Paradigm Shift

What you see depends on what your told to see.

We’ve grown up in healthcare seeing education, policy writing and checklists as the most powerful tools for improvement.

Those in the most influential positions are often academically gifted and tend to reinforce this behaviour. Education has served them proud, it has enabled them to excel. They may believe if others are as well educated many of the issues will be resolved.

Resultantly in the top down structures of healthcare education and policy writing is where the energy is invested.

Unfortunately human factors engineering teaches us that these people focussed interventions are relatively ineffective when it comes to improving safety.


If healthcare safety is to improve we need a paradigm shift which fosters system focussed interventions, understanding they’re more effective than people focussed interventions. The aviation industry underwent his paradigm shift many years ago leading to massive improvements in safety.

Forcing functions, which come top of the list, prevent staff from committing the error – in effect designing the error out.

Patient Safe have focussed on several forcing functions and are striving to implement them. See:
Central lines which don’t open to air
APL valves which don’t become trapped open
Using only distinct or non-pourable chlorhexidine 
Valved intravenous fluid bags

Our hospitals are teaming with thousands of similar unnecessary hazards. We’ve focused on these few because they help highlight the problem. The longer these hazards remain in place the more obvious it is healthcare safety desperately needs this paradigm shift.

Change won’t happen overnight – perhaps it will occur through hundreds of thousands of steps.

All healthcare staff have it within them to recognise and focus on a specific hazard, take a position of leadership, gather a team around them and work tirelessly until the hazard is removed.

For this paradigm shift to occur we need tens of thousands of leadership teams, focussing on specific hazards – healthcare safety needs a ‘team of teams’.

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