary. They use a number of examples. One is of a famous violin player dressed casually playing complex tunes in an underground station during rush hour. hardly anyone paid him any notice at all. Yet some would pay large sums of money to hear him play on stage dressed in his dinner suit. The book is worth the read in this chapter about the discovery of a human fossil and how scientists of the day were not prepared to give it credence because the discoverer wasn't "one of them".

If you are currently either interviewing people for a job or going for interviews yourself, then the next chapter which looks at how initial diagnoses or decisions sway our long term responses to individuals.

Perceptions, beliefs and context come under scrutiny in the next chapter. If you want to understand why the USA has a Bipolar epidemic then read about it here. If you are involved in training and developing individuals then the examples of belief are important to understand.

So what is fairness? Read on to discover the importance of context.If you think monetary incentives are a motivation to change behaviour then the next chapter provides some examples which may rattle your thoughts. By now I was beginning to understand just how irrational we are as human beings. And just when I've grasped a bit of my own irrationality, the authors move onto the irrationality of groups, particularly looking at blockers and dissenters.

If you are wondering why no-one is following your instructions, why it is too difficult to plan something, why you always seem right and no-one else wrong... etc. then I thoroughly recommend this very readable book. It is an easy and relatively quick read (once - I had to reread to make sure I grasped what was being said).

WHO Patient Safety Curriculum Guide

More great resources from the World Health Organisation.  To be frank - this curriculum guide is the most comprehensive set of teaching resources on patient safety that I've come across in a decade.  It has been developed by multi-professional groups so avoids the biases that so often occur when courses are developed by a single organisation.  Whilst it's aimed at integrating patient safety into educational curricula, there's no reason why you can't use this within your own organisational setting.

You can access the multi-professional guide here. If you would like the teaching slides for each of the 11 topics then you can download them here, where you will also find background and evaluation information.

And unless I'n missing something - these are free to use - so no there is no excuse in wasting time creating, developing, designing, discussing how to educate and train staff in patient safety. Nor should you be paying anyone to do the creating, designing, developing etc.

Well done WHO!

How safe are clinical systems - report on the evidence by The Health Foundation

This report for The Health Foundation is excellent. I like the way it is based on research and whilst it doesn't cover any specifically new ground, it does provide insight for anyone wishing to improve the safety of patients in hospital. 

"While the knowledge that poor systems can cause harm is not new, this report provides groundbreaking evidence of the extent to which important clinical systems and processes fail, and the potential these failings have to harm patients.

The results of this study, covering seven NHS organisations, identify the variation in the reliability of five key healthcare systems and processes:

• availability of information when making clinical decisions
• prescribing
• handover
• availability of equipment in operating theatres
• availability of equipment for inserting intravenous lines.

The research, led by Professor Bryony Dean-Franklin, was conducted by The Centre for Patient Safety and Service Quality (CPSSQ) at Imperial College, and Warwick Clinical Systems Improvement (CSI), University of Warwick."

Never events: what's on your list of ensuring patient safety?

I was talking about Never Events at a dinner party, trying to explain what they are, and two friends were horrified - at the concept that in healthcare we need to draw up a list of things that should never happen.  I agree, as a patient the list below does feel scary - not because they might happen, but because we need to talk about them not happening...


The NHS in England has just expanded the list to 26 from 8 (details are in this policy document); I'm still not sure whether this is a good thing or not.I have heard that some countries and regions don't bother with Never events lists. I'd be interested in finding out whether they do this for a reason.

There are 25 "never events" on the expanded list. This includes the original eight events from previous years, some of which have been modified, and builds on the draft list published in October 2010. The list is as follows:

1. Wrong site surgery (existing)
2. Wrong implant/prosthesis (new)
3. Retained foreign object post-operation (existing)
4. Wrongly prepared high-risk injectable medication (new)
5. Maladministration of potassium-containing solutions (modified)
6. Wrong route administration of chemotherapy (existing)
7. Wrong route administration of oral/enteral treatment (new)
8. Intravenous administration of epidural medication (new)
9. Maladministration of Insulin (new)
10. Overdose of midazolam during conscious sedation (new)
11. Opioid overdose of an opioid-naïve patient (new)
12. Inappropriate administration of daily oral methotrexate (new)
13. Suicide using non-collapsible rails (existing)
14. Escape of a transferred prisoner (existing)
15. Falls from unrestricted windows (new)
16. Entrapment in bedrails (new)
17. Transfusion of ABO-incompatible blood components (new)
18. Transplantation of ABO or HLA-incompatible Organs (new)
19. Misplaced naso- or oro-gastric tubes (modified)
20. Wrong gas administered (new)
21. Failure to monitor and respond to oxygen saturation (new)
22. Air embolism (new)
23. Misidentification of patients (new)
24. Severe scalding of patients (new)
25. Maternal death due to post partum haemorrhage after elective Caesarean  section (modified)

