Accountability

Accountability, quite literally, is the ability to give an account: account-ability. An account is a narrative – the telling of an honest story about what happened, why we did what we did, what was known at the time and what wasn’t, told from our particular position, and situated within the context of what was actually happening. To be accountable is to have the ability to give an account. This isn’t a wordplay or a clever rhetorical manoeuvre. It’s the simple etymology of the word – accountability is meant to be about our capacity for honest explanation. To be accountable is not the same as to be punishable.

But accountability has been colonised by blame. In the world of work, almost without us noticing, the meaning of accountability has been displaced by its near-opposite. The tell is the phrase “Someone must be held accountable” (or something similar), and what that usually means in practice is that someone should suffer consequences. It’s rarely used to mean that someone should be given the conditions in which they can honestly explain what happened, but that someone should bear the cost of it happening. Accountability has turned into blame with better marketing.

Roberts (1991) formalised accountability as a relational tension between an account giver and a recipient, and that framing is important. Accountability requires at least two parties, someone willing to give an account and someone capable of receiving it; it’s relational and dynamic. Philip Tetlock’s work on accountability and cognition shows why the receiving end is so consequential. What he found was interesting but unsurprising: when people know who they’re accountable to and can anticipate what that audience wants, the account they give is shaped accordingly – designed to satisfy the audience rather than give the truest description of events as they actually happened. Every performance review, every post-incident investigation, every board report is subject to this dynamic. The account we receive is the account that the teller believed the audience wanted.

Accountability as a construct has been studied extensively across public administration (Bovens), organisational behaviour (Tetlock, Frink & Ferris), philosophy (O’Neill), and safety science (Dekker), and what strikes anyone who reads across these fields is how rarely any of them mean the same thing by it. The kaleidoscopic definitional confusion is part of the core problem with accountability. Even the classic RACI matrix (the popular tool that gives the appearance of clarity while achieving the texture of a spreadsheet) gets accountability wrong. Much of that confusion is semantic and probably unavoidable, but some of it has structural consequences. The most significant conflation is between accountability and responsibility. Ieraci (2007, via Parris, 2025) draws the distinction clearly: responsibility involves doing, accountability involves reporting. Responsibility is about the work itself, and accountability is about the account of the work. They overlap and interact, but they are not the same thing, and treating them as synonyms has problematic consequences. 

Misunderstanding Accountability

Accountability and responsibility have been used interchangeably for so long that even legislation gets it wrong. This isn’t just pedantry. The conflation matters because once accountability is understood to mean “being responsible for outcomes,” the logical next step is: if the outcome was bad, the accountable person is at fault. Consequence then follows automatically and the account (the narrative, the context, the conditions that were actually present) gets dismissed before it can be heard. And accountability for outcomes is, in any case, the wrong target. Outcomes are partly beyond any of our control. What we can reasonably ask people to account for is their reasoning, their decisions, and their actions, situated within their context. Not the outcome.

“People aren’t just people, they are people surrounded by circumstances.”

Karl Weick’s sensemaking work is useful here, and shows why this is even worse than it first appears. Accountability in organisations is almost always exercised retrospectively, after the outcome is already known, and hindsight does much of the work before the inquiry begins. The account becomes a post-hoc justification exercise rather than a genuine rendering – an attempt to prove innocence in a process that has already assumed guilt. Structural bias is at play, and the knowledge of the outcome contaminates the inquiry before it begins.

Parris’s example from maritime law shows both mechanisms operating at once. New Zealand’s Maritime Transport Act assigns responsibility to vessel Masters where it clearly means accountability in the liability sense, and the confusion has structural consequences for who gets blamed when things go wrong. The Master at the sharp end becomes legally exposed for outcomes shaped by systemic decisions made at the blunt end. The legislative conflation and the retrospective framing work together: context and conditions get set aside because the outcome is already known, and the law reaches for the nearest human rather than the most relevant cause.

“…they took the captain to court, even though there was not a thing I could have done to have stopped it, to have known about it, or anything… I was held accountable… But I wasn’t responsible.”
Parris, 2025 pp.35

And here’s the crux: responsibility is actually closer to what organisations think they mean by accountability. Responsibility is about roles, obligations, and the act of doing. We can assign responsibility, but we cannot assign accountability – an account is given, not extracted, and every organisational system built around ‘holding people accountable’ rests on a category error with real-world consequences. If accountability cannot be assigned, only taken, then the pressure organisations apply in its name does not produce genuine accounts. It only produces performances of them.

Accountability without context is blame

When we strip the account (the narrative, the context, the local rationality of the person who was there) and retain only the assignment of fault, we haven’t done accountability. We’ve dressed something much older and more primitive in accountability’s clothes.

Blametropism is the organisational tendency to orient toward fault, the way a plant orients toward light, regardless of whether finding fault serves any operational (rather than emotional) use. The organisational or political apparatus of accountability (the investigation, the finding, the consequence) is seldom deployed to truly understand what happened, but instead to locate where the fault should land. The true account is rarely sought; what’s more often sought is a name, a goat that we can expel from the village, laden with our sins. Accountability-as-blame is blametropism in its business suit. It gives the impression of rigour while reliably producing the outcomes of blame.

Marilyn Paul’s systems framing captures the consequences well: blame generates fear, fear generates cover-up, cover-up degrades information quality, degraded information produces more errors, more errors generate more blame. The feedback cycle is self-sustaining and self-defeating, and as reliable as it is depressing. An organisation that uses accountability as a pressure tool destroys its own capacity to learn what’s really happening inside it.

When people learn that giving an account: an honest one, with all its uncertainty and complexity and acknowledgement of error, leads to punishment, they naturally stop giving honest accounts. Instead they give performed accounts – narratives designed to survive scrutiny rather than enable learning.

And the demand for a single account is itself part of the problem. Real situations are experienced differently from different positions within a system. The account of the nurse who administered the wrong medicine, the ward manager who created the rota, the software developer who designed the drug cabinet interface, and the executive who approved the staffing budget are all partial, all genuine, and all necessary. Accountability-as-blame doesn’t just suppress honest accounts. It demands that a complex, plural reality be rendered as a single story with a single author. 

Take the cases of Hadiza Bawa-Garba and RaDonda Vaught: both clinicians who made errors in systemically compromised conditions, both of whom were honest about what happened, and both of whom were subsequently prosecuted. In both cases, the logic was that someone had to be held to account. Investigations were conducted, findings were made and severe consequences followed. What was not sought, in any meaningful sense, was a genuine account. Both clinicians were already carrying the burden of what happened before their prosecutions even began, and the prosecutions compounded an existing problem by converting private grief into public liability. The systemic conditions and the context behind the errors (staffing levels, equipment failures, normalised workarounds and more) were noted but set aside. The apparatus of “accountability” produced the outcome that blame always produces: a conclusion that foreclosed rather than opened inquiry.

