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Tom Rose
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Profile Information
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First name
Thomas
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Last name
Rose
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Country
United Kingdom
About me
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About me
I'm working on a solution to the 'error' situation in the NHS
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Organisation
University of Birmingham
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Role
Research Fellow
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Content Article Comment
The same should applies to the delivery of healthcare in our NHS but it very often doesn't.. -
Content Article Comment
ABHI Patient Safety System Foundations: A Call for Action (12 December 2025)
Tom Rose commented on Mark Hughes's article in Leadership for patient safety
- Patient safety strategy
- Healthcare
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(and 2 more)
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A SMS is certainly a prerequisite for patient safety in healthcare. The NHS must not go down the track of designing a SMS in each Trust. The NHS SMS must be universal and be designed by people that really understand management systems. A universal management system framework has been in use, Internationally, for many years and in 2023 a version of this MS was developed and published specifically for healthcare. Our NHS should be International leaders on its application in our Trusts. Within the UK, but not the NHS, there is a vast amount of knowledge on this MS that could be used to make our NHS that World leader in patient safety management. WHY ARE YOU NOT INTERESTED NHS?- Posted
- 2 comments
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- Patient safety strategy
- Healthcare
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Content Article Comment
Embedding Martha's Rule into practice—Lessons from the national pilot
Tom Rose commented on Efi Wilson's article in Quality Improvement
- Training
- Healthcare
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'Everyday clinical practice' - is that a documented process? If so it would be easy to integrate Martha’s Rule into everyday clinical practice - that's providing you can achieve compliance!- Posted
- 2 comments
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- Training
- Healthcare
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Content Article Comment
Patient Safety Learning: World Patient Safety Day 2025
Tom Rose commented on Patient Safety Learning's article in Patient Safety Learning
- WPSD25
- Paediatrics
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The NHS has an appalling record on Patient Safety. Nothing changes are investigation recommendations remain un-implemented. Why Patients put up with this situation I don't know. The solution has been around for many years and is well proven in many other organisations. The solution is the implementation of a Management System. The problem is that the NHS think they know better. Over the last 76 years they have proven to us Patients that this is definitely not the case. The stupid thing is that Trusts are using Management Systems already in some areas and they don't even realise it as I've previously illustrated. Is no one brave enough to stand up and say lets at least give it a try. Some Trusts say that they already have a Management System, this just goes to show the total lack of knowledge regarding Management Systems within NHS leadership.- Posted
- 1 comment
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- WPSD25
- Paediatrics
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Content Article Comment
Patient barcode scanning in NHS hospitals: safety, snags and workarounds. A nurse’s perspective
Tom Rose commented on Claire Cox's article in Stories from the front line
- Patient identification
- Technology
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Great post. Process design, process management, and process continuous improvement are so important in healthcare delivery. It all starts and finishes with good, simple, process documentation. Without process documentation process design, process management, and process continuous improvement are not possible; it is a prerequisite. Process documentation is not difficult, I've talked about my preferred method on many occasions. What is important is that the process documentation represents 'Work as done' and that 'Work as done' is the same as 'Work as imagined'. I just don't understand how they are allowed to be different in the NHS. There can be no patient safety if this is the case. The solution is not 'rocket science' and does not require any more 'research' papers; it's basic stuff.- Posted
- 4 comments
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- Patient identification
- Technology
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Content Article Comment
PSIRF glossary (Tavistock and Portman NHS Foundation Trust)
Tom Rose commented on Patient Safety Learning's article in Patient Safety Incident Response Framework (PSIRF)
- PSIRF
- Investigation
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A vary useful list. Thanks- Posted
- 1 comment
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Content Article Comment
Never Events: The Big Debate
Tom Rose commented on Patient-Safety-Learning's article in Patient safety in health and care
- Never event
- Consultation
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Are the slides available please?- Posted
- 3 comments
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- Never event
