Safety Differently

Safety Differently PDF Author: Sidney Dekker
Publisher: CRC Press
ISBN: 1482242001
Category : Technology & Engineering
Languages : en
Pages : 304

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Book Description
The second edition of a bestseller, Safety Differently: Human Factors for a New Era is a complete update of Ten Questions About Human Error: A New View of Human Factors and System Safety. Today, the unrelenting pace of technology change and growth of complexity calls for a different kind of safety thinking. Automation and new technologies have resu

Safety Differently

Safety Differently PDF Author: Sidney Dekker
Publisher: CRC Press
ISBN: 1482242001
Category : Technology & Engineering
Languages : en
Pages : 304

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Book Description
The second edition of a bestseller, Safety Differently: Human Factors for a New Era is a complete update of Ten Questions About Human Error: A New View of Human Factors and System Safety. Today, the unrelenting pace of technology change and growth of complexity calls for a different kind of safety thinking. Automation and new technologies have resu

Learning Not Blaming

Learning Not Blaming PDF Author: Great Britain: Department of Health
Publisher:
ISBN: 9781474123716
Category :
Languages : en
Pages : 102

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Book Description
Dated July 2015. Print and web pdfs are available at https://www.gov.uk/government/publications. Government response to: The Freedom to speak up consultation, the Administration Select Committee's 6th report , HCP 886 session 14/15 (ISBN 9780215085757) & The report of the Morecambe Bay investigation (ISBN 9780108561306) Web ISBN=9781474123723

Beyond Blame

Beyond Blame PDF Author: Dave Zwieback
Publisher: "O'Reilly Media, Inc."
ISBN: 1491914467
Category : Business & Economics
Languages : en
Pages : 92

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Book Description
"IT veteran Dave Zweiback describes an incident that threatens the very existence of a large financial institution, and the counterintuitive steps its leadership took to stop the downward spiral. Their novel approach is grounded in proven concepts from complexity science, resilience engineering, human factors, cognitive science, and organizational psychology. It allows us to identify the underlying conditions for failure, and make our systems (and organizations) safer and more resilient."--Page 4 of cover

Running on Empty

Running on Empty PDF Author: Jonice Webb
Publisher: Morgan James Publishing
ISBN: 161448242X
Category : Self-Help
Languages : en
Pages : 250

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Book Description
A large segment of the population struggles with feelings of being detached from themselves and their loved ones. They feel flawed, and blame themselves. Running on Empty will help them realize that they're suffering not because of something that happened to them in childhood, but because of something that didn't happen. It's the white space in their family picture, the background rather than the foreground. This will be the first self-help book to bring this invisible force to light, educate people about it, and teach them how to overcome it.

Lead Without Blame

Lead Without Blame PDF Author: Diana Larsen
Publisher: Berrett-Koehler Publishers
ISBN: 1523000562
Category : Business & Economics
Languages : en
Pages : 197

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Book Description
A detailed framework for leaders to move past outdated workplace blame and shame strategies to cultivate resilient teams capable of facing adversity and setbacks confidently. Workplace finger-pointing stifles creativity, reduces productivity, and limits psychological safety. Although no one sets out to be judgmental, learning new habits is hard. Two experienced leadership and agilists coaches share a road-tested leadership model that continuously embraces humility and failure as part of the growth process to deliver results. By facilitating blame-free retrospective meetings, leaders chart a productive path forward. They amplify three essential motivators of purpose, autonomy, and co-intelligence within their team. Layered on with four resilience factors: inclusive collaboration, transparent power dynamics, collaborative learning, and embracing conflict. After applying these strategies, learning leaders will help their teams and themselves become more resilient and better equipped to handle any unexpected and challenging tasks that comes their way.

The Age of Inquiry

The Age of Inquiry PDF Author: Nicky Stanley
Publisher: Psychology Press
ISBN: 0415283159
Category : Governmental investigations
Languages : en
Pages : 297

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Book Description
Wide-ranging in scope, 'The Age of the Inquiry' focuses on service and policy development in the fields of health and welfare in the 1990s. It provides an invaluable text for students, teachers and professionals from a wide range of disciplines and professional groups.

Patient Safety and Quality

Patient Safety and Quality PDF Author: Ronda Hughes
Publisher: Department of Health and Human Services
ISBN:
Category : Medical
Languages : en
Pages : 592

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Book Description
"Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043)." - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/

Keeping Patients Safe

Keeping Patients Safe PDF Author: Institute of Medicine
Publisher: National Academies Press
ISBN: 0309187362
Category : Medical
Languages : en
Pages : 485

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Book Description
Building on the revolutionary Institute of Medicine reports To Err is Human and Crossing the Quality Chasm, Keeping Patients Safe lays out guidelines for improving patient safety by changing nurses' working conditions and demands. Licensed nurses and unlicensed nursing assistants are critical participants in our national effort to protect patients from health care errors. The nature of the activities nurses typically perform â€" monitoring patients, educating home caretakers, performing treatments, and rescuing patients who are in crisis â€" provides an indispensable resource in detecting and remedying error-producing defects in the U.S. health care system. During the past two decades, substantial changes have been made in the organization and delivery of health care â€" and consequently in the job description and work environment of nurses. As patients are increasingly cared for as outpatients, nurses in hospitals and nursing homes deal with greater severity of illness. Problems in management practices, employee deployment, work and workspace design, and the basic safety culture of health care organizations place patients at further risk. This newest edition in the groundbreaking Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety.

Black Box Thinking

Black Box Thinking PDF Author: Matthew Syed
Publisher: Penguin
ISBN: 069840887X
Category : Business & Economics
Languages : en
Pages : 377

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Book Description
Nobody wants to fail. But in highly complex organizations, success can happen only when we confront our mistakes, learn from our own version of a black box, and create a climate where it’s safe to fail. We all have to endure failure from time to time, whether it’s underperforming at a job interview, flunking an exam, or losing a pickup basketball game. But for people working in safety-critical industries, getting it wrong can have deadly consequences. Consider the shocking fact that preventable medical error is the third-biggest killer in the United States, causing more than 400,000 deaths every year. More people die from mistakes made by doctors and hospitals than from traffic accidents. And most of those mistakes are never made public, because of malpractice settlements with nondisclosure clauses. For a dramatically different approach to failure, look at aviation. Every passenger aircraft in the world is equipped with an almost indestructible black box. Whenever there’s any sort of mishap, major or minor, the box is opened, the data is analyzed, and experts figure out exactly what went wrong. Then the facts are published and procedures are changed, so that the same mistakes won’t happen again. By applying this method in recent decades, the industry has created an astonishingly good safety record. Few of us put lives at risk in our daily work as surgeons and pilots do, but we all have a strong interest in avoiding predictable and preventable errors. So why don’t we all embrace the aviation approach to failure rather than the health-care approach? As Matthew Syed shows in this eye-opening book, the answer is rooted in human psychology and organizational culture. Syed argues that the most important determinant of success in any field is an acknowledgment of failure and a willingness to engage with it. Yet most of us are stuck in a relationship with failure that impedes progress, halts innovation, and damages our careers and personal lives. We rarely acknowledge or learn from failure—even though we often claim the opposite. We think we have 20/20 hindsight, but our vision is usually fuzzy. Syed draws on a wide range of sources—from anthropology and psychology to history and complexity theory—to explore the subtle but predictable patterns of human error and our defensive responses to error. He also shares fascinating stories of individuals and organizations that have successfully embraced a black box approach to improvement, such as David Beckham, the Mercedes F1 team, and Dropbox.

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.