The lesson that clinicians drew from both cases was not “be more careful.” It was “be less transparent.” That is what accountability without context reliably produces. Onora O’Neill saw the same mechanism from a different vantage point: systems designed to demonstrate transparency often produce performances of transparency rather than the thing itself. The safety audit, the Ofsted inspection and the compliance checklist all create the appearance of account-giving while systematically degrading the conditions in which genuine accounts are possible. The mechanism defeats its own purpose.

An organisation that punishes honest accounts will eventually receive only dishonest ones.

You can’t assign accountability, only take it

The moment an account is compelled, demanded, or extracted under threat of consequence, it ceases to be an account and becomes testimony. Modern societies do not treat confessions given under duress as genuine, and for good reason –  what is said under compulsion is shaped more by the compulsion than by the truth. The same mechanism operates inside organisations. Forced accountability produces self-protection, not transparency. A performance of accountability, not learning. It’s worth noting in this light that we tend to call the most common formal accountability mechanism in organisations an “annual performance review”.

“Currently fashionable methods of accountability damage rather than repair trust.”
– Onora O’Neill

A genuine account has to be a voluntary act. It requires the account-giver to be willing to be seen: to expose their reasoning, their uncertainty, their errors, and their context. That exposure carries real interpersonal and career risk, and where candour carries significant risk but little benefit, most of us will err on the side of caution and silence. This isn’t a character flaw, it’s a rational response to the environment, and changing that calculus is the only reliable route to better accounts.

The distance between the account an organisation says it wants and the account it actually rewards is navigated through social inference: reading the room, calibrating our degree of honesty to the audience, knowing instinctively how much truth is too much. It’s also a skill that is unevenly distributed in most organisations. For many neurodivergent people, candour is simply how to communicate, not a choice to be weighed against consequences. An organisation that performs a desire for honesty while punishing it in practice fails those workers and risks actively deceiving them.

Cultivating the conditions for honesty is considerably more difficult than demanding it, and considerably more effective. The phrase “holding people accountable” implies a power that organisations do not have. We cannot hold someone else accountable. We can only nurture the organisational substrate in which people are able and willing to give an honest account.

What real accountability looks like

Real accountability is dialogic rather than monologic. Roberts draws on Senge’s distinction between discussion and dialogue: discussion in this sense, is like a debate, with positions defended and a winner declared. Dialogue is different: meaning, nuance, context and information flow freely between parties, with the intention of surfacing something neither party could reach alone. Organisational accountability processes are almost universally structured as a defensive discussion – and a genuine account cannot be extracted through cross-examination. It can only emerge through a more open, reflective dialogue, which requires the account-giver to feel safe enough to think out loud, be uncertain, and say “I don’t know” without it becoming evidence against them. Both giving and receiving are equal components of accountability, and the receiving requires its own kind of discipline: the willingness to be changed by what we hear, rather than confirm what we already believed. Maybe the hardest part is the moment right after the event, when everyone is nervous and the pressure to find a name is enormous, and someone has to be the person who says: let’s slow down, let’s find out what actually happened.

Parris’s typology reinforces this binary. Backward/hierarchical accountability is structurally monologic: it already knows what it’s looking for. Forward/process accountability requires dialogue, because it’s genuinely interested in what the system contributed, which can only be discovered, rarely confirmed.

“But surely there have to be consequences sometimes?” Yes, but consequences and accountability are separate questions. We can impose consequences without ever actually receiving an honest account. And if negative consequences are attached to the account, we will never receive an honest one. Consequences cannot come first without contaminating everything that follows. The desire for consequence after failure is often a desire for justice, and that is a fundamental human impulse worth taking seriously. But retributive justice and learning are different projects, and the accountability mechanisms most organisations use are poorly designed for either.

The question after a failure, Dekker argues, is not just “who is accountable?” but (more importantly) “how do we learn?”, and answering the second question well requires the conditions that make genuine accounts possible. It follows that psychological safety and true accountability are mutually dependent. We cannot give a true account if we don’t feel safe, and accountability as punishment makes honesty unsafe. A genuine account shouldn’t feel like a confession. It should feel like a contribution to our collective understanding, and treating it as the former guarantees we will never receive it as the latter. Building the conditions in which genuine accounts are possible is what accountability, properly understood, actually requires.

Account-ability

In the vast majority of organisations, accountability is expected to flow upwards. The powerful receive accounts; whilst they are seldom required to honestly account for themselves to those ‘below’ them. And I’d argue that the most valuable accounts are actually those that flow sideways, worker to worker, where honesty isn’t calibrated to hierarchy.

We have collectively spent considerable energy perfecting the art of demanding honesty from the people for whom we have made honesty unsafe. “Accountability”, a word that belonged to everyone who needed to give an honest account, was appropriated by institutions that needed a more respectable name for blame. Blame is cognitively cheap, emotionally satisfying, and operationally useless. It produces a very clear answer to the question of what to do next, and it is almost always the wrong one.

However, blame is also often politically useful. Blame doesn’t just emotionally satisfy: it secures power. When the investigation concludes and the name is named, someone’s position is secured and someone else’s is eroded, or ended. The apparatus of “accountability” in this case is functioning exactly as designed, just for purposes that aren’t on the tin. 

This is why genuine accountability remains so rare. It asks the powerful to submit to the same conditions they currently use accountability to avoid: to give an honest account of themselves, to be uncertain in public, and to say “I don’t know” to the people they lead. In cultures where blame secures position, a genuine account risks it. The rarity of genuine accountability in organisations is its rational consequence.

Many organisations “hold people accountable” by imposing negative consequences for failure. The organisations that actually handle failure best are the ones that make it safe to give an honest account – they foster account-ability. They are not the same thing. They are, in fact, complete opposites.

References

Bovens, M. (2007) ‘Analysing and assessing accountability: a conceptual framework’, European Law Journal, 13(4), pp. 447–468.

Dekker, S.W.A. (2012) Just Culture: Balancing Safety and Accountability. Farnham: Ashgate. (See also: Dekker (2011) in the map)

Frink, D.D. and Ferris, G.R. (1998) ‘Accountability, impression management, and goal setting in the performance evaluation process’, Human Relations, 51(10), pp. 1259–1283.

