Atrainability Blog

Here we share some thoughts, insights and ideas related to Human Factors Training

Trevor is a specialist in human factors teamwork training since its introduction in commercial aviation in 1990. Since 2002 when he formed Atrainability he has been working extensively in healthcare, with extensive experience in training and coaching clinical teams in a multitude of operating theatres across the UK in NHS and private hospitals.

Trevor enjoyed a full career as a pilot with British Airways, retiring as a senior Training Captain flying Boeing 747 aircraft in 2005. By then he had been a trainer in classroom, simulator and aircraft for over 12 years. In this time he had extensive experience in facilitating learning and with a small team developed a range of innovative train the trainer courses that have gone on the become mandated internationally in commercial aviation. It is these skills which have been widely recognised in healthcare and have been utilised in courses for such as the Royal College of Surgeons and a variety of research programmes conducted with teams at the RCS and the University of Oxford.

As a result of these he was approached to tender successfully for the development and design of the Productive Operating Theatre teamworking modules for the NHS Institute. His experience across healthcare is wide and far-reaching, including a specialty in Surgery, Radiology as well as Primary Care, Emergency Care, Critical Care, Mental Health and Secondary Care.

He is widely sought as a conference speaker internationally on the subject of human factors training in healthcare. Trevor is an active member of Lions Clubs for over 30 years and has been President of his local club twice.

How compassionate care can reduce mistakes.

One of the questions we ask on many of our courses is "who is in your team?"

It is always fascinating to see how long it is before someone mentions the patient or service user in amongst all the doctors, nurses, porters, ODP's, managers, HCA's, therapists, allied healthcare professionals etc.

On one memorable occasion with a roomful of a particular group of specialist surgeons (no clues) the mere suggestion that the patient could be part of the 'team' was like a grenade going off. "They are the task, how can they be part of the team?"

My next question was "Could the patient save you making a mistake?"

"Yes of course" came the reply.

It is obvious. If you treat people like a task, you might inhibit them speaking up and potentially stopping calamity happening – wrong leg etc (there's a clue!). Compassion, empathy and demonstrating a genuine interest of the patients main concerns will reduce stress and empower your patients to have their voices heard.

During our time working with the Medical Protection Society we learned that there is compelling evidence that the initial interaction between medical professional and patient affects the willingness to complain and sue if things subsequently go wrong. If they feel valued and listened to, they are more likely too forgive, and vice versa.

"Empowered patients can communicate changes and observations that can make a real difference in their medical care…many times patients are intimidated, or sometimes bewildered, by the medical world around them. Also, it can be hard to speak up if the doctor or nurse is perceived to be rushed and ready to move on to the next patient." - Elizabeth Cohen, CNN senior medical correspondent and author of The Empowered Patient

The book 'If Disney Ran Your Hospital: 9 1/2 Things You Would Do Differently' by Fred Lee also makes interesting reading. Describing staff at Disney theme parks as 'actors' is in fact exactly what we would expect a 'professional' healthcare worker to do. We all adopt a cloak of professionalism at work don't we? Well, clearly some do better than others, judging by the evidence about abusive and inappropriate behaviour we hear about."Patients judge their experience by the way they are treated as a person, not by the way they are treated for their disease."

It's also well acknowledged that patients recover quicker if they feel cared about. If bed blocking is as much of a problem as it is reported; then anything that can be done which helps patients to recover, have a positive experience and get home again fast, has got to be worked on.

Treating patients like numbers – "go check the BP on bed 5" is entirely different to "pop along to Mrs Smith in bed 5 and check her BP".

It's clear that many providers are becoming more aware of compassionate care, and implementing training to help staff achieve this. Many staff may feel that this is something they do every day naturally; caring for people after all, was perhaps one of the main reasons for choosing their profession, but it is easy to become complacent.

I was recently admitted to a private provider where everyone who came into my room started with "Hello my name is .." However it was quite clear that because every single person used exactly the same form of words it had all the sincerity of concrete. Why couldn't one of them at least say something like "Hi Mr Dale, I'm Bill .."

You can reduce error by treating your patients as part of the team. However it is important that compassion, empathy and a genuine interest come across as sincere.

