ABSTRACT
Occurrences of patient harm in healthcare represent a significant burden, with serious implications for patients and families and for the capacity of health systems to manage patient access, flow, and wait times. Interest in the science of high reliability, developed originally in industries such as commercial airlines that have demonstrated exceptional safety records, is an emerging trend in healthcare with the potential to help organizations and systems achieve the ultimate goal of zero patient harm. This article argues that zero patient harm is a fundamental imperative, and that high-reliability science can help to accelerate and sustain progress toward this vital goal. Although the practices used in other industries are not readily transferable to healthcare, and no single proven model for High Reliability Organizations in healthcare is yet available, leading organizations are beginning to demonstrate effective healthcare-specific strategies. Experience from Studer Group's international network of partner organizations is used to illustrate and understand these early efforts. Studer Group's Evidence-Based LeadershipSM framework is applied in diverse healthcare settings to provide a foundation of culture transformation and change management to support high reliability. It offers an approach and resources for moving forward toward the goal of zero patient harm, with concurrent benefits related to the efficient use of our valuable healthcare resources.
Subject(s)
Delivery of Health Care/organization & administration , Organizational Culture , Patient Safety , Quality of Health Care/organization & administration , Delivery of Health Care/standards , HumansABSTRACT
Les préjudices que subissent les patients recevant des soins de santé représentent un fardeau considérable et peuvent avoir de graves répercussions sur les patients et les familles ainsi que sur la capacité des systèmes de santé de gérer l'accès des patients, leurs déplacements dans le système et les temps d'attente. L'intérêt pour la science de la haute fiabilité, mise au point à l'origine dans des secteurs comme l'aviation commerciale, qui ont un bilan exceptionnel en matière de sécurité, est une nouvelle tendance en soins de santé qui pourrait aider les organisations et les systèmes à atteindre le but ultime : zéro préjudice subi par les patients. Cet article fait valoir que zéro préjudice au patient est un impératif fondamental et que la science de la haute fiabilité peut aider à accélérer et à soutenir les progrès vers ce but vital. Bien que les pratiques utilisées dans d'autres secteurs ne soient pas facilement transférables aux soins de santé et qu'il n'existe pas encore un seul modèle éprouvé pour les organisations à haute fiabilité en santé, des organisations de premier plan commencent à faire la démonstration de stratégies efficaces propres aux soins de santé. L'expérience du réseau international d'organisations partenaires du groupe Studer est utilisée pour illustrer et comprendre ces premiers efforts. Le cadre Evidence-Based LeadershipSM (leadership fondé sur les données probantes) du groupe Studer est appliqué dans différents milieux de soins de santé pour transformer la culture et la gestion du changement visant à favoriser une haute fiabilité. Il propose une démarche et des ressources pour progresser vers le but zéro préjudice subi par les patients et tous les avantages liés à l'utilisation efficiente de nos précieuses ressources en soins de santé.
Subject(s)
Delivery of Health Care/organization & administration , Organizational Culture , Patient Safety , Quality of Health Care/organization & administration , Delivery of Health Care/standards , HumansABSTRACT
Beginning in 2005, the aorn foundation and Safer Healthcare implemented a human factors program based on Crew Resource Management training in five diverse surgical facilities across the United States. Highly interactive, customized training sessions were designed to help clinicians standardize communication, enhance teamwork, implement preprocedure briefings and postprocedure debriefings, maintain situational awareness, and recognize red flags in the workplace. Pretraining and post-training surveys were used to determine the effectiveness of the program. Brief overviews from the participating facilities detail specific issues encountered in each setting.
Subject(s)
Ergonomics , Inservice Training/methods , Medical Errors/prevention & control , Safety Management , Surgical Procedures, Operative , Health Plan Implementation , Humans , Models, Organizational , Patient Care Team/organization & administration , United StatesABSTRACT
Ingestive responses of 50 rats and 4 gastric-cannulated dogs to ethylene glycol-based antifreeze (AF) were found to be inversely related to concentration. The antifreeze was never preferred to water. Do thirsty animals that encounter weak AF solutions drink them solely for their water content, water-related oral tactile sensations, or both, being inadvertently poisoned in the process?
Subject(s)
Dogs/physiology , Ethylene Glycols , Rats/physiology , Thirst/physiology , Animals , Dose-Response Relationship, Drug , Ethylene Glycols/administration & dosage , Ethylene Glycols/adverse effects , Ethylene Glycols/poisoningABSTRACT
The 4th Amendment of the United States Constitution protects American citizens against unreasonable search and seizure without probable cause. Although law enforcement officials routinely rely solely on the sense of smell to justify probable cause when entering vehicles and dwellings to search for illicit drugs, the accuracy of their perception in this regard has rarely been questioned and, to our knowledge, never tested. In this paper, we present data from two empirical studies based upon actual legal cases in which the odor of marijuana was used as probable cause for search. In the first, we simulated a situation in which, during a routine traffic stop, the odor of packaged marijuana located in the trunk of an automobile was said to be detected through the driver's window. In the second, we investigated a report that marijuana odor was discernable from a considerable distance from the chimney effluence of diesel exhaust emanating from an illicit California grow room. Our findings suggest that the odor of marijuana was not reliably discernable by persons with an excellent sense of smell in either case. These studies are the first to examine the ability of humans to detect marijuana in simulated real-life situations encountered by law enforcement officials, and are particularly relevant to the issue of probable cause.
