Now here is an interesting development.
For years I have been talking about systems processes, fatigue mitigation, workplace health and safety laws, safety cultures and kindness.
When I was the Workplace health and safety representative in theatres, my main observation was that the overburden of workload pressure resulted in the large amount of harmful stress echoing around in the department.
The fact I was most overwhelmed with was that nobody else seemed to be able to see it.
It was so pervasive that it was invisible, just like air is invisible, and yet it is everywhere.
What is so interesting today is the news that the ongoing investigation into the Lucy Letby saga is now headed down a path of investigating contributory negligence on the part of Health executives.
Suddenly executives seem less immune from direct responsibility for decisions they make with respect to how a hospital operates.
Errors with a root cause directly attributed to fatigue?
Errors with a root cause directly attributed to production pressure?
Errors with a root cause directly attributed to the fact that the culture does not allow them to say “No”?
In a culture of blame, errors are the sole property of the person who makes the mistake.
We stop investigating as soon as we have found who to blame.
And yet, there is rarely an incident I have ever seen where the problem does not go much deeper than that.
Pete!
