1. Transforming Culture & Improving Clinical Care in the Scottish Ambulance Service through Human Factors Karen Wilson Alison Ferahi Gary Rutherford Colin Crookston

2. National provider of pre-hospital care 4,076 Staff 666,857 A&E Incidents 1,170,105 PTS journeys 3,235 Air Ambulance Missions Context

3. From blame culture to just culture From person-specific to Root Cause & Human Factors From censure to learning opportunities Our Journey

4. Variety of ways of getting there: Significant Adverse Event Process Cultural work OD work & Flying Lessons 3RU project Education Person-centred health & care programme Delivering Future Leaders & Managers