Cambridge Analytics – Where patient safety went next!

On Wednesday evening I am coming back up the coast while the sun goes down over Anglesey. Three days of learning and reflection with the HealthFoundation’s Improvement Science Fellows in Cambridge. This is an annual get-together of specialists in Improvement Science now hosted by THIS institute. The careful analysis and development of new solutions for patient... Continue Reading →


The James Reason Swiss Cheese Failure Model in 300 Seconds

And a great summary about systems approach to failure.

What's the PONT

James Reason Swiss Cheese Model. BMJ, 2000 Mar 18:320(7237): 768-770
James Reason Swiss Cheese Model. Source: BMJ, 2000 Mar 18:320(7237): 768-770

This week I’m at the Cardiff pilot of Practical Strategies for Learning from Failure (#LFFdigital), explaining the Swiss Cheese Failure Model in 300 seconds (5 minutes).

In the event of failure (ha ha ha, I couldn’t resist that), this is what I’m aiming to cover….

The Swiss Cheese Model of Accident Causation (to give it the full name), was developed by Professor James T. Reason at the University of Manchester about 25 years ago. The original 1990 paper,“The Contribution of Latent Human Failures to the Breakdown of Complex Systems”, published in the transactions of The Royal Society of London, clearly identifies these are complex human systems, which is important.

Well worth reading is the British Medical Journal (BMJ), March 2000 paper, ‘Human error: models and management’. This paper gives an excellent explanation of the model, along with…

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Top 3 lessons learnt from healthcare improvers worldwide: the International Forum 2018

Digested read of a BIG conference! And don’t forget to follow Sara Riggare on Twitter!

NIHR CLAHRC Northwest London Blog

The International Forum on Quality and Safety in Healthcare 2018 took place in Amsterdam, the Netherlands, on 2-4 May 2018. The International Forum is a biannual event organised by the BMJ and the Institute for Healthcare Improvement (IHI). It sets out to connect healthcare practitioners and leaders from across the globe, sharing improvement ideas and promoting research on quality and safety, with the aim to improve outcomes for patients. Dr Julie Reed, Rachel Matthews and Sophie Spitters attended representing the NIHR CLAHRC Northwest London (NIHR CLAHRC NWL) team. We attended the event with two main purposes; to share some of the NIHR CLAHRC NWL learning we had synthesized and to develop our thinking by learning from and with others. And developing our thinking we did! The International Forum, with over 3000 attendees, provided a fruitful environment: to get feedback on our work; to listen to experts; and to have friendly…

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