Encore Release: The Real Reason Training Alone Cannot Fix Patient Safety

This December, health care leaders from around the world will gather in Phoenix, Arizona, not simply to discuss what must change, but to learn how to change it. At the 2026 IHI Forum, Brook Shills, Dr. Robert Wachter, Dr. Katie Boston Leary, and artist Michael Townsend will challenge how we think about women's health, technology, nursing, equity, creativity and collaboration. Join us December 6th through the night for ideas that sharpen our thinking, relationships that strengthen the work and learning we can carry home. Learn more and register at iHI.org/form. Hello, and welcome back to Turn on the Lights brought to you by iHI, the Institute for Health Care Improvement. I am Philip McAdoo. Today, we're revisiting another one of our most popular episodes. The real reason training alone cannot fix patient safety with Professor Charles Vincent. And the title says a lot. Training matters, we know knowledge matters, but patient safety cannot depend only on asking people to try harder. This conversation reminds us that safety is shaped by the systems people work in, the pressures they carry, and the conditions that either support or undermine care. Safeer care requires more than individual effort. It requires systems designed for safety. This professor Charles Vincent. One of the important continuing frontiers in improving health care is to make it safer. It's still true just by decades of research that we know that health care is a hazardous enterprise. Patient people are trying hard to keep patients safe, but things do go wrong. There is luckily a collection of researchers and advocates around the world now who have been working on patient safety for decades and have developed a tremendous amount of scientific understanding about how things go wrong in medicine and why they go wrong. Our guest today is one of the leading scholars in this field. It's Professor Charles Vincent. Charles is a clinical psychologist who moved his research in the late 1990s into the field of safety and what makes complex things safe and not. He's been a leading thinker in the safety movement in health care and one of the deep students of the psychology of safety. What is the psychological background of human error and how to protect patients through changes in the environment in which the clinicians are working. He's also a close colleague and friend and it's a delight to welcome you, Charles Vincent, to turn on the lights up thrilled to have you. We've been friends and colleagues for many years and I'm really happy to introduce you to our audience. It's a great pleasure, don't. Charles, may you say a few words about yourself first. We can give the formal stuff but tell us about your background and what your activities have been in our nano. I began my career first. I was a nursing assistant for a year which was very instructive in a psychiatric hospital and acquired a lot of responsibility at a very young age which was, and I was just a feckless youth. Then I trained as a clinical psychologist and I worked in the RNHS, the British NHS for several years. Then I became a researcher and my first job was on a project called A Voidable Mishaps in Medicine. It's a very polite title for looking at disasters in the 1980s. Since then, in one way or another, I've been looking at risk, medical error, how to make health care safer, how to improve health care and following a parallel track to you as a researcher. Well, as you too modest to say it, but I'll tell our audience you're one of the really premier researchers and developers of modern approaches to improving and very complex systems including health care. Whatever got you interested in things that went wrong, what drew you into that is a topic to devil yourself too. I was trying to finish a PhD and it was part time. I had no funding. I had, I think, four or five, maybe six different activities, several jobs part time and the whole thing was a nightmare and I needed a job and the job came up in the department in University College London in psychology where I was doing my PhD. The job was on a Voidable Mishaps in Medicine, so it was the study of accidents came about by accident. What's an example of an unavoidable Mishap? What is something you counter that pros into that category? Avoidable, unavoidable, things of either you pick. Okay. So the avoidable, in the original project, which was a very long time ago now, this was funded by a medical legal company, insurance company, but doctors and they were concerned with, particularly with the misfactures, particularly in the emergency department, various maternity cases as well, brain damage children. These were the things that people were concerned with at the time, mainly I think because they were identified because they led to litigation. At that time, we I don't think anybody had any idea of the scale of harm, this is for Lucian Leap and everybody's, before the Harvard Medical Practice study came out. So it was these, these are the sort of incidents people worried about and we did early studies on looking at the medical legal, the legal records and the medical records of babies who had been brain damaged and where cases where obstetricians had judged there was some sort of problem. And very early on, we found that it wasn't random errors. There were themes, lack of supervision, poor monitoring. If you like systems, themes coming through these tragic cases. So this was an early sort of, probably around the time