To Err Is Human

To Err Is Human PDF Author: Institute of Medicine
Publisher: National Academies Press
ISBN: 0309068371
Category : Medical
Languages : en
Pages : 312

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Book Description
Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

To Err Is Human

To Err Is Human PDF Author: Institute of Medicine
Publisher: National Academies Press
ISBN: 0309068371
Category : Medical
Languages : en
Pages : 312

Get Book Here

Book Description
Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

I Am Error

I Am Error PDF Author: Nathan Altice
Publisher: MIT Press
ISBN: 0262534541
Category : Computers
Languages : en
Pages : 439

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Book Description
The complex material histories of the Nintendo Entertainment System platform, from code to silicon, focusing on its technical constraints and its expressive affordances. In the 1987 Nintendo Entertainment System videogame Zelda II: The Adventure of Link, a character famously declared: I AM ERROR. Puzzled players assumed that this cryptic mesage was a programming flaw, but it was actually a clumsy Japanese-English translation of “My Name is Error,” a benign programmer's joke. In I AM ERROR Nathan Altice explores the complex material histories of the Nintendo Entertainment System (and its Japanese predecessor, the Family Computer), offering a detailed analysis of its programming and engineering, its expressive affordances, and its cultural significance. Nintendo games were rife with mistranslated texts, but, as Altice explains, Nintendo's translation challenges were not just linguistic but also material, with consequences beyond simple misinterpretation. Emphasizing the technical and material evolution of Nintendo's first cartridge-based platform, Altice describes the development of the Family Computer (or Famicom) and its computational architecture; the “translation” problems faced while adapting the Famicom for the U.S. videogame market as the redesigned Entertainment System; Nintendo's breakthrough console title Super Mario Bros. and its remarkable software innovations; the introduction of Nintendo's short-lived proprietary disk format and the design repercussions on The Legend of Zelda; Nintendo's efforts to extend their console's lifespan through cartridge augmentations; the Famicom's Audio Processing Unit (APU) and its importance for the chiptunes genre; and the emergence of software emulators and the new kinds of play they enabled.

ATC System Error and Appraisal of Controller Proficiency

ATC System Error and Appraisal of Controller Proficiency PDF Author: William F. O'Connor
Publisher:
ISBN:
Category : Ability
Languages : en
Pages : 20

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Book Description
The report presents suggestions for the design of an air traffic control (ATC) incident-reporting system aimed at maximizing the amount of corrective feedback to the ATC system. The approach taken is system-oriented rather than controller-oriented. Included is a discussion of a philosophy of corrective and punitive action relative to controller involvement in an incident. Recommendations and examples of format are included for the design of incident-report forms and incident chronology and of a checklist to be used in periodic appraisal of controller performance. Emphasis is given in format design to use of systems and human function, rather than regulatory and procedural terminology. Implementation and data-analysis techniques are also discussed. (Author).

Just Giving

Just Giving PDF Author: Rob Reich
Publisher: Princeton University Press
ISBN: 0691202273
Category : Philosophy
Languages : en
Pages : 258

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Book Description
The troubling ethics and politics of philanthropy Is philanthropy, by its very nature, a threat to today’s democracy? Though we may laud wealthy individuals who give away their money for society’s benefit, Just Giving shows how such generosity not only isn’t the unassailable good we think it to be but might also undermine democratic values. Big philanthropy is often an exercise of power, the conversion of private assets into public influence. And it is a form of power that is largely unaccountable and lavishly tax-advantaged. Philanthropy currently fails democracy, but Rob Reich argues that it can be redeemed. Just Giving investigates the ethical and political dimensions of philanthropy and considers how giving might better support democratic values and promote justice.

Ten Questions About Human Error

Ten Questions About Human Error PDF Author: Sidney Dekker
Publisher: CRC Press
ISBN: 1410612066
Category : Technology & Engineering
Languages : en
Pages : 233

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Book Description
Ten Questions About Human Error asks the type of questions frequently posed in incident and accident investigations, people's own practice, managerial and organizational settings, policymaking, classrooms, Crew Resource Management Training, and error research. It is one installment in a larger transformation that has begun to identify both deep-rooted constraints and new leverage points of views of human factors and system safety. The ten questions about human error are not just questions about human error as a phenomenon, but also about human factors and system safety as disciplines, and where they stand today. In asking these questions and sketching the answers to them, this book attempts to show where current thinking is limited--where vocabulary, models, ideas, and notions are constraining progress. This volume looks critically at the answers human factors would typically provide and compares/contrasts them with current research insights. Each chapter provides directions for new ideas and models that could perhaps better cope with the complexity of the problems facing human error today. As such, this book can be used as a supplement for a variety of human factors courses.