Ieraci, S. (2007) ‘Responsibility versus accountability in a risk-averse culture’, Emergency Medicine Australasia, 19(1), pp. 63–64.

O’Neill, O. (2002) A Question of Trust. Cambridge: Cambridge University Press. → Explore in map

Parris, R. (2025) Accountability: A Lived Experience. MSc thesis. Lund University. → Explore in map

Paul, M. (2017) ‘Moving from blame to accountability’, The Systems Thinker.

Roberts, J. (1991) ‘The possibilities of accountability’, Accounting, Organizations and Society, 16(4), pp. 355–368. → Explore in map

Roberts, J. (1996) ‘From discipline to dialogue: individualizing and socializing forms of accountability’, in Accountability: Power, Ethos and the Technologies of Managing, pp. 40–61.

Tetlock, P.E. (1985) ‘Accountability: the neglected social context of judgment and choice’, Research in Organizational Behavior, 7, pp. 297–332. → Explore in map

Weick, K.E. (1995) Sensemaking in Organizations. Thousand Oaks, CA: Sage. (See also: Weick & Roberts (1993) and Weick (1993) Mann Gulch in the map)

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The cases of Dr Hadiza Bawa-Garba and RaDonda Vaught

Content note: this article discusses the deaths of patients, including a child.
Co-created and edited by Jade Garratt and Bea Poyton.

Dr Hadiza Bawa-Garba is a British paediatrician. RaDonda Vaught is an American nurse. Both made errors in complex, high-pressure systems and both were subsequently prosecuted for it.

Their cases are very different, but they do share a consequence: the implicit message sent to healthcare workers was that honesty about error carries criminal risk. What happened to patients in both cases mattered a great deal – the harm was only too real, and so was the grief of the families and the staff involved, the sometimes-called “second” and “third” victims. But what happened to Bawa-Garba and Vaught afterwards may have put far more patients at risk, by eroding something that safe healthcare depends on – the safety and freedom to speak up and share learning from mistakes. 

“Underneath every simple, obvious story about ‘human error,’ there is a deeper, more complex story about the organization.”
Sidney Dekker

The Case of Dr Hadiza Bawa-Garba

On 18 February 2011, six-year-old Jack Adcock was admitted to Leicester Royal Infirmary. He had Down’s Syndrome and a pre-existing heart condition, and had come in with vomiting, diarrhoea and breathing difficulties. He died that evening.

Dr Hadiza Bawa-Garba, a paediatric registrar (ST6 – which means she was in year 6 of her post-grad training), led Jack’s care. In the subsequent investigation and legal proceedings, a number of errors in the clinical management of Jack’s case were identified. A chest X-ray indicating infection sat unreviewed for over two hours – Dr Bawa-Garba was not notified it was available and antibiotics were started late as a result. Blood test results were held up for over five hours due to IT failures. Jack’s regular heart medication was discontinued by Dr Bawa-Garba due to his deteriorating condition, but this wasn’t documented, so when his mother visited that evening she administered his usual dose (which was, and still is, standard practice for family members to administer medication to children), unaware it had been stopped. This led to the circulatory shock and subsequent cardiac arrest. During his cardiac arrest, Dr Bawa-Garba briefly confused him with another patient and paused resuscitation before restarting.

These were real errors and the consequences are devastatingly real too. But to understand them only as individual failures would be a misread of the situation.

The ward was short-staffed, and the on-call consultant was off-site. He hadn’t realised he was on call that day, a rota failure that left Dr Bawa-Garba with sole responsibility for the entire unit. The IT system was also malfunctioning and nursing communication was fragmented. 

Dr Bawa-Garba was working in conditions that systems thinkers would recognise immediately, with performance-shaping factors stacked against her at every turn. In such conditions, the errors she made can be seen not as aberrations but as predictable outcomes of the system she was embedded in. This is local rationality – the idea that people’s actions almost always make sense from inside their situation, given what they knew, the tools they had, and the pressures they were under. She was a trainee doctor managing an entire unit alone because of a rota error, with an IT system that was actively delaying critical results, in conditions that would have stretched a far more experienced clinician. Her actions made sense in context, even where they fell short.

In 2015, Dr Bawa-Garba was convicted of gross negligence manslaughter. She was suspended, then struck off, then reinstated following a crowdfunded legal battle and significant professional outcry, and finally cleared to practise without restrictions in 2021. It had been a decade of professional limbo for a registrar who was, by most reasonable analyses, failed by her system before the system failed her patient.

The outrage across the medical profession was substantial, but one element of the case stood out above the others, and it matters enormously for psychological safety.

A few days after the incident, Bawa-Garba was asked to meet Stephen O’Riordan, the duty consultant at the time of the incident. At the meeting she was asked to reflect on the circumstances, setting out what she should have done differently. She was sent home immediately afterwards and told not to come back until she was asked to. These reflective learning notes are the kind of structured, honest self-appraisal that medical training actively encourages. She reflected at length on the points where, as a trainee, she felt she could have managed Jack’s care better – all the things she would do differently given the chance. Reflective notes aren’t just for the author to learn from: their intended purpose is at least in part to facilitate collective learning – so we can learn from each other’s experiences. 

But those reflective notes were obtained by the prosecution, legally, because nothing prevented it – and the prosecution QC, Andrew Thomas, pressed Dr Bawa-Garba on the reflections she made after Jack’s death. “List for us, please, all of the mistakes,” he said. Her own reflections became evidence that she knew she had made errors. 

There is something epistemologically dishonest in that. Reflective notes are hindsight documents by definition: written after the outcome is known, in conditions nothing like those on the ward that day. After the event, Bawa-Garba had time and space to process what happened, and the knowledge of how things had ended. She also had the support in making those notes of the consultant who should have been on call that day. The Bawa-Garba on the ward, in the moment, had none of that – she was a junior doctor managing multiple sick children in an understaffed, overstretched and underfunctioning unit, without adequate consultant cover. Treating her reflection after that event as evidence of what she understood during it mistakes the nature of the document (and of causality) entirely. 

The very act of learning from the event was weaponised against the person who tried to learn from it.

“Blame is emotionally important, not operationally important.”
Todd Conklin

The effect on the profession was significant. The fact that no law protected those notes from prosecution use only sharpens the point: the boundary between learning material and legal scrutiny had never actually existed. If honest reflection can be read by prosecutors and treated as admission of culpability, why would anyone write honestly? A survey found that over 80% of junior doctors changed how they write reflections after this case — they rationally self-censored out of fear. 