Publishing negative studies is good for learning

Humans learn by making mistakes. When the mistakes of others are hidden then we all have to go over the same ground to discover the errors - a waste of time, in many cases. The issue of publishing negative studies is a bit one.  When I was researching my book "Why good practice doesn't spread" I could find no-one who was prepared to share, publicly, their experience of a large scale change project that did not achieve what it set out to do. They would talk in private and anonymously - but not openly.

One of my ambitions is to start the online Journal of Quality Improvement and Patient Safety Program Failures. I would love to be able to read about projects that went pear-shaped. I think I would learn more from them than from the ones which advertise greatness.

If you have ideas on what should be included in this Journal then please leave a comment on this blogpost or email me directly.

In the meantime if you want to read a few articiples and papers about the issue check out:
Increased calls for publishing negative clinical trial data
Publish or perish culture distorting research results
The importance of publishing negative results

Airlines & Healthcare; what can we learn

We consider airlines safe so in healthcare we adopt some (and only some) of the techniques they use to be safe - like checklists used by pilots and engineers. I say @some@ because we often forgot some of the more basic and fundamental safety aspects employed by arilines - the often more complex human resources, financial aspects, organisational learning, training etc.

Putting safety aside I read the report by the USA Bureau of Transportation on the statistics for 2009. In 2009 of the 19 airlines who reported they had an average on-time arrival performance of 79.5%. Hmmm. What I like about this figure is it represents the complexity of different airlines, operating in different ways, to different airports - and all affected in some way by the things out of their control, like the weather. This sounds to me like the healthcare system - in public sector systems anyway. So the airline travel system in 2009 was designed for 1 late arrival in every 5 flights. This makes me feel a lot better about the flow of patients around the National Health Service in England. A way higher percentage experiences experiences on time care. I also feel that the NHS is able to work well in a crisis like bad weather.

Ever lost your baggage? Well in the USA in 2009 3.91 bags were mishandled (isn't that a lovely term!) in every 1000 handled. This was an improvement from the 5.26 in 2008 - well done. As rates go these mishandlings are very few. Of course, if it is your bag lost, then the amount of year on year improvement and the overall rate is of no interest. A failure is a failure. This reminds me of the way most healthcare projects adopt goals that are less than perfect. For instance, 95% of patients to be treated xxx. What this tells me is that the improvement project team and the organisation are opting to design for a certain amount of failure. And I am not sure I am happy with this. Mistakes I can forgive. Designed in failure rate, often large ones, are to me a sign of lack of confidence in the people and processes. And as a patient I am less confident being treated there.

We have a great deal to learn about and adopt from other sectors as part of improving healthcare. What have you adopted from another industry and how has it worked for you?

Fear of failure? Never Events need a target of zero

So how would you feel if you were the patient of a surgical team whose improvement target for the "Never" event of wrong site surgery was - to reduce by 20%? A "Never" event is something that, by definition, should never happen. The NHS in England have a list of 8 that are so well evidenced they should be adopted for implementation with no further discussion.

Why then are we seeing targets for Never Events that are not zero? My recent experiences suggest the following dynamics at play:

• zero is too difficult a target to achieve in healthcare (try telling that to the patient who has just had their wrong kidney removed or the suicide that happened when on 1-1 watch and using non-collapsible rails). Admittedly in some healthcare processes zero may be a tough tartget, however, Never Events mean never.
• we may not meet the target (fear the failure and the knock on consequences for individuals, teams and project work); when I encounter this I realise I am working with an individual or group who fear the failure of improvement greater than they feal the failure of harming a patient.
• it's not worth all the changes for zero (the costs of the change outweight the cost of full redeuction of a never event); this is, of course, a judgement call and my hope is it is made with full data analysis and consultation of those involved. Some never events happen so seldom it may be difficult to justify the changes required.
• we don't believe the research is good enough; the NHS in England (National Patient Safety Agency) have streamlines a varietyof Never Event lists to determine a core 8 which are well proven in all aspects. More research I suggest is not required.
• we will take a while to get to zero; that's ok, then let's see a desired outcome of zero and some leeway to reduce over time. The trick is perhaps not to design for a 20% reduction in year 1 but rather to design for zero in year 3 and monitor progress over time.

