Kenneth Catchpole

Guest Speaker

Despite 25 years of global interest and effort in patient safety, progress has been slow. The promise that this would usher in new collaborations between engineers, safety scientists and clinicians did not materialize. Traditional clinical views of performance being solely based on the intent, training and skill of practitioners has been difficult to change. Fundamental misconceptions – such as linear determinism, equating error and harm, the ‘human factor’ as a cause – are repeatedly made, with Just Culture, High Reliability, Lean 6 Sigma, Resilience all being misused or misinterpreted. However, a slow but steady infusion of human factors, complexity, and safety science has been guiding clinicians and healthcare leaders towards a very different view of patient safety, and of the causes of success and failure in healthcare systems. Though many may not have realised it yet, this has both awkward and profound implications for care