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Change the System, not the people: Neil Spenceley at DFTB19


Neil Spenceley is a paediatric intensivist and is the National Lead for Paediatric Patient Safety.

This talk is packed with nuggets that will change the way you view the world in which you practice. Neil explains Safety 1 and Safety 2 thinking. The talk is wide-ranging and covers poor behaviours in healthcare both at a personal level and at an institutional level.

If you just want to read one key paper to get you started then read this one from paediatric surgeon, Lucian Leape.

Leape LL. Error in medicine. Jama. 1994 Dec 21;272(23):1851-7.

If you want to read two papers (and we suggest you should) then download this one too.

Hollnagel E. Human error. InPosition paper for NATO conference on human error 1983 Aug.




Doodle medicine sketch by @char_durand 


©Ian Summers



This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

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Selected References

Cook RI, Nemeth CP. “Those found responsible have been sacked”: some observations on the usefulness of error. Cognition, Technology & Work. 2010 Jun 1;12(2):87-93.
Katz D, Blasius K, Isaak R, Lipps J, Kushelev M, Goldberg A, Fastman J, Marsh B, DeMaria S. Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ quality & safety. 2019 May 31:bmjqs-2019.
Kellogg KM, Hettinger Z, Shah M, Wears RL, Sellers CR, Squires M, Fairbanks RJ. Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?. BMJ Qual Saf. 2017 May 1;26(5):381-7.
Hollnagel E, Amalberti R. The emperor’s new clothes: Or whatever happened to “human error”. InProceedings of the 4th international workshop on human error, safety and systems development 2001 Jun 11 (pp. 1-18). Linköping University.
Peerally MF, Carr S, Waring J, Dixon-Woods M. The problem with root cause analysis. BMJ Qual Saf. 2017 May 1;26(5):417-22.
Wu AW. Medical error: the second victim: the doctor who makes the mistake needs help too. BMJ Online 2000



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