Site Reliability Engineering

Site Reliability Engineering PDF Author: Niall Richard Murphy
Publisher: "O'Reilly Media, Inc."
ISBN: 1491951176
Category :
Languages : en
Pages : 552

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Book Description
The overwhelming majority of a software system’s lifespan is spent in use, not in design or implementation. So, why does conventional wisdom insist that software engineers focus primarily on the design and development of large-scale computing systems? In this collection of essays and articles, key members of Google’s Site Reliability Team explain how and why their commitment to the entire lifecycle has enabled the company to successfully build, deploy, monitor, and maintain some of the largest software systems in the world. You’ll learn the principles and practices that enable Google engineers to make systems more scalable, reliable, and efficient—lessons directly applicable to your organization. This book is divided into four sections: Introduction—Learn what site reliability engineering is and why it differs from conventional IT industry practices Principles—Examine the patterns, behaviors, and areas of concern that influence the work of a site reliability engineer (SRE) Practices—Understand the theory and practice of an SRE’s day-to-day work: building and operating large distributed computing systems Management—Explore Google's best practices for training, communication, and meetings that your organization can use

Error Control Systems for Digital Communication and Storage

Error Control Systems for Digital Communication and Storage PDF Author: Stephen B. Wicker
Publisher:
ISBN:
Category : Computers
Languages : en
Pages : 536

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Book Description
For introductory graduate courses in coding for telecommunications engineering, digital communications. This introductory text on error control coding focuses on key implementation issues and performance analysis with applications valuable to both mathematicians and engineers.

Improving Diagnosis in Health Care

Improving Diagnosis in Health Care PDF Author: National Academies of Sciences, Engineering, and Medicine
Publisher: National Academies Press
ISBN: 0309377722
Category : Medical
Languages : en
Pages : 473

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Book Description
Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€"has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.

Human Reliability and Error in Medical System

Human Reliability and Error in Medical System PDF Author: Balbir S. Dhillon
Publisher: World Scientific
ISBN: 9812795235
Category : Medical
Languages : en
Pages : 233

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Book Description
Human reliability and error have become a very important issue in health care, owing to the vast number of associated deaths each year. For example, according to the findings of the Institute of Medicine in 1999, around 100000 Americans die each year because of human error. This makes human error in health care the eighth leading cause of deaths in the US. Moreover, the total annual national cost of the medical errors is estimated at between $17 billion and $37.6 billion. There are very few books on this subject, and none of them covers it at a significant depth. The need for a book presenting the basics of human reliability, human factors and comprehensive information on error in medical systems is essential. This book meets that need. Contents: Human Reliability and Error Mathematics; Human Factors Basics; Human Reliability and Error Basics; Methods for Performing Human Reliability and Error Analysis in Health Care System; Human Error in Medication; Human Error in Anesthesia; Human Error in Miscellaneous Health Care Areas and Health Care Human Error Cost; Human Factors in Medical Devices; Mathematical Models for Predicting Human Reliability and Error in Medical System; Health Care Human Error Reporting Systems and Data; Appendix: Bibliography: Literature on Human Reliability and Error in Health Care. Readership: Health care and safety professionals, administrators, students, human-factors/psychology specialists, biomedical engineers and health care researchers.

A Human Error Approach to Aviation Accident Analysis

A Human Error Approach to Aviation Accident Analysis PDF Author: Douglas A. Wiegmann
Publisher: Routledge
ISBN: 1351962353
Category : Technology & Engineering
Languages : en
Pages : 174

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Book Description
Human error is implicated in nearly all aviation accidents, yet most investigation and prevention programs are not designed around any theoretical framework of human error. Appropriate for all levels of expertise, the book provides the knowledge and tools required to conduct a human error analysis of accidents, regardless of operational setting (i.e. military, commercial, or general aviation). The book contains a complete description of the Human Factors Analysis and Classification System (HFACS), which incorporates James Reason's model of latent and active failures as a foundation. Widely disseminated among military and civilian organizations, HFACS encompasses all aspects of human error, including the conditions of operators and elements of supervisory and organizational failure. It attracts a very broad readership. Specifically, the book serves as the main textbook for a course in aviation accident investigation taught by one of the authors at the University of Illinois. This book will also be used in courses designed for military safety officers and flight surgeons in the U.S. Navy, Army and the Canadian Defense Force, who currently utilize the HFACS system during aviation accident investigations. Additionally, the book has been incorporated into the popular workshop on accident analysis and prevention provided by the authors at several professional conferences world-wide. The book is also targeted for students attending Embry-Riddle Aeronautical University which has satellite campuses throughout the world and offers a course in human factors accident investigation for many of its majors. In addition, the book will be incorporated into courses offered by Transportation Safety International and the Southern California Safety Institute. Finally, this book serves as an excellent reference guide for many safety professionals and investigators already in the field.