We have developed "The Keys from Courtesy to Compassion" course which covers the aspects of helping staff deliver compassionate care on a regular basis and it is clear that some places would benefit from it.

Here is a testimonial from one of our recent clients:

"Atrainability was wonderful to work with. They took our needs for instilling 'Disney' values into healthcare, and they worked closely with us to develop and deliver an enjoyable training session for our senior midwifery leadership team. The team enjoyed the fresh concepts and attuning these to their daily practice." - Amy Maclean, Head of Patient Experience at Birmingham Women's NHS Foundation Trust

"Thank you for helping us…and giving us some really useful strategies to complete our journey and make our business all about people." – Helen Young, Director of Nursing & Midwifery at Birmingham Women's NHS Foundation Trust.

To enquire about this course, click here to contact us for further information.

Trevor

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Sharing the Learning

I had never really thought about situational awareness in the past. I'm a pharmacist myself. I know that I've made mistakes. None of my mistakes have been life threatening; in fact, they've probably been near-misses, but this (course) made me think about how situational awareness affects the way we do things- Julie Jones, Birmingham Healthcare NHS Trust

Atrainability has provided Human Factors training for over 14 years and during that time our team has spoken to lots of people at various stages in their career, and across a range of different disciplines.

We've always been grateful when participants are open about sharing their learning experiences with us. One thing that seems to occur often is that during or shortly after the training sessions there is a moment of clarity when dots are joined and suddenly that person understands how and why those near-misses happened and more importantly what they can do to avoid future errors. There are many stories we could share, but here are a couple :

I was talking about having compassion for patients as well as colleagues on a course recently, and a Dental Surgeon who was attending said: "Quite a lot of patients are just awkward with unrealistic expectations" he went on to say that he'd received a significant number of complaints and some claims. I asked him if this was just something which he encountered or did his colleagues also find the same? After the course, he thanked me and said that moment had made him realise he was perhaps playing a part in the problems he was experiencing, and he would be more aware of his communications with both patients and colleagues when he returned to work. – Trevor Dale

During the coffee break of a course I was running an F2 Doctor approached to thank me, and explained the Situational Awareness module was a light bulb moment for her. During a night shift, she had a difficult hand-over at a time of high workload. The nurse had handed over a patient with a verbal description of a dosage of a respiratory drug, there was a mistake made but the Doctor was clear of the dosage in her mind. The Doctor was working very hard and so did not acknowledge the dosage handover to the nurse. She told me she now understands why she did not read back the instruction. She was stressed and her speech had been degraded due to an overload of information. Although she was cleared of any wrongdoing, she was troubled why she made the mistake. The Doctor was delighted to understand that her mistake was just an indication of her human fallibility; not incompetence, and that now she felt she had the tools to help her avoid repeating that error. – Matt Lindley


As you may be aware, Atrainability has been running Human Factors Open Courses this year at key locations in England. We can't promise Light bulb moments for all, but we can promise a course which will help you find solutions and gain a greater awareness of how you and your teams' behaviour, communication, leadership and briefing and debriefing skills can improve outcomes for everyone. 

If you can't make the dates listed on our Open Course page, or if we haven't announced new dates yet, do get in touch to discuss how our bespoke in-house courses can help your team. 


Trevor

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The Remarkable Truth about 'People Stuff'

​If you ask the question "What makes a difference to your every working day?" and other than the weather, your IT systems and somewhere to park your car, you begin to realise that everything else is about PEOPLE.

So if 'people stuff' has the most impact on your performance, how can we ignore it? Human Factors may be considered a 'buzz word' for some, but the fact is; it's an unavoidable part of everyday life. If you gain an understanding of why colleagues and patients behave the way they do and understand why some communications turn out to be 'Chinese whispers' you can also gain insight into why some of your processes are failing and what you can do to avoid repeating mistakes. This is why Human Factors is so important.

I recently had a morning session with the board of an NHS Mental Health Trust, where they have been fortunate to apply for and gain funding for a coherent training programme to embed Human Factors principles in their organisation.

Virtually all of the Board were completely unaware of the term 'Human Factors', what it meant and of course how important it is to ensure the safe, effective, efficient performance of their Trust.