Reflective practice only works when clinicians believe that candour is safe. Once that belief breaks, so does the practice – a completely understandable outcome. If honesty about work as done risks prosecution, silence becomes the safer choice, and a profession that has learned to stay silent is a much less safe one.

The Case of RaDonda Vaught

On 24 December 2017, 75-year-old Charlene Murphey was admitted to Vanderbilt University Medical Center in Nashville with a subdural haematoma. Two days later, she was recovering well and nearly ready to go home, but needed a PET scan before discharge, something she was a little nervous about. To ease her anxiety ahead of the procedure, she was prescribed Versed (midazolam).

Nurse RaDonda Vaught went to retrieve the drug from their notoriously flaky automated dispensing cabinet. When she typed “VE”, no results appeared (because unknown to her, the system required the generic name of midazolam). Vaught activated the cabinet’s override function. This was not unusual – Vaught herself later explained that nurses had been instructed to use the override function when they couldn’t access medications patients needed, and many experts have said that this is a common occurrence at lots of hospitals. Scanning the results, she selected what she thought was Versed, but was actually vecuronium: a neuromuscular blocking agent that causes full paralysis. She administered it to Charlene Murphey, a patient who had been on the cusp of going home. Charlene lost consciousness, suffered a cardiac arrest, and died.

Vaught immediately disclosed her errors. She told the truth.

The Medical Center terminated her employment in January 2018 after an internal investigation, but in fact recorded Murphey’s cause of death as natural causes and did not report the medication error to the authorities. It took a whistleblower and a federal investigation to bring the full picture to light. In 2022 (four years after the event) Vaught was convicted of criminally negligent homicide and abuse of an impaired adult. Her nursing licence was revoked as a result. Although a Tennessee Bureau of Investigation agent testified that the hospital had a “heavy burden of responsibility” for the error, no further action was brought against the institution.

The inversion here is stark: the nurse who admitted her mistake was prosecuted, whilst the institution that actively concealed its more structural and systemic role to avoid scrutiny got away with it. With echoes of Bawa-Garba, Vaught’s transparency became the mechanism of her prosecution.

“There is almost no human action or decision that cannot be made to look flawed and less sensible in the misleading light of hindsight.”
Sidney Dekker

As with Bawa-Garba’s incident, context is essential. The dispensing machines used drug naming conventions that made confusion easy. The override function existed precisely because the system regularly failed staff who needed to access medications quickly: indeed, staff had been taught how to use the override for exactly this reason. As far as Vaught could tell, the only way for Charlene to get the medication she needed was to bypass the system safeguards, which were designed to catch exactly this kind of error. 

But the dispensing cabinet was only part of it. There was no second-nurse verification required for medications pulled via override. Vecuronium – a paralytic agent with no legitimate emergency use case that would require rapid override access – should never have been available via that route at all. Vanderbilt removed it from the override list after Charlene’s death, a relatively simple safeguard that had always been available, but hadn’t been made. There was also no medicine barcode scanner in the radiology department where the drug was administered, which meant a standard check that would have caught the error at the bedside couldn’t happen. 

These are not factors that excuse what happened – Charlene Murphey died, and that matters very much – but they do help explain it, and there is a meaningful difference between explanation and absolution. If we address any one of those systemic factors, the outcome might have been different. If instead we focus only on the individual – blame, shame, retrain or dismiss – none of those conditions change. The next nurse walks into the same ward, faces the same broken system, and the same or very similar thing happens again.

The Observation Effect

Psychological safety is not primarily about our own direct experience. Most nurses will never be prosecuted for a clinical error. But when we observe it happen to someone else – someone who made a mistake, admitted it, tried to learn from it, and was then criminalised for it – it affects how we calculate the risks of speaking up and being open about our decisions and mistakes. We don’t need it to happen to us personally for the lesson to land. Vicarious experience is more than sufficient to alter our behaviour, even if those cases are very rare: we may observe 99 successful speaking up attempts, but if we observe just one where the consequences were severe, that’s the one that looms large.

The Bawa-Garba and Vaught cases sent a powerful signal, at large scale, across entire professions: that honesty about error carries serious risk, and that doing the right thing after a mistake offers no protection. Bawa-Garba’s case also showed that our reflective learning notes can be turned against us.

The result is all too predictable: clinicians become more guarded, errors go unreported, near-misses go undiscussed and reflective practice becomes performative rather than genuine. The very data that organisations need to improve patient safety is systematically suppressed. 

The Learn Not Blame campaign, which emerged in the UK partly in response to Bawa-Garba, and the widespread commentary from nurses and nursing bodies following the Vaught conviction, both speak to exactly this: that criminalising error doesn’t make healthcare safer: it produces a culture of silence, which ultimately results in far greater risk to the patients the system is meant to serve. 

Learning, or Punishing

RaDonda Vaught went to work on 26 December 2017 to help patients like Charlene Murphey. She went to work to do a good job. So did Hadiza Bawa-Garba on 18th February 2011, the day Jack Adcock was brought into her ward. Neither arrived intending to cause harm, but both were working in systems propped up by workarounds that were well known and under-addressed. When things went wrong, both did what we say we want people to do: they were honest about it.

A reasonable objection at this point: surely individuals must be “accountable”? Surely we can’t simply excuse errors because the system was imperfect?

Of course. And that’s not what anyone serious in this space is arguing. The point is not that we as individuals bear zero responsibility. It is that individual accountability and systemic learning are not the same thing; and treating them as equivalent, by prosecuting individuals as the primary response to systemic failure, produces neither justice nor, more importantly, improvement.

What happened to both Bawa-Garba and Vaught after the incidents speaks volumes about what it can cost a person to tell the truth, and about the gap between the cultures that organisations often say they want and the ones that get built. A Just Culture distinguishes between human error, at-risk behaviour, and recklessness. The vast majority of clinical errors fall into the first category: things that happen to competent, well-intentioned people working in imperfect systems. And somewhere right now, after one of those errors, a nurse is deciding whether or not to file an incident report, and a trainee doctor is wondering whether to write honestly in their reflective log. They are making that calculation in the shadow of, admittedly, rare cases like these, in systems that are intended to enable safe candour, but on occasion, dramatically fail to do so.

Vaught and Bawa-Garba weren’t reckless people. They were people doing their best in imperfect systems, who then did the right thing afterwards. If we want people to speak up, we have to make speaking up actually safe. That means in practice, not just in principle, and it means we need to take care of the next person who tells the truth. 

Note: This piece was researched in depth from multiple sources (many included below), but some factual errors may remain. We always welcome corrections and clarifications.