Never events need targets of Zero - 0. They should never happen.

Innovation may be a barrier to improving healthcare

I know I am on a sensitive topic here. However, the angle I'd like to mention is one that concerns me. I worry it might be a case of the emperor's new clothes. So just in case, I'd like to strip the outer layer of clothing off something that we take for granted and assume is "a good thing". Innovation.

It was announced this week that the NHS in England will have a prize fund of £20 million pounds to go to individuals, teams or organisations who come up with innovations that make a substantial improvement to services. So what I am wondering, is whether this is helpful, or in fact whether prizes and the ongoing emphasis on innovation is helping deliver long term, sustainable, effective and efficient improvements in the delivery of healthcare?

Disconfirming question #1: Why develop more innovation when the current good ideas, innovations etc are used by so few? I wonder what the impact would be if £20 million pounds was up for grabs if you could demonstrate you have implemented an existing evidenced good practice? Do we need more activity on research and new stuff when we have lists and lists of practices that can be of benefit if actually implemented? If an innovation comes up with an idea to get evidence into practice across whole systems and large groups of people, without them really noticing it, then yes, I am behind it. But I am not behind single, one off innovations which are so off the wall that the normal healthcare population can't conceive of ever implementing them.

Disconfirming question #2: Why emphasise innovation and not research? Though a part of me is frightened that any more research will go over old ground - so maybe that is why an innovation focus may be better?

Disconfirming question #3: Why focus on starting something new when stopping something that doesn't work might have more of an impact. The BMJ published in 2004 a list of "bad ideas" or practises in general use which are no longer considered "good practice". These sorts of practices continue to mean large variations in care. So if the innovation rewarded is one which erasing the use of "bad ideas" then I'm all for it.

Disconfirming question #4: Why focus energy on creating new ideas when the same energy could be focused on activity around implementing known and evidenced good ideas. Before I turn entirely into a "grumpy old woman" I do see that innovation and creativity is good. However, as a taxpayer in our system I want to see action on what we know already can work. I suspect tough times like a recession will enable the natural innovators to do their stuff - and they will do this regardless of prizes or focus. It's the greater norm population that doesn't regularly do innovation that bothers me; how can we get action underway there?

Disconfirming question #5: What is innovation anyway? This could leave to a philosophical debate. It could be that anyone implementing an existing known-elsewhere practice will feel it is like an innovation when they implement it in their own context. I suspect this is not what the prize organisers have in mind.

Yes, I do understand innovation and the need for it. My feeling is the innovating population will innovate anyway - that's their nature. I want support, profile and focus on getting existing known practice into place and in stopping known "bad ideas". We could start with hand washing - or someone could come up with an innovative something that means hand washing is an irrelevant activity in the drive to reduce hospital acquired infections.

Healthcare needs new norms to counter abuse of power

I believe the problem we’re facing in improving the quality and safety of healthcare is about setting new norms rather than the eternal quest to take innovative ideas or set of guidelines and then impose these on the rest of the system. Yes, this “pilot and spread” approach is useful and can be demonstrated to raise standards, though there may be questions about sustainability of results and few organisations review improvement programs three or more years after they were completed to test this.

Obviously new norms can’t be “set” as such. Where does our current norm come from? I think of a norm as the sum of all the behaviours actually at work in a system. A different norm therefore requires a different set of behaviours – not only (if at all) a planning meeting to decide and list these behaviours but an actual change in the behaviour of one, then two, then three, then four and so on people in the way they act and interact with each other.

