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?
Maximize benefits of IV workflow management systems by addressing workarounds and errors. - ISMP Medication Safety Alert! Acute Care Edition. September 7, 2017;22:1-4.
1 day ago