Yesterday was our @ClinicalHF seminar on safety and human factors in healthcare asking “why is it so difficult?” A thread 🧵 providing a small number of examples of what our speakers identified as barriers to learning and improvement….1/9 “When NHS organisational performance is challenged it’s met by a search for more data……rather than confronting reality”. We have lots of data, inc the narrative of disaster, but action is hidden amongst siloed players none of whom take full responsibility for any one thing 2/9

Took yesterday to read the @DOckendenLtd report. The scale and extent of death & injury is appalling. The behaviours reported are unacceptable. That staff withdrew statements very recently is deeply disturbing. But this is not about one Trust 1/5 Nationally the NHS, professional bodies etc need to identify what behaviours are more likely to lead to optimum outcomes & which ones are commonly present in disasters. And how the better behaviours can be encouraged by the systems that influence the frontline. 2/5 #humanfactors

For #WorldPatientSafetyDay myself & @PatrickWaterso1 have some thoughts about human factors & maternity. @PatrickWaterso1 is one of the @ClinicalHF Trustees & expert, he’ll be tweeting about systems, here I’ll share reflections about non-technical skills 1/ It’s #WorldPatientSafetyDay In maternity tragedies we hear “teamwork” is the issue. But what is teamwork? I’ve experienced excellent teamwork, learnt about it, trained it, examined others in it & been examined in it myself. But……. 2/