More about this norm approach in forthcoming posts. In this post I am thinking more about why we end up with the norm we have. For example, what is the norm at work in an organisation where 400 or more patients are harmed or die inappropriately (for a series of reports / investigations on UK health organisations http://www.cqc.org.uk/publications.cfm?widCall1=customDocManager.search_do_2&tcl_id=2&search_string=&top_parent=4513&tax_child=4574 ) or where one nurse is able to harm and kill a number or patients http://www.nytimes.com/2009/04/03/us/03nurse.html?_r=1? No doubt there are many causes involved in each and every event. However, I’ve been asking myself the question “Why is it so difficult to shift the norm?” Allied to this is the question for me of “How can professionals reach the stage where they become part of a norm that seems to go against their stated values, yet do nothing – their behaviour continues “as normal?”

There are procedures for the NHS in England to manage whistleblowing http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4050929 and again, there will be many reasons why people don’t step outside of a norm and take action. So why is this norm “pull” so strong?

One reason I have been dwelling on is the abuse of power. Not so much a conscious step but rather one which is part of our human condition. And when enough people behave in ways where power is being abused, then a norm develops so others, who may not be inclined to do so, end up part of the problem.

How is abuse of power part of our human conditions? We know from a number of experiments that stated values, professional promises and personal beliefs can go out the window if the circumstances are right. For example, the Stanford Prison Experiment in 1971 (http://www.prisonexp.org/ for a slideshow / discussion guide on the whole process) demonstrated in laboratory conditions that when put in a position of power (the guards) about a third of the “guards” showed sadistic tendencies, meting out punishments and inventing ways to humiliate their “prisoners”. The famous Stanley Milgram experiment http://en.wikipedia.org/wiki/Milgram_experiment in 1961 showed how when participants are morally distanced from the consequence of their actions and when they believe in the power of the authority demanding action, they will continue behaviour even when they can see it is physically harming another person. Around two-thirds of participants showed this behaviour. There are many other examples as well, not least of which come from politics and wars.

So what does this mean for raising the standards of healthcare? Imagine working in an organisation where a critical mass of people (clinical professionals as well as managers and administrators) feel distanced from their actions, feel the need to respond to authority figures, are in a stressful context and feel they can act in ways that are driven by their own very personal demons. The sum of the behaviours exhibited become the norm culture.

So when I encounter really good examples of clinical or administrative practice and I am asked to help with spreading this to other places, then one of the key things I am thinking about is the underpinning behavioural dynamic. What is it about the team and the behaviour of the individuals in the team, that contribute to their identified quality / safety improvement performance? What is their norm? To what extent is this about how they manage the power dynamics? And if others are to adopt their work, what will this do to their use and abuse of power within their own systems? How will they break free of their current norm? Whose behaviour will be critical in this shift of norms?

I’ve been through the process of listing, rather objectively, the behaviours required for good practice to be adopted. Maybe this is helpful in working out just what needs to be done to effect the change. What I know now is a list of behaviours is not the same as the behaviour itself. I am also a great deal more aware of the context in which behaviours are played out and I am open as to the impact of power dynamics in a system.

This is messy stuff that doesn’t lend itself to the predominant method of change in healthcare, namely the issuing of a “how-to” guide. I think it requires conversation, dialogue, self-awareness and attentiveness. There’s no quick fix.

Surgical Safety Checklist Sprint 10th March 2009

The IHI www.ihi.org are leading a "sprint" to have every hospital in the USA test the World Health Organization (WHO) Surgical Safety Checklist at least one time with one operating room team. Sprint Day is 10th March 2009. The version in England is more marathon-like with a target set for February 2010 for all hospitals and teams to be using the checklist. So, we have two different approaches to getting this life-saving tool implemented.

If I had to place a bet as to the effectiveness of each strategy I would go for the sprint. Yes, the aim here is only for one team in each hospital to test it out. This strategy is going for coverage by having every hospital participate. The marathon version is going for both coverage as well as completeness - wanting every team to be using it. I expect the Sprint version will migrate into a marathon so completeness is developed in each of the hospitals that tested the checklist.

I'm placing my bet on the Sprint because I would rather the checklist got tested soon. If a team finds it helps and is not too onerous then they'll gossip about it in the surgeon's coffee lounge. To me that is preferable to planning sessions and meetings about how to implement marathon-style. Better to get on and test it.

As a patient, there is no choice - the sooner the better.

The IHI has all the tools you need to get started http://www.ihi.org/IHI/Programs/ImprovementMap/WHOSurgicalSafetyChecklistSprint.htm. So what are you doing? Sprinting, doing a short jog or planning for a marathon?

