Just Culture Is a Promise You Have to Keep
17/09/2026
“We fix systems, not people.” It is one of the finest sentences in modern healthcare, and in a great many organisations it is a lie, not because anyone intends to deceive, but because they have made the promise without building the thing that keeps it. Just Culture, done properly, is a genuine commitment. Left as
What High-Reliability Organisations Actually Do Differently
17/09/2026
Aviation and nuclear power get held up so often as models for healthcare that the comparison has gone slightly numb. The phrase high-reliability organisation gets printed on posters and strategy decks, admired, and left there, as if reliability were an attitude you could adopt by deciding to. It is not an attitude. It is a
Checklists Don’t Fail. The Conditions Around Them Do.
17/09/2026
The surgical safety checklist is one of the genuine success stories of modern patient safety, and it is also one of the most misunderstood, because its success has convinced a great many people that a checklist is a thing you can install. Print it, laminate it, tape it to the wall, and safety follows. Then
Bowtie Diagrams: A Whole Risk on One Page
17/09/2026
Some risks are too tangled to hold in the head and too important to leave that way. The bowtie diagram exists for exactly these, and its whole appeal is that it puts a complete risk story on a single page, in a shape anyone can read without training. Picture a knot in the centre, the
The Swiss Cheese Model Is Older Than You Think, and Still Right
17/09/2026
James Reason gave safety its most durable picture decades ago, and it has survived every fashion since because it happens to be true. Imagine the defences protecting a patient as a series of slices of Swiss cheese, stacked one behind another. Each slice is a barrier: a check, an alarm, a protocol, a second set
Root Cause Analysis Has One Job. Don’t Give It Two.
17/09/2026
Root Cause Analysis is a fine tool asked, constantly, to do work it was never built for. A serious event happens and someone says, reasonably enough, let us also use this to make sure the process is safe going forward. Or, stranger and increasingly common, a team reaches for RCA to assess a process where
When the Patient Is the Last Line of Defence
17/09/2026
A patient goes home from a hospital that has, for days, surrounded every process with barriers. A second clinician’s eyes on the high-risk medication. A scanner that checks the wristband against the dose. A colleague who happens to walk past and notice something off. Then the front door closes behind them, and every one of
Between Two Beds and on Nobody’s List
17/09/2026
The most dangerous place in a hospital is not a room. It is a transition. A patient is handed from one team to another, from one unit to another, from one shift to the next, and in that handover something essential is supposed to pass along with the body: not just the facts, but the
The Recommendation That Reached Two People Out of Six
17/09/2026
A speech-language pathologist finishes a bedside swallow assessment and writes a clear recommendation: this patient takes thickened liquids only, and nothing by mouth without supervision. The assessment was expert, the recommendation is correct, and it is about to fail, not because anyone disagrees with it, but because of how many people need it and how
What the Pharmacy Override Log Is Trying to Tell You
17/09/2026
Every automated dispensing cabinet keeps a log of its overrides, the times a nurse pulled a medication before a pharmacist reviewed the order. In the imagined version of the process, this pathway is rare, urgent, and justified, an emergency valve for the moments when waiting for review would itself be dangerous. Then you open the