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I love Berwick, nice chap with a good heart, who's done some great stuff. But on this occasion he's out of his depth - his favourite Deming-only approach to process engineering ain't going to cut the mustard.

"Zero Harm" means intolerance: it means blaming not learning; it means compliance to orthodoxy not professional judgement; it means historical evidence not cutting edge practice; and it means killing the sort of innovation and development that has made the NHS world leading. The old fail-safe industrial theories are mostly irrelevant, read some Weick, Reason, or Vincent. Modern complex human system must be, safe to fail, assuming the presence of and necessity to recognise, prevent and (when it inevitably occurs) recover from, failure.

What Berwick really mean is Less Avoidable Harm, but for that, you need a professional debate that the politicians couldn't possibly engage in!

Less (failure created by standardised processes that were not applicable in the situation and for the person who ended up getting hurt by staff that are made to comply with doctrine, rather than practice the situational awareness and adaptability that command and control organisations will beat out of them) Harm. People know what harm means, but it has been academically redefined for convenience, and the ZERO is a harmful message.

Healthcare is bloody dangerous and most people should be doing their utmost never to be anywhere near it. We put people in harms way deliberately, with their consent, and for their own greater good. Surgery is dangerous, it takes effort to recover from knocking you out and cutting you open, let alone the problem it's aimed to overcome. Chemotherapy deliberately poisons people to try and save their life and it is bloody crippling! Zero harm means zero science, no risk taking, no experimentation and no building the new science that makes the old assumptions of evidence, irrelevant.

http://en.wikipedia.org/wiki/Zero_tolerance

Zero Tolerance doesn't work, because in the real world it means that diversity is unacceptable. It is based on old fashioned monotheistic dogma that people must comply to an ideology, no matter what the situation. It means the kind of secretive, hidden, protectionist fog of a culture that creates Mid Staffs. Zero is a fascist ideology, or perhaps from my favourite philosophers, "only a sith deals in absolutes"!

In the real clinical world some people fight every step of the way, with anything and everything they can get their hands on, all the way down to the day that they die ... so that you won't have to.