I started to hear about Jim Reason and understand accidents in a different way, but these sort of thematic aspects of the whole thing were quite new, I think at that time, certainly new to me. Jim Reason was the great scholar of human error, he has to be very recently and what was it about Reason's work and his point of view, the culture, culture interest? Well, we too were interested in errors because this is what litigation focused on. This is what the people funding us for interesting, how do you stop these errors? And I suppose psychologists have been interested in, have been studying errors for decades, often with a view to understanding ordinary functioning, but I suppose that was primarily how we were thinking about it. And I went to my boss, Professor Bob Ornery, who was responsible for the project and a wonderful man. He was a friend of Jim Reason's and I went to a meeting in the Royal Society in London where Jim was speaking. And I remember the impact was astonishing on me and many other people. When I heard him just give a completely different account of how things went wrong and talk about latent conditions, the factors that might lead to people making mistakes and that it was not much help, really, people were always going to make mistakes, that's life. But what you could look at was why, were they tired, hungry, were the procedures terrible, how could you improve the teamwork, how could you improve the system overall to make it easier for people to work in? That was basically the idea. And the idea in many industries outside healthcare as, but to hear Jim talk about this was a revelation to me. What was the pre-existing theory you had in your head about errors? Talk about Reason's approach, but what, before a reason, let's say, how were you thinking about errors that you changed, what you heard about this new way to think about it? I do think I thought that there were evidence of bad character or anything like that, as I think people, as is widespread in healthcare, if you made a mad mistake, you must be a bad doctor or bad nurse or whatever. There's no thought of that thinking still around now. There's not much thinking, it's a gut feeling. I don't even ever thought that, but I suppose I would have thought about it that if we were going to improve things, that be a matter of training or a matter of understanding cognition or why particular things happened. And I think that's probably also the kind of thing we were looking at early on were rather particular errors. We became quite unpopular, my friend Peter Driscoll and I was a emergency doctor for discovering that an emergency department in Central London, a junior doctor has missed a third of serious fractures, like broken hip and things like that. One out of three, my goodness. One out of three. Mostly they were picked up later by somebody, but maybe 24 hours, 48 hours later. So it looked like a problem of doctors not knowing what they were doing, though he'd have shown me these x-rays and I couldn't see the breadth fractures, so I wasn't feeling too superior about it. I think later when we looked at maternity, when you look at instance that evolved over several hours, maybe a day or two sometimes, it's always not really about errors. There's quite a story here. And then we've started to understand, need to understand the stories and all the factors that play in. And the whole idea of an era begins to break down when you begin to look at the stories. Tell us a story. What do you mean by a story when you're looking at an error, a mist fracture, a maternity, maternity? Well, I'm no expert. I'll stick with an alternative, not because I'm any kind of expert on this at all. It's a long time since we did these studies, but I suppose when you look at a tragic outcome and an obstetrician, my writer report saying this could all have been avoided. If they just recognized the emergency and done the scissorion, then this baby would be okay, whatever it might be. But then when you read the reports and you read, perhaps read the report. for midwife looking, saying, actually the problem started three months ago. This woman had high blood pressure, whatever it was, and various problems. This was not picked up in the anti-natal visit, and then the woman herself missed this appointment, and then there was a delay getting to hospital. When she did get to hospital, it would be very slow acting on it, and then there was this period when they didn't really monitor her property for several hours, what was going on there, and then they didn't call the senior doctor fast enough. So why did that happen? All of these things start to play in to the eventual problem. Yeah, how do you now really at the pinnacle of the research community on Erid? How do you now think about that series of what we call the mishaps or errors? What would you say is the modern, the informed way to think about that kind of story that you just told them? I suppose I still think about it much in the same way as Jim Reason does. I think not everyone does. I think about it as the questions I ask are different. I think I say, what is it about this system that allows these things to happen? And that's perhaps a more productive question that's saying, why did somebody do this wrong? It's not that I think you can't study people's individual mistakes. I think you can, but they're normally firstly just part of a much bigger picture, and the contribution, especially in something as complex as medicine, when you've got teams of people looking