Further reading

Royal Court of Justice Final Judgement: https://www.judiciary.uk/wp-content/uploads/2018/08/bawa-garba-v-gmc-final-judgment.pdf

Back to blame: the Bawa-Garba case and the patient safety agenda – Deborah Cohen: https://www.bmj.com/content/359/bmj.j5534 

The role of reflection in the post Bawa-Garba era: https://www.rcp.ac.uk/news-and-media/news-and-opinion/the-role-of-reflection-in-the-post-bawa-garba-era/ 

Reflecting on the Bawa-Garba case: https://www.patientsafetylearning.org/blog/reflecting-on-the-bawa-garba-case 

Learn Not Blame campaign: dauk.org/campaigns/learn-not-blame

The Inside Story: Dr Hadiza Bawa-Garba: https://www.bbc.co.uk/news/resources/idt-sh/the_struck_off_doctor

Reconsidering the application of systems thinking in healthcare: the RaDonda Vaught case: https://pmc.ncbi.nlm.nih.gov/articles/PMC9724400/ 

Investigative approaches: Lessons learned from the RaDonda Vaught case: https://www.sciencedirect.com/science/article/pii/S2772501423000210 

The RaDonda Vaught Case: A Critical Conversation on Nursing Practice and Technology: https://aacnjournals.org/aacnacconline/article-abstract/34/1/11/31881/The-RaDonda-Vaught-Case-A-Critical-Conversation-on

Just culture: https://psychsafety.com/just-culture/

Human error: https://psychsafety.com/psychological-safety-human-error/

HOP Core Principles: https://psychsafety.com/the-hop-core-principles/

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Plan Continuation Bias, or “Get-There-Itis”

I got pretty sick this week. I was wiped out with a nasty bout of tonsillitis – high temperature, exhausted and felt awful. The doctor put me on strong antibiotics, painkillers, and told me, in no uncertain terms, to rest up and take it easy. 

What felt even worse than the illness was having to cancel a client workshop. As far as I can remember, we haven’t cancelled one in about four years. We usually manage to build in enough redundancy for someone else to deliver it, but this time, for various logistical reasons, it just wasn’t possible.

And we really wrestled with it. We spent far too long trying to find a way to make it work. Maybe I could load up on painkillers and caffeine. Maybe the 3 hour drive there, delivering the workshop, driving back and then collapsing wouldn’t be that bad. Maybe I could just power through on adrenaline. 

Looking back, I can see all the forces pulling us toward keeping the plan on track: a worry about disappointing the client; all the preparation, travel planning and childcare we’d already arranged; and, if I’m honest, the deeply normalised idea that “pushing through” is the right thing to do. All of that created a powerful feeling that we should still try to deliver.

In reality it would have been a very bad idea for me, for the client, and for other road users! Eventually, we contacted the client, postponed the session… and they were perfectly fine about rescheduling.

This fierce desire to continue with the plan, even though it no longer makes any sense, or is actually unsafe to do so, is a great example of plan continuation bias.

What Is Plan Continuation Bias?

Plan continuation bias (also known as get-there-itis in aviation, course correction bias, or “summit fever” in mountaineering) is the cognitive tendency to stick with an existing plan even when the conditions have changed and the plan no longer makes sense or isn’t safe to continue.

It’s best known in aviation, where get-there-itis means that pilots may press on with planned courses in bad weather, continue flights with marginal fuel, or persist with unstable approaches that should really demand a go-around. The same pattern is common in mountaineering, and I’ve got many experiences of this myself – I can particularly remember one occasion on Crib Goch where we reluctantly turned around after bad weather set in, but the decision itself was really hard, almost emotionally painful, because we were already well up onto the ridge.

It happens in healthcare too, where teams continue to attempt procedures when it’s time to stop or change (as in the tragic case of Elaine Bromiley), and we also see it in product or project teams, where people press on towards the original brief even though the context around them has completely changed.

It’s worth noting that plan continuation bias isn’t plain old stubbornness – it’s about how we humans make sense of the world, particularly when we’re under pressure, operating in uncertainty, and subject to social risk.

“You’ve got to know when to hold ’em, know when to fold ’em.”
— Kenny Rogers

Cognitive load and confirmation bias.

When we’re under high workload and time pressure, our attention naturally narrows on the task – the goal we’re trying to achieve. We may simply not have the bandwidth to process everything, and our confirmation bias means that we pay more attention to information that appears to support the plan, and discount, or don’t even see, information that suggests we should change course. So even when most of the signs point towards “turn back”, we cling to the scraps of evidence that say “it’ll be fine, keep going”.

This is one reason why we can often spot plan continuation in hindsight, and it can become something of a counterfactual, as “obviously wrong” after it’s already happened. Although to an outside observer afterwards, it seems obvious that we should have changed course, this may have been cognitively invisible to the person in the moment. 

Sunk cost fallacy

There’s a strong sunk cost element to plan continuation – when we’ve already invested time, money, effort, and reputation something, it means that stopping or changing direction feels like a failure: “We’ve put so much into this, we can’t stop now.”

But of course, that’s a fallacy, even though it feels right and noble to continue. It doesn’t make sense to keep pouring resources into something that’s no longer going to deliver value, or is actively unsafe to ourselves or others. Yet the more we have invested, and the closer we are to our goal, the more we tend to rationalise continuing.

Power, authority, and interpersonal risk

Plan continuation bias is compounded when the plan was defined by someone in power – a CEO, senior leader, major client, or powerful stakeholder. In these cases, we may well predict that challenging that goal is likely to incur interpersonal or career risk. None of us want to disappoint our boss, and challenging decisions that were made by someone with power over our employment status or career success is rarely easy. And of course, there are other risks too. We might worry that in raising concerns about the plan, we’ll be seen as a poor team player, as not being “committed enough”, or as the negative one in the group.

We humans tend to have a deep need for harmony and belonging, so continuing with the plan often feels more coherent, comfortable and socially safe than being the dissident who says, “We should stop.”

Symbolic goal fixation 

Some goals become symbolic of what overall “success” means – in mountaineering, it’s the summit, but in organisations, it might be a launch date, a target, or an OKR. This is especially true if that goal has been made public, or committed to with large posters and announcements. Sometimes organisations even use mountaineering metaphors to describe these lofty and ambitious goals. All this can mean that we drift into an all-or-nothing mindset where summit = success, and turning back = failure.