There are still many organisations that are seemly unaware of the crucial importance of factors that affect their Front Line staff and in fact everyone in the organisation. Notwithstanding the publication of the HF Concordat ( link -  https://www.england.nhs.uk/wp-content/uploads/2013/11/nqb-hum-fact-concord.pdf ) in 2013.

We have helped a number of NHS and private healthcare providers improve their performance and the CQC positively encourages Human Factors initiatives. We are very keen to come and help your organisation be it already successful or indeed in need of some improvement or help. All of our work is bespoke and our experience stretches all the way across the entire health and social care spectrum from acute through to community and primary care.

Don't ignore your 'People Stuff'. People are the lifeblood of your organisation.

Trevor

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More of the same? Don’t limit yourself

​The New Year: a time of self-analysis; looking back and looking ahead. 'New Year, New You' is an overused line that you will probably see almost everywhere.

So here's our piece of advice. Let's look beyond ourselves and reflect on your teams work environment too.

If we concentrate on our model of Whirlwind Debriefing – what is one thing we do well? What is one thing we could do more of or indeed less of ?

In general it is accepted that few of us emphasise our successes and share what we do well. Let's try and change to doing that.

That doesn't work for us

In aviation it is mandatory to have an in depth initial course with each new company that a crew member joins and by international law it must be refresher trained and assessed 2 or 3 times a year. Even then our human frailty and fallibility is still susceptible to error.

Human Factors training is about transforming behaviour to create safer more efficient staff. You cannot completely error-proof the human but you can provide the right training and support to give them the best chance to get it right and be safe under quite trying and stressful conditions.

This can't always be achieved in one brief intervention. In order to see noticeable effects your team should be allowed the time to fully digest the learning points from the training sessions and attend refresher sessions so that they can begin to embrace a new way of thinking.

Make achievable targets

Do you want your team to be part of the solution? We don't need to tell you that motivation is one of the first steps to making positive changes.

If you're struggling to make a New Year's resolution that's achievable for you and your team, here are a few suggestions:

This year we will:

  • Gain the confidence to raise issues
  • Be more motivated and effective
  • Find long term solutions to recurring issues and everyday challenges

Once you've decided on your resolution, we can help you stick to it.

Start your team on the journey to a successful New Year...

We offer help for individuals and small teams in the form of Open Courses click here to visit the page on our website. We can also provide training and support for departments and larger teams click here.

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Safer Solutions that support staff relationships

​One of the most popular subjects when we talk about Human Factors is the understanding of behaviour and personality types. The differences in how individuals react and see things especially in high stress, high risk situations can result in a strong team but sometimes they can cause misunderstandings or communication errors.

The relationship between team members is an important one. If individuals feel secure and supported within the team it will promote better communication and reporting long term.

" The importance of everybody having a say in safety situations and feeling able to speak up "
 - Mr Andrew Aldridge (BMI Eastbourne, June 2015)

" We have the right to make mistakes and learn from them "
- Erica Rapaport (SAS Ipswich, November 2015)

We regularly receive feedback from course participants which highlight how our training helped them to go back to work and find solutions to what seemed insurmountable problems.

Understand the facts

Understanding Human Factors principles better will help you recognise the facts underlying human behaviours and stresses. This includes identifying stress in yourself and others and using techniques to remain calm in stressful situations; enabling you to be more aware of your own behaviour and see other persons point of view.

Put aside hierarchical barriers

Intimidation and fear of reporting errors can lead to recurring problems. Human Factors training can equip you with the ability to cut through whichever side of the hierarchical barrier you are on. This will help your team to maintain a focus on safe, compassionate care for colleagues, patients and relatives, which is the upmost priority.

Don't skip on the briefing and debriefing

We can't stress the importance of these enough. Briefings and debriefings will ensure better communication between staff, more detailed handovers and give staff the support and confidence to raise issues, which will help to reduce unnecessary errors. Furthermore debriefings are a simple, often underutilised aspect of learning from success and near-misses. Our training will provide you with the skills to ensure you create the opportunity to maximise team-working during this time.

Promote learning, avoid inappropriate blame and make your team more effective

Communication and behaviour can be an ongoing challenge. Our Human Factors Open Courses are the perfect introduction for both front line staff and managers who want to improve communication, enhance performance and increase safety. Discounts are available for early bird bookings. 