after a patient in almost every environment. The contribution of anyone person is usually relatively small to a tragic event. And also, I don't think I think at that point time we and everybody else were focused on the big events. And that's, I still think that's an understandable and correct. We should give more attention to those events. But I suppose underneath that, I see a background of systems working not quite as they're meant to. And minor problems happening all the time in healthcare, lots of other systems too, but particularly in healthcare, where people I think are quite perhaps compared with other industries, quite tolerant of not following procedures, getting away with it, doing things in a bit of a rush, being tired, being hungry, all of the things that in ordinary life, we would know very well, we'd be underperforming. And I see that sort of continuous background as occasionally giving rise to disasters. And I don't think I saw it that way early on. I thought I saw mostly the big problem. Now I see that system generally is being very vulnerable to problems. If that's not too abstract, no, I think it's, but it is a different way to think. Do you believe, maybe you haven't formed an opinion of this, but do you believe that when things go wrong in medicine today, a diagnosis, mistaken diagnosis, a mist fracture, too much delay that harms the patient? Do we have a culture which is attuned to this system view or is it a culture more oriented toward finding someone to blame and maybe even punishing them or correcting them? Where are we in the development of our understanding of the psychology of error? I suppose it varies from a place to place, from country to country, from culture to culture. It varies from person to person. I suppose in England, I'd say that the idea that we should look much more at the system than the person most of the time is well publicized. It would be quite unacceptable to say that now. And that wasn't true, say 25 years ago. Nowadays it would be ordinary, but it doesn't always happen in practice. And I think often the gut reaction is to find somebody to blame. It's very instinctive. It's a human thing. And I think often when people panic and organize, particularly when organizations get nervous and defensive, then they do some very nasty things, sometimes to their employees. It's very different, I think, to how it was, perhaps years ago. But every clinician knows of colleagues who've been wrongly castigated, if you might say, or I'm badly treated. But it's curious. I don't think that we shouldn't blame people. I think it's much more we blame people for the wrong things. I think hell's cares very odd in responding very badly and oppressively, punitively, if you like, to people making mistakes and being far too tolerant of people behaving badly or disrespectfully or being excessively hierarchical and dominant, which is in itself dangerous. Very tolerant of poor behavior, as you might say, and intolerant of error. That's a rather, I'm caricaturing it. Yeah. Well, the curious situation. Are you willing to say what you mean by a bad behavior, an example of that? And then what is its connection to errors in safety? Let's take a couple of examples. We know, say, if you think about the World Health Organization's Social Safety Checklist, which is now pretty well embedded, I would guess in the UK and in many countries. And I would also think probably that for most young surgeons and anesthes growing up, coming through the system now, it's a very ordinary thing to do. And yet I would also imagine that there's quite a number of senior clinicians who can't be bothered to do it or do it in a way that shows their disdain for running checks that might protect their patients. It just shows you don't know what is the Social Safety Checklist as a work. It's just a series of routine steps checks that are done before an operation, rather analogous if you like to the checks that pilots make before they take off. So you check, you would probably know this better than me, Donald, but you check the identity of the patient, you check they've had the antibiotic at the right time. But you also do some other things like introduce people in the operating theatre to each other if need be, where you should say, which has the effect of perhaps making things a little easier socially. And the particular reason for doing that is that you hope that there's a problem people speak up and feel able to speak up. So to be disdainful about those sort of practices sets a very bad tone in the theatre. It keeps everybody not willing to speak up and clamps everything down. So there's that kind of behavior. Then there's just sort of behavior like being very rude and dismissive to people and domineering and this sort of ordinary things that you see. But it's particularly dangerous in any safety critical environment because safety relies partly on doing things properly and following procedures and all that sort of thing. But that's never enough. And you always rely on a very open communication and people being willing to talk to each other and say, I'm not bit worried about that. Or do you sure that's right? And all this sort of thing. And you can't have that open free communication. If you've got people being unpleasant, disrespectful, nasty to each to it, to junior people, for instance, it's not only unpleasant, it's dangerous. It's a patient, that's how I see it. So what has to be done about it? What helps make things safer on both counts, both understanding the