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Tom Rose started following National NatSSIPs Network
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Content Article Comment
Locum doctors in the NHS: Understanding and improving the quality and safety of healthcare (31 January 2024)
Tom Rose commented on Patient Safety Learning's article in GP and primary care
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Better process visibility/documentation would help. The new British standard, BS ISO 7101:2023 would help with this. Currently it's a case of the blind leading the blind. Documenting healthcare processes is not difficult if it's kept simple. It would be a big step towards a Learning Health System.- Posted
- 1 comment
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Content Article Comment
Can you measure safety? Part 1
Tom Rose commented on NMacLeod's article in Improving patient safety
- Safety management
- System safety
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I agree that the NHS's version of quality is not sustainable nor effective. For WAD to equal WAI in the NHS will take a lot of work and careful design. The current situation with WAD must change, and, I should add, WAI. I'm looking forward to Parts 2 and 3. Thanks.- Posted
- 3 comments
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- Safety management
- System safety
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Content Article Comment
Can you measure safety? Part 1
Tom Rose commented on NMacLeod's article in Improving patient safety
- Safety management
- System safety
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The NHS is a long way from the aviation industry when it comes to safety and you have hit the nail on the head with this blog. A solution for the NHS will not be found until two two conditions are first met. For simplicity I have come up with two formula. Fist: WAD=WAI, and second: QI=CI. There is a great deal of change required for the NHS to meet these two conditions, far too much to show here. WAD is Work as Done. WAI is Work as Imagined. QI is Quality Improvement as interpreted by the NHS, and CI is Continuous Improvement. Once these two conditions are met then the NHS can start to implement three, universally recognised systems. These are Process Management System (PMS), Quality Management System (QMS) and finally a Safety Management System (SMS). Clinicians', on there own, will not achieve this, they need to seek help from outside the NHS.- Posted
- 3 comments
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- Safety management
- System safety
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Tom Rose started following Claire Cox
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Content Article Comment
HSSIB video: Introduction to safety management systems (16 October 2023)
Tom Rose commented on Patient Safety Learning's article in Improving systems of care
- Safety management
- System safety
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'Health and Care processes' and 'assuring processes are safe' are mentioned during the video. Lots of work required here in the NHS. Are you talking about 'work as imagined' or 'work as done'? because in the NHS they are very much not the same thing. You can't design a SMS without Process Management. You will find that all the industries that you listed above have very strict Process Management Systems as the key foundation to their SMSs.- Posted
- 1 comment
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- Safety management
- System safety
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Content Article Comment
What is a ‘safety management system’? A blog by Norman MacLeod
Tom Rose commented on NMacLeod's article in Improving systems of care
- Safety management
- System safety
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I'm working on the design for a Quality Management System with an integrated Safety Management System for the NHS. It's proving to be hard to get support for this as the NHS think that they have already got quality and safety covered.- Posted
- 1 comment
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- Safety management
- System safety
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Content Article Comment
This is a great blog. very well done. Fantastic imagination in putting it together. Work-as-done is so important. Much more important than work-as-imagined as this is very rarely to current practice. Have you seen my Roadmap and Framework for change?- Posted
- 4 comments
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- PSIRF
- Investigation
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Content Article Comment
Putting the writing on the wall: Explaining work as imagined vs work as done (by Claire Cox)
Tom Rose commented on Claire Cox's article in Process improvement
- Staff factors
- Process redesign
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https://www.eventbrite.co.uk/e/quality-management-in-the-nhs-tickets-696649366007?aff=oddtdtcreator&utm_campaign=Informz&utm_medium=Informz&utm_source=Email Join the webinar where I'll be talking about my ideas for healthcare- Posted
- 10 comments
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Content Article Comment
Putting the writing on the wall: Explaining work as imagined vs work as done (by Claire Cox)
Tom Rose commented on Claire Cox's article in Process improvement
- Staff factors
- Process redesign
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It is that very tactic that I have been working on. There is no simple solution but never-the-less a solution is required and quickly.- Posted
- 10 comments
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