This report looks at how we can identify red flags and harmful patterns of behaviour in healthcare.
We commissioned the Patient Experience Library to analyse warning signals from avoidable harm inquiries in health and social care. The report finds harmful patterns in behaviour and cultures, and the red flags that can help to identify them.
The outcome of the analysis includes the Red Flag Tracker tool, which compiles evidence from the 10 years of inquiries used for the report. This can help anyone who feels something is “not quite right” to check their initial concerns against evidence.
Download the full report
Purpose of the report
We commissioned the report to draw out the patterns of harm in organisational and professional behaviour.
It uses an evidence-based approach to help develop a common language and identify red flags that can be used to:
- recognise avoidable harm
- break harmful patterns
- understand what poor and harmful cultures look like
- open up evidence-based conversations
- support organisational learning and training.
Findings
The report found that where there is a problem, it usually involves multiple people who have failed to spot or deal with avoidable harm.
It identifies 3 states in which problem cultures can give rise to failures:
- complacency
- avoidance
- denial.
It further identifies 6 different organisational subcultures that feed into an overall harmful culture where failures happen. These are:
- reporting culture
- compliance culture
- caring culture
- teamwork culture
- accountability culture
- learning culture.
Through these findings, a framework to help spot red flags in harmful cultures was set out.
Red Flag Tracker
Based on these organisational subcultures and states, the Patient Experience Library developed the Red Flag Tracker. This is an online resource and tool that groups ‘red flags’ and provides a framework to identify and report on an organisational culture in which safety failures are more likely to occur.
Using filters, you can find quotes and full inquiry reports related to specific red flags, roles in the healthcare system, and cultures. This allows them to be better understood and shared with others.