systems view of error and also this issue you're raising about behaviors that it need to be dealt with? Well, on the systems view, I think it's funny, we haven't, we've made a lot of process improvements in the sort of quality improvement, but paid enough attention to say the usability of medical equipment, interfaces, anesthetic monitors, for instance, or the conditions in which people work, you know, poor lighting, noise, distraction, all this sort of thing. These would be system changes, which would help things a lot. On the bad behavior side, I'm no authority on this. I would just like to see less tolerance of it. And I'd like to see it seen by managers, by senior leaders as a safety issue. As I think people would in, people don't like comparisons of aviation, I think it's too crude, but I think it would certainly be seen that way in commercial aviation, behaving, whatever your personality, just behaving in a sort of respectful way, is demanded. It's not, I think health care still has a history of mavericks and people feeling it's okay to behave how they like. Not so much as perhaps it was. You think it's changing. I don't know, you would know better than me, probably. Yeah, yeah. But you should chip in your own examples of done for this, because you'll remember me. Oh, I think you're doing just fine. How they intervene, I would say when behaviors are not okay in terms of deteriorating the climate for safety, you've got to have senior, I think it's correctable, maybe not only, but best by senior leaders who are explicit about the culture that is going to support great patient care. And I think sometimes a little resident reticent to speak up. Indeed, remember my own training. There's almost a sort of bizarre romanticism about the rude Dr. Surgeon who's not here by everyone. The best there is and gets gets to behave anyway they want. I don't have much time for that, but I think it's still a pretty prevalent. Yes, it's one of these bizarre myths. It's artists have to be reckless and unpleasant and treat their husbands or wives badly. It's all part of their greatness, rather than thinking, well, they're great, but they're also awful as people. So your work has been massive and you've done an awful lot. That's been very important. I think would I be wrong to say that some of the centers on this, what you've been talking about, which in our world we will call psychological precursors or psychological safety. It's the psychology ambient environment that relates to the probability that someone will either experience an error or not speak up on there is one. Can you dive into that a little more your own research on what it is you've discovered? I hadn't really worked directly on what would be called psychological safety or safety culture. These are terms that are often used and banded around. I think they have a meaning, but they're quite general, but I think I have, for instance, I used to work in surgery for 10 years, but I've worked in a subject about no surgeries. I'll use some examples from there, because when you break it down, I think the cover of the word culture and the sort of ambiance is it's quite hard to pin down. But once you start doing studies on surgical teams, we used to do studies where we would have observers in the operating theatre and the observers often would be a psychologist and also often a young surgeon, often very experienced, actually, in the operating for ten years. But when they stood at the back and watched, they would often be surprised, well, they saw, even though they knew the environment intimately. So they might be just surprised, perhaps, it might be to do with looking at the way the equipment was laid out that people were moving across wires or the monitor was in the way or that people kept walking in front of the monitor and in front of the anestists between. So they couldn't see the monitor. There's all that sort of ergonomic stuff. They would also begin to notice that communications were not followed up or when people weren't listening or when they were intending to listen but distracted. Or when people were a bit snappy and not really listening, when somebody was saying, look, we've really got this problem here. I need you to pause and worry about the blood pressure or something like that. So this is more than just culture on psychological ambias, but they would begin to see a lot of minor problems which were making life difficult for the people and therefore degrading team performance. And that's what I mean by the sort of background detriment where a team is just, they're not performing badly, but they're on the edge and drifting if you like. So this is interesting. These were people who had worked in that environment for years, but you had, you usually have to take them out of it so that they can see this so they can observe these. We were developing measures of team performance, measures of leadership, communication, coordination and so on. It's been done in other areas. And the people, these surgeons were often doing, or needs this for often doing PhDs or nurses actually as well. So part of it was to actually observe surgical teams actually to watch and to see not what you assume is happening but what is actually happening. And they were surprised not, it's also as if there were things happening that they'd never seen or never encountered. But because, and it's something to do with surgeons or anybody, but if one is busy, if you're busy and you're operating on some one of your managing anesthesia, you can