This suggests a culture problem.

The correct use of the incident form would be to report “incorrect name on band” and then to rapidly understand root cause by using humble inquiry and curiosity, with immediate safeguard in place to prevent recurrence. https://twitter.com/eileenc_foster/status/1327760223566778368

Use of a structured problem-solving techinique is key to this, and a fundamental part of the @NorthMidNHS partnership with @westernsussex as we continue down our continuous improvement journey https://planet-lean.com/what-is-a3-thinking/

And for those who get a bit sniffy about continuous improvement - a great example of A3 thinking is the way we take a medical history - what’s the problem, what’s the background, what further investigations/data do I need, what’s the plan, when will I review it?

In medical history taking we are tough on the presenting complaint, not the person. The same approach must be taken to wider improvement in the NHS. @gilbert_helen