Obstacles to Patient Safety

Everyone who belongs in healthcare passionately wants the best for patients.

Medical error, however, persists as the third greatest cause of death.


We have tremendous opportunity to improve.

So what are the obstacles to patient safety?

Despite appearing simple, removing unnecessary hazards within healthcare frameworks is extremely difficult. This ongoing series of posts uses specific hazards to demonstrate the obstacles to patient safety.

We’ll persist to remove these hazards through generating support and interacting with healthcare bodies. Concurrently we aim to introduce frameworks which simplify the removal of other similar hazards.

Your qualities put you in a great position to demonstrate leadership. How can you help us all overcome the obstacles to patient safety?

Please click on each heading to read the posts in full:

1. Cognitive Dissonance

Because what is our great fear in medicine? Hurting people. Not being good enough. And when we change a process for the better it inevitably implies that our PREVIOUS way of doing things was (at least relatively) harmful. To make a minor change for the better, we might have to accept we have been hurting people, maybe killing people (or putting them at risk of death) for years, even decades!

2. Ego

A disturbing (but very natural) ego-protective attitude occurs where staff reject innovations that make their carefully-honed skills less relevant. Senior clinicians may actively oppose or denigrate methods which are safer and/or more successful — not just for themselves but for their learners and the system as a whole too — in part because the innovation makes their own deft skill with the old tools less important.

3. Lack of Transparency

In healthcare front line staff can’t access valuable information in their error databases. This lack of transparency leaves us flying blind. Without seeing our errors we can’t improve.

4. The Bystander Effect

Psychologists launched a series of experiments resulting in one of the strongest and most replicable effects in social psychology. Is healthcare safety suffering the ‘Bystander Effect‘? Several factors contribute to this phenomenon.

5. Bad Apple Theory

‘When faced with a human error problem you may be tempted to ask ‘Why didn’t they watch out better? How could they not have noticed?’ You think you can solve your human error problem by telling people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure. They are all expressions of the ‘Bad Apple Theory’ where you believe your system is basically safe if it were not for those few unreliable people in it. This old view of human error is increasingly outdated and will lead you nowhere.’ – Sidney Dekker.

6. Mind the Gap

‘The Gap’ exists between work as perceived by managers and work as performed by front line staff. This gap is endemic to top down safety approaches.

7. The Blame Game

‘While most of us assume that “errors = accidents”, aviation knows that “errors – safeguards = accidents”. By obsessing over error reduction (via root-cause analysis), we miss opportunities to increase safeguards. – Nick Argall.

8. Complexity

Our hospitals are increasingly complex and humans err. We need to understand the healthcare safety problem is not bad people. Adverse events will continue to occur if we don’t act wisely.

9. Dispersion

Adverse events, by their nature, are dispersed in time and place. Given we’ve numerous different error reporting systems, which don’t inter-communicate, the effect of dispersion is compounded. Adverse events, as a result, are presented as ‘one off events’.

10. Alerts & Other Less Effective Interventions

It’s counter-intuitive that an alert designed to improve safety may actually be detrimental to patient care. Unfortunately alerts on their own may absolve governing bodies from ensuring more effective interventions.

11. Distraction

Front line work environments are full of unnecessary distractions detracting focus from the task at hand. They come in many forms from a noisy vacuum cleaner disrupting a patient consult, to a poorly designed electronic medical recording system. Removing distractions will lead to improved patient outcomes. Top down healthcare frameworks, however, impair our ability to do this.

12. Bullying, Threats & Intimidation

If patient safety is to improve healthcare will need to transition from its historical top down approach to one where the voices of front line staff are truly heard. This may require thousands of small steps taken by numerous staff deciding to demonstrate leadership. Perhaps the most primitive but effective way of stifling change is through bullying, threats and intimidation. Be prepared.

Your qualities put you in a great position to demonstrate leadership. How can you help us all overcome the obstacles to patient safety?

We’re interested and will all benefit tremendously from your insights, feedback and support.

