Headlights, Not the Rear-View Mirror
17/09/2026
An organisation learns about its own risks in two very different ways, and most organisations are quietly excellent at one of them and have barely tried the other. The first way begins after something goes wrong. An event occurs, someone is harmed or nearly so, and the organisation investigates: what happened, why, and how do
What a Near Miss Is Actually Telling You
17/09/2026
“No harm done.” Three words that end more safety conversations than any others, and almost always in the wrong place. The dose was caught before it reached the patient. The wrong-site marking was spotted at the time-out. The specimen with no label was noticed before it was run. Relief goes round the room, the moment
The Cheapest Hour in Patient Safety
17/09/2026
Every facilitator hears the objection within the first week, usually from the busiest and most credible person in the room. We do not have time for this. It deserves a straight answer, because the people saying it are not being obstructive. They are describing their week accurately. So let me concede the whole of it
Why Your Best People Keep Making the Same Mistake
17/09/2026
“Human error” is the most reassuring phrase in the whole language of safety, which is exactly what makes it dangerous. It closes the file. Once we have decided that a competent person simply erred, there is nothing left to examine except the person, and the person, being competent, will promise to try harder. Then the
The Failure Was Foreseeable. The Surprise Was Optional.
16/09/2026
Every serious safety event arrives with the same quiet feeling attached, the sense that somewhere in the building, someone already knew. Not the day it would happen, and not the patient. The weak spot. Someone knew that the shift-change handoff ran on one nurse’s memory, that the infusion alarm had been overridden so often it
The recovery plan was good
15/09/2026
The recovery plan was good. Six months later, one of the three fixes has been delivered. The plan was never the problem. By the time an organisation admits an implementation is in trouble, it has usually been in trouble for a year. Each individual difficulty was explained — this site has a leadership problem, that
Your override rate is falling
15/09/2026
Your override rate has fallen from fourteen per cent to three. Before you call that growing confidence, check what it costs somebody to disagree. A model produces a score. A human assessor makes the decision. Human review is the control on which the whole arrangement rests, and it is described that way to the regulator.
Compliance is high and the data is unusable
15/09/2026
Compliance with the new system is high. The data coming out of it cannot be used. Both are consequences of the same decision. Making use compulsory changes the motivation and nothing else. It does not make a task possible, a design usable, a process workable, or data trustworthy. Where any of those is the obstacle,
The pilot succeeded, the rollout did not
15/09/2026
The pilot succeeded. The first rollout site did not come close. Nobody wrote down the difference. A pilot does not run under normal conditions, and the result cannot be extrapolated until somebody has. Project staff on site. Direct access to developers. Defects fixed in forty-eight hours. Reduced caseload targets. Key users released. A general willingness
Six findings, all classified as minor
15/09/2026
Six findings on the same daily task, all correctly classified as low severity. Together they can cost you several full-time equivalents. Severity is assessed per item and experienced in aggregate. No triage process that scores findings separately can see the difference. An extra confirmation step. A field that defaults incorrectly. A list that resets its