If you can't make the dates listed on our Open Course page, or if we haven't announced new dates yet, do get in touch to discuss how our bespoke in-house courses can help your team.

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How can we help minimise errors in Child Protection?

​What does safeguarding have in common with flying Boeing 747s? Well in terms of why things go wrong, perhaps more than most people realise.

No matter what walk of life you work within, human fallibility interferes. A brief examination of many serious case reviews shows comments about missed signs of abuse, missed opportunities to intervene. The recent SCR into Levi-Blu Cassin refers to serious failings and 'professional optimism' http://www.bbc.co.uk/news/uk-england-birmingham-34416644 . Professor Eileen Munro in her report subtitled 'A child-centred system' published in May 2011 wrote "errors and mistakes should be accepted as to some degree inevitable and to be expected, given the complexity of the task and work environment."

Of course it is never quite so easy to spot things when perpetrators are concealing the harm. Consider Baby P where his Mother concealed his facial bruising under chocolate. Furthermore the paediatrician who examined him before his death had not been told he was on a child protection plan. This was an apparently simple communication error that had immense consequences because she was not aware of the background.

Very few of us work with colleagues who intend harm, but error is rife. Much of it is due to our being asked to work in ways which we are simply not designed for, such as extreme workload, interruptions and distractions. Also this case as I write http://www.bbc.co.uk/news/uk-england-somerset-34547660 demonstrates the importance of shared information to build Situation Awareness. The police failed to pass on vital information that the father had a relevant record of domestic abuse. Situation Awareness is a crucial concept referring to the 'mental model' we all have of what we are expecting now and what happens next. When this conflicts with what we see and experience there is clearly a problem.

There is a potential danger sign anytime you hear yourself or others say "Oh, I thought this or that was what we are doing" or perhaps "I am seeing this and you are not". There are classic signs that Situation Awareness is being lost, such as conflict between 2 sources of information. However to simply blame 'being human' is not good enough for the professional. To us it is incumbent to recognise how and why we all make mistakes and adopt methods that help keep us, our colleagues and our clients safe.

These non-technical skills are well understood and can be trained and coached. They encompass social skills such as Leadership, Followership, Cooperation and Management of others and cognitive skills of Situation Awareness and Decision making.

The culture is also riddled with blame, but what does it achieve? High reliability organisations recognize blame is mostly inappropriate and counter-productive. If it drives near-miss and error reporting underground it is useless.

The frontline teams know where the barriers to safety are, which procedures are not fit for purpose and where communication blocks occur. Their reports should be welcomed, responded to and acted upon. This is how commercial aviation has become safer and it can be adapted to safeguarding. Atrainability offers training solutions to address these issues.

Trevor Dale, Atrainability


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Guest — Angela cassin
I am Levi-blus Nan and I have just read your blog. Firstly the police never failed to pass on information it was never requested, ... Read More
Monday, 10 October 2016 20:37
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Human Factors – no longer an option

​The publication in September 2015 of the National Safety Standards in Invasive Procedures is a major positive move. http://www.england.nhs.uk/2015/09/07/natssips/

Dr Mike Durkin, NHS England Director of Patient Safety, said: "This is the first time that national safety standards have been set and endorsed by all relevant professional bodies". These include the royal colleges, the Care Quality Commission, the Nursing and Midwifery Council, the General Medical Council, Monitor, the Trust Development Agency, and Health Education England.

Dr William Harrop-Griffiths, Consultant Anaesthetist at Imperial College Healthcare NHS Trust and chair of the group that developed the standards, said: "The NatSSIPs contain 13 key standards which cover all aspects of the patient journey throughout an invasive procedure, ensuring safety checks are performed by the team providing care at every critical step in the pathway."

"However, this work is not just about establishing a network of safety checks. It is about ensuring that safe care standards are harmonised both within and between hospitals, and that learning from the development of local standards based on these national standards is shared by all."

Now good Human Factors practice is no longer an option.

Indeed the GMC has recently run its own online discussion document focussing on Human Factors which will undoubtedly have a bearing on future accepted practice.

