Beyond RCA. #Quality2018 
Aviation analogies! #quality2018
Can we learn from other sectors? @CarlMacrae
Safer Healthcare available for download free of charge. #Quality2018
Different concepts of safety and risk from Vincent & Amalberti. They are all "valid", but very different. #Quality2018
Which model for healthcare? Depends! Probably at least 20! Problems arise when we have to switch models. #Quality2018
Didn't break any rules, but 11 people died. Independent, professional investigators. Experienced, including near misses and low harm. Legal implications #Quality2018
Human Factors/Ergonomics analysis a crucial part of incident investigation in aviation. We need more of this in healthcare. #Quality2018
Problems with healthcare investigations. #Quality2018
What can we adapt from aviation? Lots! Greater HF/E understanding and application is key. @hypoxicchicken
Which method? There are lots! Experienced investigators use more than one. All trying to do the same thing-moving away from the pointy end to the blunt end. #Quality2018
Which recommendations are likely to be more effective vs which are easier/cheaper? #quality2018
Lessons learnt? Independence is key. As is hearing people's stories-staff, patient, family, bystanders etc. #Quality2018
More lessons learnt. @hsib_org is noticeably different and separate, even though paid for by the same taxpayer. The public appreciates these differences, the independence, and having their stories heard. #Quality2018
What would they do differently? #Quality2018
Keys to success. #Quality2018
Yes, we can learn from aviation, but...#Quality2018
