Reacting to a never event is difficult and often embarrassing for staff involved. East Lancashire Hospitals NHS Trust has demonstrated that treating staff with respect after a never event, creates an open culture that encourages problem solving and service improvement. The approach has allowed learning to be shared and paved the way for the trust to be the first in the UK to launch the patient centric behavioural noise reduction strategy ‘Below ten thousand’.
Hewitt TaylorJ2013Understanding and managing change in healthcare: A step by step guide Hampshire Palgrave Macmillan
14.
Institute of Medicine1999To err is human: Building a safer health systemWashington,
National Academy Press
15.
KapurNParandASoukupTet al2015Aviation healthcare: A comparative review with implications for patient safetyJournal of The Royal Society of Medicine7 (1)
16.
LeapeL2008Interview with Lucian Leape MD HFACHE, Adjunct Professor of Health Policy, Department of Health Policy and Management, Harvard School of Public HealthJournal of Healthcare Management53 (2)
National Patient Safety Foundation’s Institute for Healthcare Improvement2013Through the eyes of the workforce: Creating joy, meaning and safer healthcare Available from: http://www.npsf.org/?page=throughtheeyes [Accessed February 2018]
19.
National Patient Safety Foundation’s Institute for Healthcare Improvement2015Shining a light: Safer healthcare through transparency Available from: http://www.npsf.org/?shiningalight [Accessed February 2018]
National Patient Safety Agency, National Reporting and Learning Service2009Saying sorry when things go wrong. Being Open: Communicating patient safety incidents with patients, their families and carers Available from: http://www.nrls.npsa.nhs.uk/beingopen/?entryid45=65077 [Accessed February 2018]