When something goes wrong, does the organisation ask what it needs to learn, or how quickly it can show that it has acted? Steve Franklin explores whether our emotional “Chimps” are shaping leadership decisions.

Martha’s Rule is changing care when patients deteriorate and concerns go unheard. Its deeper value lies in what every activation reveals about the safety of the system.

Using George Eliot’s candle metaphor and Daniel Kahneman’s WYSIATI principle, Katie Franklin explores how partial perspectives shape judgement, why blame culture restricts learning, and how psychological safety, diversity and just culture help organisations see more clearly

Poppy Russell’s preventable death and her family’s response ask a wider question of the NHS: do we treat listening as a courtesy, or as a safety intervention? This article connects compassion, PSIRF, family liaison, candour, human factors and good governance.

A listening organisation does more than invite people to speak. It hears weak signals, responds with curiosity and acts before warning becomes harm.

Healthcare has incident reporting, risk registers, audits and committees. This practical guide explains how to connect them into a safety management system aligned with PSIRF, CQC well-led expectations, quality improvement and board governance.

Discover how LEGO® SERIOUS PLAY® helps healthcare teams explore complex problems, strengthen reflection and turn insight into practical action across PSIRF, human factors, patient safety, governance, strategy, coaching and mentoring.

Through Tom Hamilton’s story in East of Eden, Katie Franklin asks whether the second victim concept should extend beyond healthcare professionals to family caregivers and others affected by unintended harm.

Healthcare board members reviewing evidence before making a governance decision

What can a disputed football goal teach us about patient safety and board governance? This article explores why measurable evidence is not always the complete picture, and why boards need to combine hard data with weak signals, staff experience and soft intelligence.

The Thirlwall Inquiry makes powerful recommendations on safeguarding, governance and NHS management. This article asks how the NHS can strengthen accountability without weakening systems learning, psychological safety or PSIRF.

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.

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.

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.

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

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.

What can leaders learn from Monkey D. Garp? Exploring mentorship, values-based leadership, speaking up cultures and organisational learning through One Piece.

What can Monkey D. Luffy teach us about leadership? Exploring servant leadership, organisational culture and human factors through One Piece.

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.