risks and prevention, a mindfulness of the complexities of systems in which they work and on which they rely.


Those of us working in healthcare have become dangerously complacent  acknowledge the risks.


The primary focus at all levels must be on patient safety. Governing boards must recognise their unique obligations to create and sustain a robust patient safety culture in which questions are asked proactively      patients. Sensitivity to operations in healthcare begins with trusting one another and listening and valuing the contributions of all stakeholders.


2. Reluctance to simplify: avoidance of simplistic explanations for risks or failures and a commitment to delve deeply to understand sources of risk and vulnerabilities within systems.


     to understand the complexities of our processes and the confounding  


When individuals make mistakes, and we all make mistakes, there are often multiple contributing factors. Each one warrants thorough understanding


“Those of us working in healthcare have become dangerously complacent about our environment and our own behavior. We often don’t see or acknowledge the risks.”


in order to design improvements, as do the interconnections among factors. A premium must be placed on transparency and encouraging in-depth analysis. Sadly, in many settings we have not yet achieved this mindset.


3. Preoccupation with failure: a focus on predicting and eliminating harm  go wrong and that near-misses and complaints are opportunities to learn and improve.


In healthcare, we tend to view ourselves as benevolent and that viewpoint      yet getting clinicians to wash properly, in some settings, is a seemingly insurmountable challenge.


  clinicians and patients/family members, represent enormous sources of


Annual 2014 | HEALTHCARE RISK MANAGEMENT REVIEW | 31


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