Last year the BMJ reported medical error as the third greatest cause of death in healthcare. Does the design of error reporting systems render them powerless to change this? Current systems are designed using a command structure: Command structures have been present for hundreds of years and were used with great effect to improve efficiency during the industrial era. However they only work when those … Continue reading Team of Teams

One day, some time in the future, a nurse or doctor will notice something – a piece of equipment, the way a drug is packaged, a problem with a system – and she will (metaphorically) pull a cord to sound an alarm. The siren that sounds will be a pleasant one and the issue will be made transparent. Staff will congratulate her and delight in … Continue reading Time To Pull The Andon Cord

What you see depends on what you’re conditioned 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 … Continue reading 1. 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 … Continue reading Paradigm Shift