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Patient Safety, Human Factors and PSIRF Insights for Healthcare Organisations
Featured Articles.
Start with our practical guides to PSIRF, human factors in healthcare, systems-based learning, patient safety investigations and healthcare governance.
Beyond Blame: Can Healthcare Really Build a Just Culture When the Outside World Still Wants Someone to Blame?
When something goes wrong in healthcare, how can organisations recognise system pressures while responding fairly to scrutiny? This article explores how human factors, PSIRF, restorative accountability and effective governance can help healthcare organisations move beyond blame without removing accountability.
Steve Franklin
21 hours ago
PSIRF, Human Factors and the Resource to Turn Patient Safety Learning into Action
The Patient Safety Incident Response Framework asks healthcare providers to learn proportionately and improve meaningfully. This article examines how NHS and independent healthcare leaders can use Human Factors, clinical governance and corporate governance to match expertise to the work, improve value and prevent AI from shifting the bottleneck from producing information to reviewing and acting on it.
Steve Franklin
2 days ago
When the Ridiculous Becomes Normal: Why Diverse Perspectives Matter
When questionable behaviours become familiar, we can stop noticing how inequitable, ineffective or unsafe they are. Katie Franklin explores how humour, fresh perspectives and constructive challenge can expose the ridiculousness we have accepted as normal, helping organisations strengthen workplace culture, inclusive work design and safety.
Katie Franklin
Aug 27
Browse by Topic.
Explore articles by theme: Human Factors in Healthcare; PSIRF Training and Implementation; Patient Safety Learning and Investigations; Governance, Risk and Assurance; Leadership, Culture and Improvement; Digital Health, Usability and Work Design.
Beyond Blame: Can Healthcare Really Build a Just Culture When the Outside World Still Wants Someone to Blame?
When something goes wrong in healthcare, how can organisations recognise system pressures while responding fairly to scrutiny? This article explores how human factors, PSIRF, restorative accountability and effective governance can help healthcare organisations move beyond blame without removing accountability.
Steve Franklin
21 hours ago
PSIRF, Human Factors and the Resource to Turn Patient Safety Learning into Action
The Patient Safety Incident Response Framework asks healthcare providers to learn proportionately and improve meaningfully. This article examines how NHS and independent healthcare leaders can use Human Factors, clinical governance and corporate governance to match expertise to the work, improve value and prevent AI from shifting the bottleneck from producing information to reviewing and acting on it.
Steve Franklin
2 days ago
When the Ridiculous Becomes Normal: Why Diverse Perspectives Matter
When questionable behaviours become familiar, we can stop noticing how inequitable, ineffective or unsafe they are. Katie Franklin explores how humour, fresh perspectives and constructive challenge can expose the ridiculousness we have accepted as normal, helping organisations strengthen workplace culture, inclusive work design and safety.
Katie Franklin
Aug 27
The NHS Quality Strategy 2026: What Does It Mean for Patient Safety and PSIRF?
On 14 July 2026, NHS England published the new Quality Strategy for NHS-funded care in England on behalf of the National Quality Board. It describes a 10-year approach intended to make quality the organising principle for NHS-funded care. The strategy applies across the system, not only to NHS trusts, and places safety, effectiveness and experience at the centre of how quality should be understood, managed and improved. At first glance, some of this will feel familiar. Safety
Steve Franklin
Aug 26
The Hidden Story: How Leaders Help the Pieces Fit
What if the person labelled as "difficult" is actually responding to challenges you cannot yet see? Using Nami's story from One Piece, this blog explores Human and Organisational Performance (HOP), safety leadership, human factors and safety culture. It examines how leaders can move beyond first impressions, understand the stories behind behaviour, and design work around people to build stronger teams, better performance and safer, more resilient organisations.
Steve Franklin
Aug 21
Who Controls the Past? Investigation, Patient Safety and the Power of the Pen
What does George Orwell's Nineteen Eighty-Four have to do with healthcare investigations? More than you might think. Investigators hold the pen, shaping how events are understood and what organisations learn. Exploring PSIRF, Human Factors and Safety-II thinking, this article examines the power of investigative narratives, the risks of confirmation bias and premature closure, and why meaningful patient safety learning depends on curiosity, evidence and systems thinking.
Steve Franklin
Aug 12
Practical Resources.
Downloadable prompts, checklists, tools and board assurance questions to help teams move from insight to practical action.
