Tomorrow is #WorldPatientSafetyDay and my son’s 10th birthday, a milestone which has given me reason to pause and reflect. What have I learned in a decade? A thread... 1/

Change is slow. 2/

I’ve learned encouraging change at an individual level is, relatively speaking, easy. Clinicians are human. The vast majority do their utmost to provide good, safe care in often challenging circumstances. I have been humbled by clinicians’ willingness to listen. 3/

System change is altogether more difficult. Both within specialties and within the healthcare system as a whole. Why? A determination to protect reputations hobbles organisations’ ability to listen and learn - and to act on that learning. 4/

After a patient safety failure it isn’t easy for clinicians and managers to listen to critical feedback. I understand. But I wish more organisations understood how hard it is for harmed patients and their families to hear what may be said when organisations are on the defence. 5/

If only those organisations would hear what patients want more than anything else: for others not to experience similar harm. 6/

Moreover, listening is a key aspect of patient safety long before working through the aftermath of an error. All too often there is failure to listen to patients at the time when things go wrong. 7/

To not listen isn’t only a failure to respect a patient. Without listening, clinicians lose a vital source of information, whether the patient themselves or their family. Hearing what is said, and how, contributes to situational awareness. It may alert someone to check... 8/

A caregiver’s failure to listen greatly compounds patients’ negative experience when things go wrong. And yet patients and their families often blame themselves for not getting heard. This is especially heartbreaking to hear in the most devastating cases. 9/

All the technical skill in the world doesn’t make a clinician safe. Clinicians cannot guarantee they will deliver safe care unless they develop their non technical skills. Unless they listen with the intent to hear and to understand. 10/

A woman’s voice is as valid as a man’s. A decade ago I naively thought both were heard equally. 11/

A decade ago I hadn’t given any thought to non technical skills of doctors. In fact I thought something must have technically been done wrong at the time of my son’s birth. How wrong I was. 12/

A decade ago I had still to learn how difficult it is to give constructive feedback in healthcare. Yet if we could learn from the ‘near misses,’ we could avoid some of the heartbreak. For everyone involved. 13/

A decade ago I became briefly cynical. Now I am more determined than ever to see the good, to believe people go into medicine for the right reasons. Thank you to everyone who has restored my faith. 14/

Finally, to those patient safety advocates who speak so others might not suffer, I am inspired by your bravery. I am privileged to know some of the most lovely, strong, decent and kind people one could ever hope to meet. /end #WorldPatientSafetyDay

Comment above to you all x @MartinBromiley @morrish_scott @Mothers_Inst_UK @JonoBroad @JamesTitcombe