There is nothing new here, but just giving it the official stamp of approval makes a huge difference, especially by all the professional bodies. This is fantastic news and a real step change, at last. Now comes the challenge of how to ensure such good practice is adopted effectively, not just lip service.

Classroom teaching to raise awareness and understanding of Human Factors is the starting point as used to great effect in other high-risk, but resilient professions like aviation, but how do we embed the learning long term? E-learning certainly has its place in supporting and cementing knowledge, but is unlikely to create behavioural change in isolation.

By and large people learn through experience, through being able to put theories and practical tools into practice day to day, and the culture of an organisation has to support that learning.

The major point is that people have to want to change the way they do things. Coaching and mentoring can certainly help. Those organisations that have invested in training and role-modelling from the top have achieved high performance that has sustained. They are beacons for effective care.

These new standards are currently aimed at invasive procedures, but it cannot be long before all of Health and Social Care formally recognises the critical importance of safer working behaviours.

Atrainability have been a leading provider of Human Factors Solutions to the healthcare industry for well over a decade, with over 100 years of training experience in our delivery team across a range of safety critical/high performance industries. Many NHS Trusts and private providers have already recognised this and to we have trained thousands of professionals across the UK.

Atrainability offer a range of training and coaching options

  • Trust-wide programmes that are designed to cover all departments and embed safety Champions and train the front-line teams and individuals. This aspect also covers leadership specialised courses and Master-classes and supportive coaching
  • Train the Champion courses, minimum two days, ideally three or more. They offer an in-depth understanding of Human Factors principles and the tools and skills that help the front line teams to work safe. The by-product is sufficient understanding to look into Root Cause Analysis to see beyond what people did but to look into why
  • Human factors awareness modules for front line teams that can be delivered throughout the year in modular design
  • Supportive work-place coaching to cement the knowledge and skill.

As many of you know psychopaths are thankfully rare in health and social care but human fallibility is a given. Long term safety enhancements come from knowledge and demonstrable skills. We are here and ready to help.

Trevor Dale.

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I could have told you that

Many high-performing professionals make their job look easy. Well maybe not micro-surgery but aviation is a good example that it seems is widely misunderstood. I hear many people say "you pilots don't understand – we deal with sick people who aren't OK when we start treating them. You wouldn't get airborne in a plane that wasn't OK" 

Well pretty much of course not. But if only life were that simple! Pilots and for that matter cabin crew, are there for emergencies, generally unanticipated, often at periods of low arousal. Look at Kegworth – 1989 - routine flight Heathrow- Belfast - relaxed take-off and climb and suddenly an engine breaks apart. The crew, who must have been terrified, misidentify the problem and shut down the wrong engine. 47 people die.

Lessons learned? Well it is an imperfect World and the same essential error happened in Taiwan in January 2015. You will probably remember the horrific images of the plane with wings vertical crossing a bridge before plunging into the river killing 43. The error was the wrong engine shut down again.

However we all now accept that flying is significantly safer than any other form of transport taking into account the number of flights per annum. Things do go wrong but what helps prevent tragic potentially fatal accidents is training and preparation. Especially thinking ahead and discussing what could go wrong and having a plan in place for how it would be handled if it did. Think Captain Sullenberger and crew and the Hudson River successful outcome.

How often have you said with hindsight "I could have seen that coming" or "I could have told you that would happen"? Experience is a great learning tool but trial and error is simply not acceptable.

That seems to be what healthcare is doing though. There is still a general reluctance to learn day to day success, failure and near-misses.

This is what Human Factors training can aid such as how to share plans across the team and encourage input from everyone who might spot the impending threat and intervene for safety. Even more so when it comes to post-hoc debriefing discussions about what worked well and what could be improved.

When you get down to it aviation and health and social care is about risk management. Risk management is about Human Factors. Mental preparedness and appropriate hierarchy and open communication.

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Inappropriate hierarchy and what to do about it

BBC Radio 4 - From the Cockpit to the Operating Theatre

Why lessons learned from aviation psychology are starting to save lives in hospitals.

​Matt Lindley, trainer and coach with Atrainability, featured in a radio broadcast recently on the BBC, alongside Prof Rhona Flin and other eminent healthcare experts, speaking about the problems of dealing with inappropriate hierarchy when it comes to safety. 

