Thank you, Paul - for the selected list of materials on safety. (see welcome, post 2)
Of particular interest is "Fixing Health Care from the Inside, Today." Steven J. Spear. Harvard Business Review. Volume 83, #9, pg. 78-91. September 2005.
The speaker talks of work arounds and how they can become incideious factors that contribute to the unreliability of safe care. What information and knowledge seeking work arounds are prevelent in your environment? Ask yourselves the "Five Whys" behind the activity. What can be done to change them to make the information and knowledge transfer process more reliable?
Surgical fires: decreasing incidence relies on continued prevention efforts. - Bruley ME, Arnold TV, Finley E, Deutsch ES, Treadwell JR. PA-PSRS Pa Patient Saf Advis. June 2018;15.
2 days ago