About Jane

Jane CartheyDr Carthey was previously Assistant Director of Patient Safety (South) and Head of Research at the National Patient Safety Agency, where she led work on being open and safety culture. She also previously worked at the Health and Safety Laboratory in Sheffield. Her PhD research explored teamwork, communication and decision making during simulated nuclear emergency exercises.

Jane maintains an active research portfolio and has published research on human factors and surgical outcomes, identifying system failures that lead to adverse drug events, incident reporting, organisational safety culture, procedural non-compliance and improving Hospital at Night handovers.

She has expertise carrying out governance reviews in healthcare organisations and working with NHS Boards to improve their safety culture. She also has extensive experience working with doctors, nurses, allied healthcare professionals and executive directors on implementing human factors, being open, incident investigation and quality improvement innovations.

Human factors expertise:

  1. Re-designing handovers
    Dr Carthey was commissioned to develop a safe, efficient and reliable system to handover patients from day to Hospital at Night (H@N) teams in a NHS paediatric specialist hospital. Observation, interviews, task analysis, failure modes and effects analysis, document and case note review, were used to explore the impact of the different handover protocols on handover performance.  A human-factors based handover was introduced in response to problems identified with the handover protocol in place when the study started. The HF-based handover included implementing a prioritisation system whereby the sickest patients would be “flagged” at the start of the handover, facilitating H@N induction to junior doctors and senior nurses, revising handover start time, staggering shifts, using Situation Background Assessment Recommendation (SBAR), read-backs, and safety huddles. Results showed that the human factors-based handover was better at identifying acutely unwell patients or patients who might potentially deteriorate overnight.
  2. Systems re-design to improve policy compliance
    In 2012, Jane worked with a London based acute Trust to identify and eradicate ‘systems factors’ that lead to policy non-compliance. ‘High risk’ Trust-wide clinical policies, (i.e. those where non-compliance could lead to serious patient or staff safety, reputation issues), were identified using a bespoke risk assessment matrix (developed by Dr Carthey).In the next phase of the work, interactive clinical vignettes were written. The vignettes included examples where staff non-compliance with policies and procedures had increased risk. These were used to educate and raise awareness of the consequences of non-compliance amongst healthcare staff in two multi-disciplinary workshops facilitated by Dr Carthey.During the workshops, data was collected on how long it took doctors, nurses and pharmacists to locate policies on the Trust intranet site using a ‘hide and seek’ task. Feedback from healthcare staff about the usability of specific policies was also collated by asking workshop participants to write ‘postcards to policy authors.’This information was then fed back to policy authors in a separate workshop and structured brain-storming was used to identify solutions to improve existing practice in developing and disseminating Trust-wide policies and procedures.As a result of the work, senior managers in the Trust now understand that policy compliance is a systems problem. The Trust is implementing a range of solutions (including re-designing the intranet and increasing clinical staff engagement in policy development) to ensure that policies and procedures work in the real world.

Consultancy services:

  1. Improving patient safety    
    Jane has led work in several acute trusts, for a hospice charity, a UK-based community pharmacy chain, and national agencies and with general practitioners to raise awareness of and to implement human factors. Her consultancy experience includes carrying out external reviews of the quality of incident investigation, leading strategic risk assessment work with Boards, developing a tool to enhance foresight in a community pharmacy setting and educational material on patient safety (including e-learning and interactive workshops for GPs, junior doctors, nurses and allied healthcare professionals). She also has expertise on improving safety culture and teamwork.
  2. External board governance reviews
    Jane carries out governance reviews for UK higher education and NHS Boards. Human factors experts see leadership, teamwork, workload and organisational processes through a unique lens. Using her ethnographic and research expertise, she recently worked with directors and Chairs in a UK higher education Board. The review identified gaps in existing governance structures, as well as Board membership, teamwork and leadership issues.  The outcomes of the review created an impetus for senior managers to implement more robust governance structures and improve the Board’s culture.
  3. Mentoring clinical teams to lead quality improvement work
    In a recent role at a NHS acute foundation trust, Jane mentored ward sisters, pharmacists and consultants to lead quality improvement work. This involved facilitating workshops on quality improvement, as well as one-to-one mentoring on projects aimed at reducing readmissions by implementing quality improvement solutions and improving anticoagulation safety by PDSA testing run charts with patients and carers.



  1. Human factors and surgical outcomes
    As the lead human factors researcher on the landmark human factors and outcomes of the neonatal arterial switch study, Jane observed over 100 neonatal arterial switch procedures. She was able to maintain the engagement of paediatric cardiothoracic operating theatre teams at a time when the profession was under great scrutiny.The study, carried out in the early 1990s, led to a better understanding of how minor and major errors impact on surgical outcomes. It was published in the Journal of Thoracic and Cardiovascular Surgery and the Annals of Thoracic Surgery.
  2. Understanding policy compliance in healthcare
    Non-compliance with policies and procedures contributes to incidents, claims and complaints in healthcare.Research in other industries has shown that individual, team and organisational factors lead to non-compliance with policies and procedures (see Table 1).2-7 Taking a ‘systems approach’ to understanding why healthcare staff  do not comply with policies and procedures is essential. Dr Carthey’s research on policy non-compliance identified that in healthcare, volume, accessibility, length and failure to engage clinical staff when writing policies are some of the systems problems that need to be addressed to improve levels of compliance and safety.Table 1.0: Individual, team and organisational factors that increase non-compliance

Factors that lead to non-compliance with policies and procedures
  1. Perceived low likelihood of detection
  1. Lack of awareness/understanding of policies and procedures
  1. Misperception or lack  of recognition of risk
  1. Self-perceived authority  to violate
  1. Time pressure/pressure to get the job done
  1. Copying behaviour  (i.e. learn to  do the procedure from a colleague who is non-compliant)
  1. Lack of leadership
  1. Lack of end-user engagement when policies and procedures are written.
  1. Policy and procedure overload (for example, confusion over which procedure applies when)
  1. Ambiguous or conflicting messages in the policy/procedure
  1. Lack of training and reinforcement of key policy messages over time.
  1. No sanctions imposed for non-compliance
  1. Lack of monitoring systems to check procedural compliance
  1. Policies  and procedures are inaccessible
  1. Out of date procedures/policies
  1. Mismatch between the policy/procedure and how the job is actually done.

  1.  Measuring and monitoring safety
    Recently, Dr Carthey co-authored The Health Foundation report on The Measurement and Monitoring Safety (Vincent, Burnett and Carthey, 2103). The report provides a coherent framework which organisations can use to self-assess their current approach to measuring safety.


  1. hHuman factors workshops
    Many healthcare professionals do not understand what how human factors science could be applied to their clinical areas to improve safety. One of Jane’s roles is to raise awareness of human factors by facilitating interactive workshops. Workshop content includes human cognition, human error theories, systems re-design, teamwork, situational awareness, leadership and applying human factors methods.
  2.  Incident investigation
    Systematic incident investigation training and mentoring are two other services that Jane provides. She facilitates group workshops on root cause analysis and also offers one-to-one mentors for newly trained incident investigators. Bespoke training programmes can be developed and delivered on request.
  3.  Apologising and explaining what went wrong
    Formerly the lead for the NPSA’s Being open training and guidance, Jane has extensive experience training executive directors, consultants, senior nurses and managers how to give empathetic apologies to patients and carers. Simulations are used in interactive training sessions that provide healthcare professionals with a framework to approach offering apologies to patients and carers.
    One-to-one mentoring for healthcare professionals on how to give apologies and explanations is also available (and is often useful in the aftermath of a serious incident).