All about my books – Alles over mijn boeken
There is a myth that proactive risk work requires a chartered project: a sponsor, a trained facilitator, eight weeks, a wall covered in sticky notes. For a high-stakes process, all of that is appropriate. For the hundred smaller moments where a little foresight would help, it is so disproportionate that the analysis simply never happens, … Read more
Two years after a genuinely good analysis, walk back to the process it fixed and you will often find the fix gone. Not rejected, not overturned in any meeting anyone remembers. Simply evaporated. A staffing change reassigned the person who did the extra check. A software update quietly dropped the alert. The workaround crept back … Read more
Watch what happens at the end of most risk analyses. The hard work is done, the hazards are named and ranked, and then, in the last forty-five minutes, the team disposes of them. The disposal, with dispiriting regularity, reads the same way. Re-educate the staff. Revise the policy. Remind everyone at the huddle. Add it … Read more
Somewhere right now a capable team is spending forty minutes deciding whether a risk scores a six or a seven. They will not resolve it, because there is nothing to resolve. The distinction does not exist outside the worksheet, and while they argue it, the hazard they agree is serious sits unaddressed. This is scoring … Read more
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
There is a particular kind of safety document that looks flawless and describes a hospital that does not exist. Its process map is clean. Every step follows the last in good order, nothing is interrupted, no one is covering two assignments, and the night shift behaves exactly like the policy says it should. It is … Read more
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 … Read more
“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
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
“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