Embedding human factors science

On many occasions in these pages over the last few years, we have reviewed activity on patient safety in the NHS and healthcare more generally, always taking the view that professional staff and others working in healthcare have no intention of causing harm to patients; indeed it is very rare.

So, has the culture of the NHS changed since the dark days after Robert Francis made his 290 recommendations? ¹ At best, change is slowly occurring but as Tony Blair memorably likened the organisation to an oil tanker making a very slow turn, there is change, there is movement and action within this complex and multi-faceted organisation. Despite the current financial pressures there are good signs that risk is being better managed and some key changes are happening which will affect patient safety.

Don Berwick and his National Advisory team on the safety of patients in England² made a significant number of recommendations following a review of patient safety in NHS, not least that staff are not to blame for the problems which exist around patient safety. They recorded that it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems. They also cited that improvement requires a system of support: the NHS needs a considered, resourced and driven agenda of capability – building in order to drive continuous improvement.