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As in previous years, it is certain that under-reporting is significant. Reporting rates in some of the higher usage Trusts/Health Boards vary twentyfold. Given the cultural, resource and procedural similarities of these organisations, it is highly unlikely that the error and mishap rate varies by anything like this much, so reporting rates are likely to play a large part. One area where this is likely to have greatest impact is in the reporting of near misses, the most fertile learning area. The leading causes of transfusion-related incidents are, again this year, ‘human factors’ related, with procedural failures and flawed decision-making contributing in large measure. While decision support tools and information technology have gained some traction, and continue to help us progress in these areas, their universal adoption remains some way off. Until these are more widespread, we continue to rely on education and peer pressure to encourage best practice. A ‘human factors’ approach is key to understanding why errors and accidents continue to occur, despite, in many cases, adequate training, knowledge, expertise and currency. Those areas of hospitals which are under greatest stress and pressure, for example, emergency departments, continue to report a year on year increase in errors. Despite this, transfusion remains very safe indeed,with the risk of serious harm being 1 in 17,884 and death 1 in 135,705 transfused components in the UK.

The full impact of COVID-19 has not yet been realised, but what we do know is that we have been navigating with no roadmap or star to guide us. In terms of the three psychological phases of a crisis, we have worked through the initial state of ‘emergency’ where we have had (largely) shared goals and an urgency that made us feel energised, focused and even productive. However, this phase feels like it is in its descendancy and most of us are now in the next phase of ‘regression’ where the future feels uncertain and we have lost that sense of purpose. In my work with colleagues from across health and social care to understand what phase three ‘recovery’ looks like in workforce and wellbeing terms, it is clear that both aspects are starting to get the focus they always should have had but maybe not in the way we would have expected. It has not been cries of ‘more’ staff or money that have been echoing through the corridors, but the cry for ‘different’ and the freedom to make decisions without the shackles of bureaucracy and hierarchy holding the tide of necessary change at bay. In the past, workforce planning has had little shared meaning, and has often been more recruitment planning for a continuation of the same as opposed to thinking about what we need from our teams in terms of availability, skills, expectations, roles and the delivery of care designed around the person receiving it. Wellbeing seemed to be something that only HR considered if there was a staffing issue or high sickness, or even more cynically a poor outcome in survey results, resulting in lots of workshops, fabulous plans, but very little sustainable change. In the initial stages of the pandemic, I worked with a number of acute teams to look at staffing in the short term to face the initial onslaught of COVID-19. This meant looking at variation and where we could adjust care levels safely, planning to deploy a moderated skill mix of staff, and working through the cost of plugging gaps in largely traditional models of care using temporary and volunteer staff, with the hope that the 20% sickness rate wasn’t breached too often leaving us exposed to the hazards of unblocked holes in the workforce. This was acknowledged as an unsustainable and haphazard way of providing care for both staff and patients, which after the ‘emergency’ phase results in burnout, higher sickness, increased turnover, and certainly lacks in the resilience required to continue to manage COVID-19, non-COVID urgent care, elective care and the wellbeing of staff and carers. So, what do we need to do as we plan for recovery, or more precisely ‘post traumatic growth’? Despite an apparent increase in interest in joining the nursing profession since the start of the pandemic, the reported 40,000 gap in nursing numbers is not going to be closed overnight, so it seems that planning for different and capturing and capitalising on the innovation that has flourished in some areas is the only way forward. How do we do this? As an example, let me turn your heads to colleagues in social care who have known for some time that their current state was unsustainable. This has been compounded by COVID-19 and the (inevitable) delayed recognition by government of the essential role of social care in protecting the NHS and some of our most vulnerable people. Therefore, they chose to do for some what is unthinkable – they took their nurses away from direct patient care. In some of the teams I work with there was an expectation that they would have 50% of staff available to be deployed, and would have slower and more limited access to other services to support – including temporary staffing or volunteers. They collaborated swiftly both within and across organisations, changed models of care completely based on some of the data collated by Establishment Genie, and moved to a model of all registered nurses in a supernumerary supervisory role, providing support to staff in their own care home directly and also in other homes via ‘virtual’ collaboration, and using technology to connect, share, teach and learn ‘on the job’. This of course questions the future role of the nurse in these homes but is also an example of how we all may need to re-think roles and responsibilities to meet the challenges of today and the future in order to keep the people in our care – patients, residents and staff – safe. As we begin to reorient, revise our goals and focus on moving beyond rather than on just ‘getting by’, it is important that we look at all settings of care so we can learn from excellence, build on the best, and support a faster response in the future if required. The response to COVID-19 for many has been an example of how a system succeeds in varying conditions; a ‘Safety-II’ approach where humans are the necessary resource for system flexibility and resilience. We need to take the time to understand where things have gone right, to celebrate and acknowledge this, and then co-create a health and social care system that people want to work and be cared for in.

Ideas about resilient systems are now becoming better known in the healthcare community, but the most common question asked is “this is great but how do I put it into practice?” CARe QI provides the answers. The aim of CARe QI is to help people to apply the insights of resilient systems and ‘Safety II’ to the design, implementation and evaluation of quality improvement interventions. It is a structured collection of information, tools, guidance and documents that helps you to develop interventions to strengthen system resilience and in turn improve quality and safety. In the handbook you will find an overview of the arguments for improving quality through resilience, followed by step by step guidance in applying the method and downloadable worksheets to help you to document your own project. There are four main steps to CARe QI – setting up the project, capturing work as done, describing resilience in everyday work and choosing resilience interventions and outcome measures. The foundation of CARe QI is that you understand your clinical system in depth before starting to design and implement interventions.

This report, Hearing and Responding to the Stories of Survivors of Surgical Mesh, describes how restorative justice approaches were used to uncover the harms and needs created by surgical mesh use in New Zealand. The actions that consumers and healthcare stakeholders indicated would restore well-being, trust and safe healthcare in New Zealand are included. Skilled facilitators used restorative practices to create a safe space for consumers and health professionals to tell their stories. The same approach supported collaboration between multiple agencies so they could act for repair and prevention. The team that co-created the project includes academics, consumers, facilitators and New Zealand's Chief Clinical Officers. Formal research will evaluate the project next year and consider findings in the context of resilient healthcare systems

In this remarkable documentary, you can follow Kym Bancroft and Sidney Dekker in one organisation's (Urban Utilities) successful adoption and implementation of Safety Differently principles.