have some sort of situational awareness, but you haven't got the leisure and the mental space to actually watch what's going on. Otherwise, you'd be neglecting your patient. So you have to stand at the back and watch in order to see the whole picture and to see why teams, to observe a team working well or working badly or not so well or fragmenting a bit. And it struck me very much. And they're going to say it's not a point about surgeons. It's a point about how any of us can work in an environment for decades. I'm sure if somebody came to watching me working in the university or certainly watching the university's working a lot of the things you think this is actually ridiculous. Why are they doing it like this? It's that sort of mindset you need to think about safety. Many of the people listening to this conversation are not clinicians. They can't change their own practice. They're mostly encounter healthcare as patients. If you're in that role and you're about to have surgery or encounter, what advice would you give to people now who want their care to be safe for it? But they're on the other side of the desk. Can people do things that make things safer by building on the work of reason and you and other scholars? Yes, it's a big question. I think the first thing I want to say to somebody is that the awareness of all these things is hugely greater than it was when I first started and the training where it is among the professionals. Among professionals. I don't want to give a message of panic. Social outcomes, for instance, have improved dramatically in the last 10, 20 years for many reasons. Safety interventions, technological sorts. So it's not a question of that. And healthcare's placed a great deal more emphasis on safety than in the past. You can see the outcomes for hit operations or whatever it is. And I think when you're in hospital as a patient and if you're feeling very sick, probably the best thing you can do is forget all about all this stuff and let people look after you and get better. I think it's probably more important to ask questions and be very clear before you enter a hospital when you're considering the decision to have an operation to be sure because sometimes surgeons would agree because as patients we push them because we want a cure for whatever and to be cautious about having treatment generally. I'm not cautious in a sort of anxious way but just quiz people a bit. What's this, is this really going to help? What's the best outcome? What's the worst outcome? What could go wrong? What's realistically good? And certainly I think it's a hard thing to do as I know from being asked for being a relative to ask questions if things are missed. And I think often it's that's not so much in the operating theatre but on the ward, nurses are very busy. So drugs have I had my drugs as he has been given his drugs today. Check ask questions but it's trivial. You have to prepare to be a nuisance. But that's probably necessary. I suppose the other thing I'd say for patients this course is that we think a lot about hospitals but I'm also working now with a team on care in the home. So medical error which used to be just for doctors and nurses and other professionals. Patients and families can now make errors because the more complex care goes into the home, the more patients and families are taking on big responsibilities at home. And they too are facing the challenges of keeping their family members safe and not and part of that is managing quite complicated medical equipment. So that's another wider story. Part of this progress that you're seeking to make an understanding and mitigating risks may do with the preparation of health professionals especially young professionals. Is this kind of stuff getting into the curriculum now medical students and nursing students and young people being made aware of the science and do they care? Are you getting positive response negative response? I don't know quite what's happening in medical schools and so on but my impression is that very little of this sort of stuff is in medical schools and nursing schools and what there is rather bureaucratic and it's only perhaps later when people do graduate degrees or get involved in say simulation centers where people are really training with a lot of knowledge of this that there are now quite a lot of clinicians who are very deeply engaged in all this stuff but it probably comes later in their careers I think. Charles in the US I don't know about the UK for sure but one of the theories of making healthcare better including safety is all about payment that we're not paying properly that we're not attaching the correct incentives in this case to patient safety. What would you say to that in terms of its concordance with all we now understand scientifically? You would know a lot more about the payment incentives and the structures and so on and they it's certainly relevant and I would say obviously we have a public funded system that I would say certainly that for us I think it's not so much incentives but I think we managers and executives in the NHS and the British NHS are so focused on money for understandable reasons because that's what they get judged on that's what they get sacked for failing to meet the budget it's not that they don't care personally about safety but professionally I don't think it gets much of a looking and I think there's almost zero discussion of what I would call the trade-off between productivity and safety that if you push more and