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Patient Safety Primers
Debriefing is an important strategy for learning from defects and for improving performance. It is one of the central learning tools in simulation and is also recommended after a real-life emergency response.
Journal Article > Commentary
Spear SJ. Harv Bus Rev. September 2005;83:78-91.
This commentary provides a broad overview of the issues facing health care systems in their efforts to promote quality and safety. The author discusses pervasive cultural barriers and process limitations that contribute to errors, while providing a series of anecdotes to demonstrate how easy and frequent these events can occur. Approaches for improvement that draw from the experiences of non-health care organizations, such as Toyota, are included. The strength of the commentary lies in the compelling stories shared and the perspectives offered to foster change.
Journal Article > Study
Noland CM, Carmack HJ. Qual Health Res. 2015;25:1423-1434.
This qualitative study examined narratives of nursing students' errors and found three common themes: "save the day" narratives (nurses recognize and mitigate physician errors), "silence" narratives (nurses do not disclose errors to patients), and "not always right" narratives (students were able to challenge supervisors). These narratives underscore the importance of a positive safety culture for identifying and mitigating errors in real time.