Positive Deviance recognised for MRSA reduction work

I blogged about Positive Deviance as a change and spread methodology a few months back. It is rewarding to see that the concept is listed in the 8th Annual Year in Ideas Issue of the New York Times Magazine http://www.nytimes.com/interactive/2008/12/14/magazine/2008_IDEAS.html

What I like about PD is it provides a different, yet proven, methodlogy for large scale change that is less "problem" focused. It works on the positive rather than the negative and in my experience is a less stressful and more rewarding improvement process in which to participate.

One of the most famous uses of Positive Deviance is in the reduction of rates of MRSA in a network of hospitals in the USA. Details about this work can be found on the PD website (see below) or for a different perspective you can go to http://www.plexusinstitute.org/complexity/index.cfm?id=3

For more information about PD go to www.positivedeviance.org

Learning communication techniques is important for spread and safety

I'm freshly back from a fabulous 2 day masterclass with a group who actively particiapted in developing their own communication skills. This was more than ideas on how to develop a technical communication plan. This was a group of individuals who spend time in front of video cameras and then assessed their own performance - with the aim of giving each other feedback and consequently improving their skills.

So often when communication is mentioned in the context of spreading good practice we default to "how to develop a communication plan". Yet I know from working with this groups, as with other groups I encounter, that it is only when we get to the finer details of communication and behaviour does anything really change.

Communication itself is an important topic. There is oodles of research about which demonstrates the link between communication and performance, communication and financial outcomes, communication and patient outcomes. In the current copy of International Journal for quality in Healthcare there is another excellent research report demonstrating how communication is linked to medical disputes.

My feeling is we can get further in the goal of spreading good practice when we pay attention to the details, like how individuals communicate with one another and resist the temptation to focus only on technical planning.

I also suggest we can stop researching the link between communication and outcomes and focus on making the desired communication changes.

Groupthink hinders the spread of good practice

This topic takes me back to one of my early posts in March 2008 when I worried about how we know whether what is being spread is a good idea in the first place. My experience of the last few weeks leaves me even more perplexed as the reality of large scale change (spread of good practice) initiatives across different continents seems to experience similar, dis-spiriting, effects. On the one hand there is a group, mostly senior leaders, who speak of success in the programs, and on the other hand, there are others, mostly those involved in the direct implementation of the changes, who want to speak of success yet talk quietly of the hurdles and challenges they face.

When I step back and look at many of these large scale initiatives they are all using similar frameworks, tools and techniques, and they are all experiencing the same sorts of problems in their implementation. Roughly, they get around a third of teams involved delivering some improvement, another third demonstrating engagement to some or another extent and the final third inactive despite a variety of tactics. These are very rough figures but the pattern is fairly consistent in a number of large programs.

So the question I ask myself is why do we accept this level of performance? There seems to be a quality improvement / spread of good practice "virus" which goes round and infects all groups to the extent everyone does copy each other with little investigation to seek out new and alternative large scale change methods. The dynamic reminds me of "groupthink" so I checked out what characterises groupthink; according to McCauley we'll see it when we have directive leadership and homogenous groups that are isolated from outside sources of information and analysis. That sounds like many of the healthcare teams and organisations I encounter along with their quality improvement consultancies they work with.

So I've started challenging the groupthink and speaking up a bit more than I usually do. In a small way this means providing information, directing teams and organisations to look outside their usual frames of reference, suggesting alternative sources of challenge (even other than myself). It also means saying no thank you to requests for support where it feels it is encouraging groupthink.

So my challenge now is to think about topics like patient safety. There's a proliferation of programs and initiatives either underway or planned around the western world. The more I think about them and talk with others who are working on the programs, the more groupthink appears to be at work. I am not convinced on the progress so far that the current large scale initiatives are sufficiently breaking free of the mindsets that got us in the mess in the first place. It feels like we're implementing workarounds. Many colleagues agree though few are ready to speak out.

If you are willing to rethink your strategy and tactics on large scale patient safety intiatives, and do so in an innovative and challenging way, involving people from different disciplines, industries and countries, then let me know. There has to be a better way.

2008 Sarah Fraser, Creative Commons: Attribution-Non-Commerical-No Derivative