Matt's background is Royal Air Force and now British Airways where he flies long haul around the World. He has an extensive training experience which for the most recent few years has expanded into Health and Social Care with Atrainability.

Clearly both military and commercial aviation enjoy the benefits and problems associated with hierarchy. Both have developed tools to try and get the message through when safety is paramount. In my case, starting flying in 1971, the hierarchy or Authority Gradient was a real problem. Captains were never called by their given name, but always 'Sir' or 'Captain' on and off the aircraft.

Just to explain the concept of the Authority Gradient this is the view from the top person versus the view from the junior. If you ever hear someone say "I could have told you that" the immediate question must be "why didn't you?" or perhaps "what is it about me that stopped you?"

How many of us believe we are very approachable but then find one of our team has hesitated to challenge what we are saying or doing? I've been there and it is a terrifying bit of personal feedback. In my case I was a Training and Checking Captain with real power over other pilot's futures. I was the veritable scary monster that triggered fear – irrational I hope, but perceived real in the moment nonetheless.

The one advantage aviation has, of course, is the 'Black Box' – real evidence of what was said and done. Thus we know that the various Human Factors are a problem. It is often said that 90% of air crashes someone is heard to voice concerns but not effectively enough to stop the ensuing accident. Aviation works very hard to deal with this and effective balanced assertiveness, perhaps using a 'Trigger' word to get attention.

We teach these techniques in Health and Social Care supported by coaching in the live or simulated workplace to get to those who, for whatever reason, find class too difficult to attend!

So the responsibility lies throughout the team – the leaders, recognising that they may not be as approachable as they think, should encourage appropriate questioning. Those more junior in status should never assume and always accept their role in checking the correct process is taking place. 'Trigger' words work very well in health and social care too. "Gorilla???"

Our Human Factors Open Courses are the perfect introduction for both front line staff and managers who want to understand how they can improve issues such as inappropriate hierarchy, among others. Discounts are available for early bird bookings, but please do get in touch if you'd like a more bespoke, in-house traininig soultion for your team. We'd be happy to help you.


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Human Factors Training – Published evidence that it works!

We all know how challenging it can be to find good quality hard evidence that training teams and leaders in Human Factors awareness and skills enhances Patient Safety. Health Education England are seeking such evidence now for all forms of training. Quite right too. We have worked with various teams over the years notably at the University of Oxford with varying degrees of success. There are a plethora of published papers out there with our names on them. One of the arguments has been what to measure and I believe firmly that the only real measure is patient outcome. We have taken part in other recent research and I am led to believe that some further positive results will shortly be published. 

Some of you who have been with us a while will know that we were invited in to Newcastle Neurosurgery unit by Patrick Mitchell, the clinical lead, in 2006 where after some in-house training they had reduced the wrong-side error rate for cranial and spinal procedures dramatically (from 1 in 300) but then had a recurrence. 
The training consisted of putting all the direct theatre team and their immediate leaders through a one day interactive training course in understanding the problems around human behaviour and fallibility and practical solutions. This was supported by coaching to help embed the skills in practice. I think it is fair to add that two senior team members found it difficult to attend.
The result is now over 5 ½ years without a side error from a pre-intervention rate of 1 in 300! That is over 21,500 sided procedures in the unit with essentially the same entire team, although one of the senior clinicians did leave a couple of years ago – to concentrate on private practice.
 
The results have been published and is available to download freely - Click here to view full report in PDF format
 
I don’t believe it is unfair to say that the fundamental issues were around behaviour, especially team briefings and checklist discipline. Incidentally this was before the WHO checklist was published. Patrick Mitchell is a private pilot himself and has a clear understanding of the importance of checklists in safe performance. 
I would like to emphasise that the Atrainability team didn't achieve this –we simply helped the front-line team to build and maintain the confidence and skills to deal with the problems successfully. 
We encourage all our clients, colleagues and prospective clients to continue to seek and share evidence and best practice to improve Patient Safety for everyone. 
The Atrainability team are of course, very happy to explore further opportunities to develop solutions to human error, poor behaviour and help teams avoid avoidable harm.
 
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