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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.


Healthcare risk management and patient safety: why yesterday’s controls may not protect tomorrow
Yesterday’s successful control may not protect tomorrow’s patient. Steve Franklin explores ergodicity, complex systems and Taleb’s risk principles, with practical implications for PSIRF, healthcare risk management and board assurance.

Steve Franklin
17 hours ago


Unauthorised access to health records: why punishment alone is not a patient safety strategy
Recent NHS record-access cases demand accountability. This article asks what system owners, boards and digital leaders must do before a breach creates another victim.

Steve Franklin
5 days ago


Are Our Chimps Running the Organisation? Emotional Decision-Making, Human Factors and Learning Culture
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.

Steve Franklin
Oct 19


Martha’s Rule: listening as a safety system, not a safety net
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.

Steve Franklin
Oct 1613 min read


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

Steve Franklin
Oct 99 min read


When the HIPPO speaks
Healthcare board members reviewing evidence before making a governance decision

Steve Franklin
Sep 2213 min read


When Presence Changes the System
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.

Steve Franklin
Sep 1717 min read


Ambient Voice Technology in the NHS
Ambient voice technology could return valuable time to clinicians and patients. But as AI scribes become more accurate, human checking may become less reliable. This article examines the changing risk profile through Human Factors, behavioural science, inclusive design and DCB0160 clinical safety.

Steve Franklin
Sep 1120 min read


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
Sep 1013 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


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


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
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