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Search results for "Conferences and Workshops"
- Conferences and Workshops
- Culture of Safety
Audiovisual > Audiovisual Presentation
Rockville, MD. Agency for Healthcare Research and Quality. June 2019.
Surveys are established mechanisms for organizational assessment of safety culture. This webinar provided an overview of the AHRQ Surveys on Patient Safety Culture. The presenters discussed the organizational characteristics required for successful web-based distribution of the survey and shared best practices for formatting, programming, and administering the surveys.
Meeting/Conference > Asia Meeting/Conference
Resilient Health Care Network. August 25–28, 2019; Awaji Yumebutai International Conference Center, Awaji Island, Hyogo, Japan.
Resilience in health care involves systems and cultures that enable care teams to reliably respond to uncertain conditions in the work environment to prevent failures. This conference and companion workshop will cover topics such as work-as-imagined and work-as-done, collaborative learning, and the role of managers and regulators. Featured speakers include Professor Jeffery Braithwaite and Professor Erik Hollnagel.
Canadian Patient Safety Institute.
Journal Article > Commentary
Sokas R, Braun B, Chenven L, et al. Jt Comm J Qual Patient Saf. 2013;39:185-192.
Oakbrook Terrace, IL: Joint Commission; May 21–23, 2012.
Perspectives on Safety > Perspective
with commentary by Alison H. Page, MS, MHA, Just Culture, October 2007
We've all been there...something goes wrong, a patient is harmed, and we, as medical directors, managers, and administrators, are forced to judge the behavioral choices of another human being. Most of the time, we conduct this complex leadership function guided by little more than vague policies, personal beliefs, and intuition. Frequently, we are frustrated by the fact that many other providers have made the same mistake or behavioral choice, with no adverse outcome to the patient, and the behavior was overlooked. Quite understandably, the staff is frustrated by what appears to be inconsistent, irrational decision-making by leadership. The "just culture" concept teaches us to shift our attention from retrospective judgment of others, focused on the severity of the outcome, to real-time evaluation of behavioral choices in a rational and organized manner.
Cook RI, Woods DD, Miller C. Chicago, IL: National Patient Safety Foundation; 1998.
A report from a workshop, this document is a well-written look at the differences between "first stories" and "second stories" describing major errors. First stories are the easy one-person or one-cause accounts and reactions to critical incidents. "So-and-so forgot to check the patient's allergy history." Or "How could they have ignored the alarm and so many other red flags?" Even now, with some penetration of the concepts of systems thinking, it is still easy to fall back on the familiar and easy explanation of human error, missing key opportunities to fix underlying problems with processes of care or the way care is organized. Identifying such problems, however, requires the far richer "second stories" about such critical incidents, and these stories do not emerge without hard work. The authors have done this hard work for many publicized medical errors, drawing on follow-up newspaper articles and other investigative documents, often in far more obscure places than headlining first stories. Even readers familiar with root cause analysis will likely find value in many of the case studies. And, for those not familiar with such accident investigation techniques, the report provides a very readable introduction to their importance and a resource for further references.