This issue of Hindsight includes articles on:
Malicious compliance by Sidney Dekker
Can we ever imagine how work is done? by Erik Hollnagel
Safety is in the eye of the beholder by Florence-Marie Jegoux, Ludovic Mieusset and Sébastien Follet
I wouldn't have done what they did by Martin Bromiley
Drawing on a dizzying array of case studies and real-world examples, together with cutting-edge research on marginal gains, creativity and grit, Matthew Syed tells the inside story of how success really happens - and how we cannot grow unless we are prepared to learn from our mistakes.
This study from Schultz et al., published in the The Canadian Journal of Hospital Pharmacy, clearly shows hat abbreviations currently used by manufacturers to differentiate short- and long-acting medications are problematic. Furthermore, it has highlighted the potential consequences of using non-intuitive abbreviations to differentiate medications with different release rates.
The study demonstrates how evidence-based research at the local level, along with feedback and input from front-line staff, can be used to address longstanding problems. Although no strategy can eliminate all errors involving medications with different release rates, this study generated evidence-based solutions that were subsequently implemented to minimise potential errors through more intuitive labelling of medications. The findings from this evaluation are applicable to other organisations seeking to reduce the risk of errors related to medication abbreviations and should also be considered by pharmaceutical companies.
The second edition takes a more practical approach with coverage of methods, interventions and applications and a greater range of domains such as medication safety, surgery, anaesthesia, and infection prevention. New topics include:
health information technology development and design
patient safety management.
Reflecting developments and advances in the five years since the first edition, the book explores medical technology and telemedicine and puts a special emphasis on the contributions of human factors and ergonomics to the improvement of patient safety and quality of care. In order to take patient safety to the next level, collaboration between human factors professionals and health care providers must occur. This book brings both groups closer to achieving that goal.
• For universal health coverage, “leave no one behind” means that countries should prepare equitable and gender-responsive health systems that consider the interaction of gender with wider dimensions of inequality, such as wealth, ethnicity, education, geographic location and sociocultural factors and implement them within a human rights framework.
• Countries must consider the health inequities within and across groups and geographic areas, and learn how gender norms, unequal power relations and discrimination based on sexual and gender orientation impede access to health services. National health plans should consider equity and gender-related barriers. The opening times, staff composition and location of health facilities should be considered from an equity perspective, and services should be age and culturally appropriate.
• Multisectoral cooperation is essential for reducing health inequities since some factors influencing disease burdens and barriers to access lie outside the reach of the health sector. Multisectoral involvement and coordination should be integrated in national health plans. Engaging civil society organisations and the public in decision-making and feedback is essential.
• An equity, gender and human rights perspective in developing social health protection schemes is needed to address the differential risks experienced by people across the life course and to assist people in avoiding or coping with the financial costs of treating illnesses. Social health protection schemes should consider the health care needs of marginalised groups and incorporate mechanisms to remove the access barriers they face.
• Effective, equitable and cost-efficient services can be delivered only when based on evidence. Further research using mixed methods – and quantitative and qualitative data – is needed to understand the mechanisms behind gender and equity barriers, which can vary by setting and population group.
• Indicators for monitoring progress towards universal health coverage should enable monitoring progress for particular groups. At a minimum, indicators should be dis-aggregated by sex and age. Further dis-aggregation by ethnicity, migration status, wealth, education and geographic location is essential to identify and tailor interventions to reach groups living in situations of greatest vulnerability.
In this blog, Steven questions:
Are we reducing the human to ‘human error’?
Are we reducing the human to a faulty information processing machine?
Are we reducing the human to emotional aberrations?
Are we reducing human involvement in socio-technical systems?
Why is there more chance we'll believe something if it's in a bold type face? Why are judges more likely to deny parole before lunch? Why do we assume a good-looking person will be more competent? The answer lies in the two ways we make choices: fast, intuitive thinking, and slow, rational thinking. This book reveals how our minds are tripped up by error and prejudice (even when we think we are being logical), and gives you practical techniques for slower, smarter thinking. It will enable to you make better decisions at work, at home and in everything you do.