If you’ve read Jon Krakauer’s Into Thin Air about the Everest disaster in the ’90s (Everest is the colonial name for the mountain known locally as Sagarmāthā in Nepal and Qomolangma in Tibet), you’ll be familiar with this story: along with other errors and misjudgements, some climbers pushed for the summit even after bad weather set in and the safe window had closed. Summit fever, along with a great deal of sunk cost (it’s expensive to climb Everest, and climbers spend months preparing) meant that climbers became fixated on this singular goal of summiting Everest at any cost. For many of them, that cost was their lives. 

But as one of my climbing instructors used to say “Getting up is optional. Getting down is mandatory.” (I don’t think he was the first to say this!)

The same goes for organisations delivering projects and products: the real failure isn’t “we didn’t ship,” but shipping something that no longer makes sense and delivers no real value. It’s much wiser to be here the following day to try something new, than to risk the business, or our lives, on a potentially already failed project.

“Hazardous attitudes”

CRM (Crew Resource Management) in aviation talks about five “hazardous attitudes” that make plan continuation bias more likely:

• Macho: “I can handle it. I’m the expert.” This is practically one of the definitions of toxic masculinity: a sense of superiority, or an anxious need to prove oneself in the face of adversity.
• Impulsivity and a bias to action: “We should do something.” We often assume that action is better than inaction, and we tend to regret waiting, or pausing, more than we do taking a step – even a misguided one. In many organisations, people are punished more for not doing something (for holding back until they can make a better informed move) than for acting too quickly, even when it would make greater sense to pause and allow more information to surface.
• Invulnerability: “It won’t happen to me.” Success can incubate failure. Just because it’s gone right in the past, doesn’t mean it will this time. Indeed, if it had gone wrong in the past, we possibly wouldn’t even be here to make this judgement.
• Resignation: “What’s the use? I can’t change this.” We may feel that once we’ve settled on a plan, we’re stuck on the railway tracks, unable to change direction. But we are not trains – we can make decisions based on new information, and change direction. And even trains have brakes.
• Anti-authority: “I’m special. The rules don’t apply to me.” In so many books and movies, the hero is the subversive renegade who breaks the rules and succeeds. But real life doesn’t always play out the way movies do. Ignoring new risks because we believe we’re the exception doesn’t actually make the risk go away. 

All of these can mean that we’re more likely to press on than to pause, turn back, or “go around”.

Organisational Examples: Projects, Products, and OKRs

In product teams this shows up all the time. We might carry on building a feature even after a competitor has released something better and captured most of the market. We may stick to an OKR even though conditions have shifted and the objective is no longer a good idea. We become so fixated on achieving the “key result” that we stop asking whether it’s still a useful or sensible result. 

If the objective is the summit and the key result is “Reach the summit camp by 3pm”, what happens when a storm rolls in at midday?

In other cases in organisations, we simply keep burning money and time on a project that clearly won’t deliver the hoped-for return. Often because the goal has been cascaded from “higher up”, and as with symbolic goal fixation, not hitting it is framed as failure. “We said we’d deliver X by date Y” becomes more important than checking “Is X still the right thing to do?” This pressure intensifies when goals are publicly announced, a tactic often intended to “motivate” teams to deliver but which frequently drives teams to chase the original commitment rather than pursue the best outcome

Without psychological safety and sound decision practices, teams will often keep climbing to the summit because that’s the OKR, even when it’s clearly unsafe or pointless.

A Plan Continuation Feedback Loop

Plan continuation bias is dangerous because it becomes a feedback loop:

• The closer we get to the goal, the harder it feels to turn back.
• The more we invest, the more we rationalise continuing.
• The more things go wrong, the more urgent it feels to “just get it done”.

Research in aviation suggests that a large proportion of decision errors, (some suggest the majority of errors) are essentially plan continuation errors: pressing on when the safer option was to stop, divert, or go around. Charles West wrote about this goal proximity dynamic in “The Barn Door Effect”: pilots who would normally deviate widely around severe convective weather while en route often continue final approaches directly beneath dangerous thunderstorms when landing, simply because they can see the runway (the “barn door”) and because aircraft ahead of them have done so successfully (social proof of the Normalisation of Risk).

This certainly isn’t unique to pilots. It’s fundamental to how humans behave in dynamic, uncertain environments.

Where Psychological Safety Fits with Plan Continuation Bias

Psychological safety doesn’t magically remove plan continuation bias, but it can provide some counter-pressure that helps to interrupt this feedback loop. In groups with higher psychological safety, people are generally more willing to say things like “Are we still doing the right thing?”, and point out issues like a storm coming or a competitor’s similar product launch. People feel safer in pulling the Andon Cord, call to Stop Work, or suggest a go-around. 

However, in teams with lower psychological safety, plan continuation bias is structurally reinforced, because people are more likely to stay silent with those insights, perspectives or concerns. If we’re in a team with low psychological safety, we don’t want to disrupt the group harmony, offend someone in power, or risk damaging our own status or reputation. We may end up pressing ahead not because it’s the right thing to do, but because it feels less interpersonally risky than challenging the plan itself.

How to Reduce Plan Continuation Bias

Plan continuation bias is a deeply human tendency shaped by many different cognitive biases and heuristics, so we can’t eradicate it, but we can reduce its impact through some practical approaches:

1. Define exit criteria in advance. We agree in advance that if certain criteria are met, we stop, change direction, or take an opportunity to re-evaluate. For example, if a competitor releases an equivalent or potentially better product, we reconsider the business case. Or if certain safety thresholds are crossed – deteriorating weather conditions or issues with the equipment – we pause or “go around”. Pre-defining the criteria for interrupting the loop takes some of the emotional and interpersonal load off making the call in the moment.

2. Establish decision points at regular intervals. Similar to above, we can also build in regular check-in points to re-evaluate and consider “Should we still be doing this?” or simply regularly ask ourselves “Do we continue, pivot, or stop?”. If we were climbing a mountain, we may check in every 30 minutes and simply ask “Are we all still good to go?” The point is to deliberately reopen the question, not simply assume the plan is still valid.

3. Invite dissent explicitly. Sometimes called “devil’s advocate”, but I prefer the less evocative and more straightforward practice of “inviting dissent” by asking things like “What are we missing?”, “How could we see this differently?”, or even “We’re not leaving this meeting until we’ve heard five reasons why this is a bad idea.” We may even designate a small “red team” whose job is to be strategically awkward: to poke holes in the plan and look for reasons we shouldn’t continue.

