Ted Baker, chair of the Health Services Safety Investigations Body, argues that systems that cannot tolerate honest accounts of fallibility cannot learn.
The NHS risks slipping backwards on patient safety because of the tension between what we now know about safety and how systems behave when pressure mounts.
In a blog, Ted Baker, chair of the Health Services Safety Investigations Body (HSSIB), writes that it is fair to say that there has been “a real and welcome shift” in how patient safety is understood.
“The language has changed. There is broader acceptance that harm is rarely the result of a single individual failure, and that learning requires curiosity, systems thinking, and psychological safety,” he writes, but he warns that progress in safety is not linear, and it is never guaranteed.
He points out that one of the consistent lessons from safety investigations, in healthcare and in other high-risk sectors, is “how easily systems revert to old patterns under stress”. This is not because people stop caring, but because familiar responses feel safer when uncertainty becomes uncomfortable.
Harm, he argues, is “rarely caused” by dramatic failures. Rather, it emerges from everyday conditions that only become visible after the event.
Baker also makes clear that while safety and quality are related, they are not the same.
“Treating safety as merely one component of quality, or concluding that good quality outcomes indicate safety, risks obscuring systemic hazards and creates false reassurance,” he writes.
The biggest danger is not that medical institutions reject modern safety thinking outright, but that it is adopted superficially.
“The lesson is clear: systems that cannot tolerate honest accounts of fallibility cannot learn; and systems that cannot learn will not be as safe as they should,” he writes. “When the system is under pressure, it is not the time for retreat. It is when we need to hold our nerve,” he concludes.