8 thoughts on “Obstacles to Patient Safety

  1. Other obstacles: ignoring bad news stories. Unable to accept or even understand systemic failings. No one wants to be accountable so buck passed.cuts and reorganisation are unsafe but no one does safety impact assessment.stories of patient and staff whistleblowers are too challenging to hear/understand . Gamekeepers appointed are former if not current poachers.no one able to speak truth to power.no safety experts in key positions. No evidence base for so many so called safety processes enhancing set up. Rhetoric ans aspiration abd Hope etc the only real watch words of people like the National guardian. No real transparency. Eg phso unto itself.flawed maladministration model.tokenism pervades system. Those are my starters based on years of my experience as an outsider survivor advocate candid but also objective observer.invited by nhsi and patients association to be so


  2. Thank you Richard. The obstacle to patient safety posts will be added to. Previously I have read about much of the effort you have put in to try and improve patient safety. I admire your leadership and continued dedication to this. Keep up the great work. Greater transparency is needed. I also look forward to hear more about the work of Dr Umesh Prabhu in Wigan – I believe that what he has done may hold some keys for system improvement from within. Thank you again for your much appreciated comments.


  3. Dear Steve

    Where there is a will there is a way, where there is no will there are plenty of excuses! None of us can ignore patient safety as one day we will all be patients of our NHS (If not already). I have had an amazing career in NHS and used NHS as a patient many times, including diagnosis of sepsis, two fractures, nerve damaged during an accident and finally 4 cancers suspected. I have come through all of this without any problem and received fantastic treatment.

    I am very proud of NHS and passionate about this great Institution and as you know we have reduced harm to patients by 90% simply by engaging our staff, valuing our staff, appointing excellent leaders and managers and with robust governance and accountability for everyone including managers and leaders.

    So it is not at all difficult if there are good leaders with good governance and accountability and sadly in many NHS Trusts governance is poor and accountability is poor and regulation of NHS is hotchpotch and here are some of the evidences.

    1. 90% of the Trusts BME staff are 3 to 15 times more unhappy and no one has been held to account.
    2. Mid-Stafford tragedy no one has been held to account.
    3. Bruce Keogh Trusts and many other failing Trusts so far no one has been held to account.
    4. Culture of bullying, Francis report including BME plight – No one has been held to account.
    5. Whistle Blowers plight – So far no one has been held to account!

    So NHS has to do lot more and can learn from our experience. I am not saying we are perfect and far from it. But 90% reduction in harm to patients speaks volumes and for staff happiness we were bottom 20% in 2011 and today we are the third best Trust in the country!

    We focused on values, culture, appointed value based leaders and implemented robust governance and also excellent patient engagement. We still have some issues and still more to do. I am also not claiming that ours is the only Trust doing so well. Nationally few Trusts are outstanding according to CQC report and rest can learn from the Trusts which are performing well.

    Patient safety and staff happiness should matter to all of us and no leader can ignore the link between staff happiness and patient safety. Managers and leaders job is to create a culture of staff happiness by getting rid of culture of bullying, naming, shaming, disciplining but caring for staff and holding everyone to account.

    NHS needs leaders who are kind, caring, compassionate but also with courage!


  4. To improve patient safety the most important thing is to create a culture of staff happiness and staff well-being. Important to have good governance and to promote learning and supportive culture than blame culture.

    The most important thing is to have robust governance and leaders who are visible, approachable so that all staff feel confident to raise concerns and when they do someone must act. Most important thing is to protect those staff who take the courage to speak to you. 70 staff have raised concerns with me or Nurse Director. We also have weekly meeting where we go through all complaints, litigation, SUI, clinical incidents and discuss any other issues which are relevant to patient safety and all these discussions are documented and actions are then decided. The most important thing to have excellent team of staff with strong leadership.


    1. Many Thanks Umesh, We look forward to your upcoming book release and finding out more detail about the frameworks which have allowed this to be achieved in your area health service. Keep up the great work.


      1. Thanks important is to get the basics right

        If we get the basics right we can make the whole of NHS and any healthcare safest and the best and they are;

        1. Appoint right clinical leaders who is the most popular consultant with nurses, juniors and GPs.
        2. Teach them leadership skills
        3. Support them to do a good job
        4. Put excellent governance system in every department.
        5. Establish excellent communication channel in every department
        6. Empower staff to speak up and when they do they are protected and someone takes action.
        7. 80% staff do very good job, 19% need help and support to learn, change and improve and 1% must be dismissed! If you don’t dismiss your consultants or senior staff including leaders and managers then you do not have robust governance. This is sad reality of NHS. Poor clinicians and poor leaders and managers are simply moved on to other Trusts and not dealt properly!
        8. Promote culture of staff happiness and learning and supportive culture and not a culture of blaming, discipline (unless a must), naming, shaming and so on.
        9. Make sure leaders are visible, approachable and staff feel confident to raise concerns and leaders who are kind, caring compassionate but with courage to do the right thing
        10. Celebrate success and create lots of positive energy by regularly thanking and praising staff and use data to change staff behaviours


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