4. Train people to recognise hazardous attitudes. This is deeper work, often part of CRM and similar training, to help people notice these hazardous attitudes emerging – in themselves and in others. That might include an inappropriate bias to action, a sense of invulnerability, resignation or resistance to authority. The aim isn’t to blame or single people out, but to build shared literacy and the skill to spot and respond to the attitudes that make continuation bias more likely.

5. Build diverse teams. The more diverse the team in background, expertise, perspectives, and experience, the more likely it is that people in the team will see what others have missed. Diversity, in its many facets, increases the chances that someone will notice the storm building on the horizon.

6. Finally, normalise and reward course correction. This is perhaps the biggest cultural shift, and the most impactful (but rather more difficult, organisationally). Stopping, cancelling, or changing course when it no longer makes sense to continue should be seen as success, not failure. That might look like celebrating teams who say, “This project no longer makes sense so we’re stopping it and moving onto something of higher value,” or explicitly rewarding people who highlight new risks or factors reducing the value of a project. Storytelling can be a powerful tool here too, by having open discussions about times when not continuing saved money, delivered greater value, or saved lives. Fundamentally, changing the plan should be framed as competent, expert, adaptive behaviour, not as failure.

Summarising Plan Continuation Bias

Reflecting on this piece, I’d describe plan continuation bias like this: 

Plan continuation bias is the cognitive, emotional and social tendency to stick with an established plan even when new information or changing conditions mean it no longer makes sense, is unlikely to deliver value, or increases risk to intolerable levels. It’s amplified by confirmation bias, workload and pressure, ever higher sunk costs and proximity to the goal, symbolic goal fixation, power dynamics, and the myriad interpersonal risks of challenging the plan; and it often leads individuals and teams to press on long after they should adapt or stop.

And sometimes, avoiding it is as simple (and as difficult) as admitting that you might be too poorly to drive across the country and deliver a workshop.

Further resources on plan continuation bias:

Managing Plan Continuation Bias with Mike Adolph on the Delivering Adventure Podcast

Orasanu, J., Martin, L., Davison, J. and Null, C.H., 1998, January. Errors in aviation decision making: Bad decisions or bad luck?. In Fourth Conference on Naturalistic Decision Making. https://ntrs.nasa.gov/api/citations/20020063485/downloads/20020063485.pdf 

“Just a Routine Operation” Martin Bromiley.

Continuation Bias: SKYbrary Aviation Safety. https://skybrary.aero/articles/continuation-bias

West, C.A., 2009. The “Barn Door” Effect. In Proceedings of the 14th Conference on Aviation, Range, and Aerospace Meteorology. https://ams.confex.com/ams/pdfpapers/162457.pdf 

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Counterfactuals

If, like me, you grew up during the Friends era, you might remember the scene where Ross is upset because he has to tell Rachel that Emily insists they can’t be friends.

Ross: “I don’t want Rachel to hate me. I don’t know what to do.”
Joey: “You want my advice?”
Ross: “Yes! Please!”
Joey: “You’re not gonna like it.”
Ross: “That’s ok.”
Joey: “You got married too fast.”
Ross: “That’s not advice!”
Joey: “I told you.”

For once, Ross is absolutely right. That isn’t advice. It’s a counterfactual: a redundant statement that sounds wise because the outcome is already known. It’s the illusion of clarity after the fog has lifted, after the complexity has collapsed into certainty. We all know the feeling of wanting to tell someone (or rather often ourselves) what should have been obvious. But that sense of “obviousness” only exists from where we’re standing now, in 20/20 hindsight, not from where the decision was made.

Counterfactuals are seductive. They tidy up messy stories. “If only we’d done X.” “If only they’d noticed Y.” They sound analytical, but they’re fictional. As the saying goes, “If my grandmother had wheels, she’d be a bicycle.” Once we start changing the facts, we’re not talking about reality anymore: we’re imagining a different one that didn’t happen.

It’s easy to laugh at Joey, but we all do it. Just look at all the hot takes on the large AWS outage this week. We look back at a failed project, a near miss, an incident or accident, and feel the seductive pull of “they should have..” or “they shouldn’t have…” because we crave causality and coherence. When something goes wrong, we want to believe that there was a single point of failure that we can fix for next time, reassuring ourselves that it won’t happen again. But as Dekker reminds us, 

“…[counterfactuals] make you spend your time talking about a reality that did not happen (but if it had happened, the mishap would not have happened.)” (Dekker, The Field Guide to Understanding Human Error, 2006, p. 39). 

Counterfactuals don’t actually explain why people acted as they did. 

Hindsight gives us the feeling that we’re seeing more clearly, when in fact we’re seeing differently. It turns messy events into clean, neat, linear stories where the outcome seems inevitable. After the fact, we reconstruct a chain of events so neatly that it feels like it couldn’t have unfolded any other way. But at the time, it could have unfolded many ways.

In complex systems, whether in tech, healthcare, or flying planes, everything seems to make sense until it suddenly doesn’t. Karl Weick describes this as the “collapse of sensemaking”, where a lack of relevant information, conflicting or contradictory data, distractions, or cognitive biases prevent accurate interpretation of the situation. As Richard Cook said, “All practitioner actions are gambles.” Every decision is made under various degrees of uncertainty, using local cues, imperfect data, and competing goals, constraints and pressures. When we uncritically apply hindsight, we risk erasing that uncertainty and turning those gambles into moral judgments. A decision that led to a failure is considered a mistake; but the same decision, if it led to success, is considered high expertise. The same action has a different label depending on its outcome.

This is the core of counterfactual thinking: imagining an alternative world where things turned out differently. Psychologists describe two main types:

• Upward counterfactuals: “We’d have been ok if we had…”, which can be painful but sometimes useful. If we’re careful in their use, they help us see what might be improved for the future.
• Downward counterfactuals: “It could have been worse…”, which might feel comforting and soothing, but is rarely instructive.

Both kinds risk making the world seem more controllable than it really is. Counterfactuals whisper in our ear that different choices would have guaranteed a different outcome. But the real world doesn’t work like that – if we change one variable, the network of interactions shifts in unpredictable, potentially cascading ways. And there’s no control group for the past: we can’t A/B test reality, so we can’t really say that another approach would have turned out differently.

Dekker calls counterfactual reasoning one of the biggest traps in investigation. It’s not that counterfactuals are evil, because used effectively, they can help us think about future prevention – but they can’t explain human behaviour. Saying what people didn’t do tells us nothing about why they did what they did. To learn, we have to reconstruct what the world looked like from their perspective at the time, not ours. To paraphrase Dekker – we need to get in the tunnel with them.