more patients through a system it's going to get less safe this is not just true in healthcare it's true in railways or oil or aviation or whatever but I think in those other industries my understanding is from colleagues who work in them there's much more explicit discussion of these problems and how to manage it was healthcare we have no barriers really it's just however many patients you can push through push more and no real clinicians may say but it's not an explicit discussion of at what point it really gets dangerous yeah I think about the incentives that okay you can have incentives and I'm sure we I'm no economist I'm sure you could structure the incentives a bit better to make the system a bit safer but on its own you've still got to know after that how to make the system safer and that's not so simple even if you have the incentive which we've done no that's a formula for frustration when you're banging the table with money or otherwise saying to better and we don't have yeah the help and capacity and systems support that as I can't thank you enough for joining me your and for your work you've been a really a hero of mine in terms of the way you've contributed to understanding and in this really important field and I appreciate that we have a tradition as we close these interviews to ask the same question to all of our guests let me ask you it's the optimism to pessimism question like you've been around a while now in this field you've certainly contributed but we still have the problems of of a safety demoralization and misunderstanding and healthcare both for countries are we how are you optimistic about where we're going to get to or are you feeling a little frustrated and that where maybe there's not so much cause for optimism at this point in terms of progress or patient safety no I'm optimistic in the sense that I think we have made a lot of progress it's transformed since I first began but what I think is now which I perhaps didn't perhaps I thought we might one day become safe but I think now I think that the whole business of safety is a never ending problem and not just for healthcare but everywhere because everything changes as I've written with Renee and Alberti particularly safety and healthcare is very difficult because it is a moving target as healthcare improves as we get better we acquire new safety problems for a variety of reasons We have new technologies, we have new risks, get like care in the home is great, but we then it brings new risks. And also as healthcare improves, sepsis was not a safety problem 15, 20 years ago. Now it is, but that's because people have got better at managing sepsis. So now it's a safety problem. So as our standards improve, we have different safety issues. So it's quite a complicated assessment. I remember. You wanted a simple answer, and I've given you a complicated one. It's a great answer. You reminded me of Jim reason at a meeting we were both at with him when he said that safety is a continually emerging property of a dynamic system, which is a little more complex way of saying what you just did, which is it's always changing. We've never done with safety, you have to keep that because the world's changing. Yeah. So at least while we stay in business. Yeah. Well luckily for us, you are and I hope you'll continue to write into your research and look forward to seeing you again soon in the Charles Vincent. Thanks for joining us on Turn on the Wights. Thank you, Don. It's been a pleasure to be on the podcast. Thank you. I hope you enjoyed not just the content of the conversation with Charles Vincent, but also the tone. I deeply admire him as a scholar, but also as a human being. His whole attitude seems to involve a sense of maturity and peacefulness that I really take heart from. He has understated in the interview the importance of his research. He's one of the people in the world who has contributed the most to understanding the psychological conditions that lead to safety in organizations and teams. He is a gentle advocate for rethinking how we are approaching safety and the message I always take away is that blame doesn't help almost never. The Charles is thorough about that, sometimes people need to be criticized. This culture of individual accountability, the use of blame and shame and think or pointing and punishments in the world of safety, it just doesn't help. If you listen to him and what he and Jim Reason and other scholars have brought to us, it's asking us to take a deep breath when something goes wrong, to understand there's a whole system of interaction, a whole collection of events and preconditions underway that lead to the event that you're looking at. And very often, the person who's at the sharp end of that, the patient and the individual doctor or nurse, for example, can be totally misunderstood if you don't realize the system of conditions that they're swimming in, which frankly would mean that almost anyone would have made an error under those conditions. You can access Charles Vincent's work, I urge you to do it on Google and you'll learn a lot about more mature way to think about things going wrong in medicine. And as they get better, we're going to have Charles Vincent to thank for a lot of that progress. At the 2026 IHI Forum, Brooke Shields, Dr. Robert Wachter, Dr. Katie Boston Leary and artist Michael Townsend will challenge how we think about women's health, technology, nursing, equity, creativity and collaboration. Learn more and register at ihi.org/form.