The Six Ways Any Step Can Fail

Cover of Before Harm Happens

Ask a group to brainstorm everything that could go wrong with a process and you will get a lively hour and a partial list. Brainstorming is generous with the failures that are dramatic, recent, or personally remembered, and quietly blind to the rest. The failure that has never quite happened yet, the one nobody has … Read more

What a Near Miss Is Actually Telling You

Cover of Before Harm Happens

“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 … Read more

The Cheapest Hour in Patient Safety

Cover of Before Harm Happens

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 … Read more

Why Your Best People Keep Making the Same Mistake

Cover of Before Harm Happens

“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 … Read more