That reconstruction (the “unfolding mindset”) is the work of effective investigation and learning. It means asking what information was available and visible, what explicit and implicit goals were people working towards, what pressures, constraints and distractions were present, and what state the people were in. It’s slower and messier than counterfactual shortcuts, but it’s the only way to understand Local Rationality – why a decision that now looks foolish made sense at the time.

This connects directly to psychological safety. Psychological safety isn’t just about speaking up in the present: it’s about how we talk about the past. Do people feel safe to be candid about their past actions, decisions, perspective and pressures? When we replay an incident, do we talk about what people missed, or do we ask what they saw? Do we focus on what should have happened, or on what actually made sense given their constraints and context? Do we treat decisions as expert gambles rather than tests of character? The way we tell the story shapes whether we learn or blame (and in the majority of cases, we can’t do both).

Put hindsight, counterfactuals, and the fundamental attribution error together, and we get a recipe for unhelpful investigation:

1. Hindsight bias says the outcome was obvious.
2. Attribution error says someone failed to see it because of who they are.
3. Counterfactuals provide the tidy fix: “They should have done X.”

A disturbing number of real incident reports follow this pattern.

The alternative is slower but more honest: reconstruct rather than rewrite. We can attempt to reconstruct the unfolding mindset of the people involved. We can ask what looked risky or safe from their vantage point. As Dekker and David Woods both emphasise, people’s actions almost always make sense in context, even if that context is now invisible to us.

James Reason’s “substitution test” can help here – asking whether another well-motivated, equally competent person might have done the same thing in that situation. 

“Substitute the individual concerned, for someone else coming from the same domain of activity and possessing comparable qualifications and experience. Then ask the question ‘In the light of how events unfolded and were perceived by those involved in real time, is it likely that this new individual would have behaved any differently?’”

If the answer is yes, the issue isn’t the person, it’s the system. However, there’s a big caution here: the substitution test is highly vulnerable to hindsight too because we still have to reconstruct the at-the-time context before we apply the test.

Here are a few practical ways to mitigate counterfactual reasoning and shift our posture from judgment to learning:

• Consider various alternatives to the actual outcome. Explore how it may have unfolded in different ways
• Name the bias early. Simply saying, “Let’s watch for hindsight bias.” can help people notice when it creeps in. It’s not a fix though.
• Reconstruct, don’t rewrite. Ask things like “What did we know then?” and “What options looked viable?” Try to keep current knowledge out until the end.
• Use neutral language. “The decision was made based on X,” instead of “Bob failed to see Y.”
• Broaden the view. Bring in different roles, disciplines, and perspectives. Complexity looks different from other angles.
• Reframe counterfactuals as system questions. Instead of “They should have…” ask “What features of the system made that outcome more likely?”
• Separate accountability from blame. Accountability can coexist with empathy, apologies and amends, but without context, accountability is just punishment.
• Don’t ignore emotional counterfactuals. “I wish I’d done X instead of Y” can be a healthy part of processing regret. It helps us move on before real learning begins.

Joey, like most of us, was satisfied by a simple story, rewritten with 20/20 hindsight. But the real world doesn’t work that way. The goal of learning isn’t to find who “should have known better” – it’s to understand how the system and context made that decision a rational one at the time, and how we can make better outcomes more likely in the future.

Further Reading

• Types of Human Error: https://psychsafety.com/psychological-safety-human-error/ 
• Work as Imagined vs Work as Done: https://psychsafety.com/psychological-safety-work-as-imagined-vs-work-as-done/ 
• Meadows, S., Baker, K. and Butler, J., 2005. The incident decision tree: guidelines for action following patient safety incidents. Advances in patient safety: from research to implementation, 4, pp.387-399.
• Weick, K. (1993). The collapse of sensemaking in organizations: The Mann Gulch disaster. Administrative Science Quarterly, 3: 628–652.
• Woods, D. D., Dekker, S., Cook, R., Johannesen, L., & Sarter, N. (2010). Behind Human Error (2nd ed.). Farnham: Ashgate Pub Co.
• Vaughan, D. (2009). The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. University of Chicago Press.
• Dekker, S. (2003). Failure to adapt or adaptations that fail: contrasting models on procedures and safety. Applied Ergonomics, 34(3), 233—238. doi:10.1016/S0003-6870(03)00031-0
• REASON, J. (1990). Human error. New York: Cambridge University Press.
• Reason J. Managing the risks of organizational accidents. Aldershot: Ashgate Publishing Group; 2003. pp. 191–222.
• Richard Cook. How Complex Systems Fail. https://how.complexsystems.fail/ 
• Why Are All the Smart People So Bad at History? Joan Westenberg. https://web.archive.org/web/20250418033302/https://www.joanwestenberg.com/why-are-all-the-smart-people-so-bad-at-history/ 
• Allspaw, J. Counterfactual Thinking, Rules, and The Knight Capital Accident https://www.kitchensoap.com/2013/10/29/counterfactuals-knight-capital/ 
• Dekker, S. (2006). The Field Guide to Understanding Human Error. Ashgate Publishing, Ltd. https://www.humanfactors.lth.se/fileadmin/lusa/Sidney_Dekker/books/DekkersFieldGuide.pdf 

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Psychological Safety in Practice

Stammering and speaking on the phone

For people who stammer, stutter, tic, or have other speech differences, phone calls can be a nightmare. Just the pressure of having to speak at the right time, and the fear that being silent for too long means the call could be dropped, can be overwhelming. Everyone who knows me knows that I absolutely hate speaking on the phone! 

If you stammer, it could mean that when you finally get through to your GP after a long wait, you get hung up on because they think you’re not there. This report shows that many people with a stammer often can’t get through voice recognition systems, and are sometimes hung up on when they stammered on a call.

This amazing campaign by Stamma encourages businesses “Don’t hang up, hang on” and give people time to speak. Find out more here. 

Staying on stammering, this is a powerful episode of the Distraction Pieces Podcast with Scroobius Pip, titled “Dissecting Disfluency” with Cherry Burns). In this, Pip discusses his stammer, and how stammering is not the problem, it’s how the world meets the stammer that is the problem.

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Neuroinclusivity and psychological safety

As we so often say, psychological safety looks different for everyone, but most psychological safety models assume that everyone processes feedback, attention, and risk the same way. Nicola Knobel pulled together this great aggregation of neurodiversity and psychological safety research, and put it into this table:

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Imagining and implementing a responsibility culture in healthcare

Here’s a great paper by Philip Berry about patient safety and investigations, and trying to find the balance between delivering what many patients wish to see and fostering a culture that is not centred on blame – which seems very hard to achieve. 

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