Manchester Patient Safety Framework- Domain 1-Commitment to Overall Continuous Improvement
Manchester Patient Safety Framework- Domain 2- Priority Given to Safety
Manchester Patient Safety Framework- Domain 3- System Errors and Individual Responsibility
Manchester Patient Safety Framework- Domain 4-Evaluating Incidents and Best Practice
Manchester Patient Safety Framework- Domain 5- Learning and Effecting Change
Manchester Patient Safety Framework- Domain 6- Communication About Safety Issues
Manchester Patient Safety Framework- Domain 7- Recording Incidents and Best Practice
All Posts
Beyond Blame: Can Healthcare Really Build a Just Culture When the Outside World Still Wants Someone to Blame?
When something goes wrong in healthcare, how can organisations recognise system pressures while responding fairly to scrutiny? This article explores how human factors, PSIRF, restorative accountability and effective governance can help healthcare organisations move beyond blame without removing accountability.
Steve Franklin
21 hours ago13 min read
PSIRF, Human Factors and the Resource to Turn Patient Safety Learning into Action
The Patient Safety Incident Response Framework asks healthcare providers to learn proportionately and improve meaningfully. This article examines how NHS and independent healthcare leaders can use Human Factors, clinical governance and corporate governance to match expertise to the work, improve value and prevent AI from shifting the bottleneck from producing information to reviewing and acting on it.
Steve Franklin
2 days ago14 min read
When the Ridiculous Becomes Normal: Why Diverse Perspectives Matter
When questionable behaviours become familiar, we can stop noticing how inequitable, ineffective or unsafe they are. Katie Franklin explores how humour, fresh perspectives and constructive challenge can expose the ridiculousness we have accepted as normal, helping organisations strengthen workplace culture, inclusive work design and safety.
Katie Franklin
Aug 275 min read
The NHS Quality Strategy 2026: What Does It Mean for Patient Safety and PSIRF?
On 14 July 2026, NHS England published the new Quality Strategy for NHS-funded care in England on behalf of the National Quality Board. It describes a 10-year approach intended to make quality the organising principle for NHS-funded care. The strategy applies across the system, not only to NHS trusts, and places safety, effectiveness and experience at the centre of how quality should be understood, managed and improved. At first glance, some of this will feel familiar. Safety
Steve Franklin
Aug 2610 min read
The Hidden Story: How Leaders Help the Pieces Fit
What if the person labelled as "difficult" is actually responding to challenges you cannot yet see? Using Nami's story from One Piece, this blog explores Human and Organisational Performance (HOP), safety leadership, human factors and safety culture. It examines how leaders can move beyond first impressions, understand the stories behind behaviour, and design work around people to build stronger teams, better performance and safer, more resilient organisations.
Steve Franklin
Aug 216 min read
Who Controls the Past? Investigation, Patient Safety and the Power of the Pen
What does George Orwell's Nineteen Eighty-Four have to do with healthcare investigations? More than you might think. Investigators hold the pen, shaping how events are understood and what organisations learn. Exploring PSIRF, Human Factors and Safety-II thinking, this article examines the power of investigative narratives, the risks of confirmation bias and premature closure, and why meaningful patient safety learning depends on curiosity, evidence and systems thinking.
Steve Franklin
Aug 126 min read
Human Factors, Decision Making and PSIRF: What Dobble Can Teach Us About Safer Healthcare
Human Factors in healthcare is fundamentally about understanding how people make decisions within complex systems. Whether we're implementing PSIRF, investigating a patient safety incident, improving medicines management or strengthening clinical governance, the key question remains the same: how do people actually get work done in the real world? Surprisingly, a family game of Dobble provided a useful reminder of why understanding work-as-done matters so much for patient saf
Steve Franklin
Aug 107 min read
Leading from the Front: Garp's Golden Rule
What can leaders learn from Monkey D. Garp? Exploring mentorship, values-based leadership, speaking up cultures and organisational learning through One Piece.
Steve Franklin
Jul 314 min read
Monkey D. Luffy: the Confucian role model you didn’t know you needed.
What can Monkey D. Luffy teach us about leadership? Exploring servant leadership, organisational culture and human factors through One Piece.
Steve Franklin
Jul 314 min read
Absence of Evidence is Not Evidence of Absence: Weak Signals, Patient Safety and Governance
A lack of reporting does not always mean an absence of risk. This article explores weak signals, human factors, PSIRF, governance review and the importance of hearing the right voices in healthcare decision-making.
Steve Franklin
Jul 286 min read
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