The Sharp End
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The Field Guide To Understanding Human Error
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Author : Sidney Dekker
language : en
Publisher: Ashgate Publishing, Ltd.
Release Date : 2013-03-28
The Field Guide To Understanding Human Error written by Sidney Dekker and has been published by Ashgate Publishing, Ltd. this book supported file pdf, txt, epub, kindle and other format this book has been release on 2013-03-28 with Technology & Engineering categories.
When faced with a human error problem, you may be tempted to ask 'Why didn't they watch out better? How could they not have noticed?'. You think you can solve your human error problem by telling people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure. These are all expressions of 'The Bad Apple Theory', where you believe your system is basically safe if it were not for those few unreliable people in it. This old view of human error is increasingly outdated and will lead you nowhere. The new view, in contrast, understands that a human error problem is actually an organizational problem. Finding a 'human error' by any other name, or by any other human, is only the beginning of your journey, not a convenient conclusion. The new view recognizes that systems are inherent trade-offs between safety and other pressures (for example: production). People need to create safety through practice, at all levels of an organization. Breaking new ground beyond its successful predecessor, The Field Guide to Understanding Human Error guides you through the traps and misconceptions of the old view. It explains how to avoid the hindsight bias, to zoom out from the people closest in time and place to the mishap, and resist the temptation of counterfactual reasoning and judgmental language. But it also helps you look forward. It suggests how to apply the new view in building your safety department, handling questions about accountability, and constructing meaningful countermeasures. It even helps you in getting your organization to adopt the new view and improve its learning from failure. So if you are faced by a human error problem, abandon the fallacy of a quick fix. Read this book.
Canada S Great War 1914 1918
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Author : Brian Douglas Tennyson
language : en
Publisher: Bloomsbury Publishing PLC
Release Date : 2014-11-25
Canada S Great War 1914 1918 written by Brian Douglas Tennyson and has been published by Bloomsbury Publishing PLC this book supported file pdf, txt, epub, kindle and other format this book has been release on 2014-11-25 with History categories.
Canada’s Great War, 1914-1918: How Canada Helped Save the British Empire and Became a North American Nation describes the major role that Canada played in helping the British Empire win the greatest war in history—and, somewhat surprisingly, resulted in Canada’s closer integration not with the British Empire but with its continental neighbor, the United States. When Britain declared war against Germany and Austria-Hungary in August 1914, Canada was automatically committed as well because of its status as a Dominion in the British Empire. Despite not having a say in the matter, most Canadians enthusiastically embraced the war effort in order to defend the Empire and its values. In Canada’s Great War, 1914-1918, historian Brian Douglas Tennyson argues that Canada’s participation in the war weakened its relationship with Britain by stimulating a greater sense of Canadian identity, while at the same time bringing it much closer to the United States, especially after the latter entered the war. Their wartime cooperation strengthened their relationship, which had been delicate and often strained in the nineteenth century. This was reflected in the greater integration of their economies and the greater acceptance in Canada of American cultural products such as books, magazines, radio broadcasting and movies, and was symbolized by the astonishing American response to the Halifax explosion in December 1917. By the end of the war, Canadians were emerging as a North American people, no longer fearing close ties to the United States, even as they maintained their ties to the British Commonwealth. Canada’s Great War, 1914-1918 will interest not only Canadians unaware of how greatly their nation’s participation in the First World War reshaped its relationship with Britain and the United States, but also Americans unacquainted with the magnitude of Canada’s involvement in the war and how that contribution drew the two nations closer together.
Behind Human Error
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Author : Dr Leila Johannesen
language : en
Publisher: Ashgate Publishing, Ltd.
Release Date : 2012-10-01
Behind Human Error written by Dr Leila Johannesen and has been published by Ashgate Publishing, Ltd. this book supported file pdf, txt, epub, kindle and other format this book has been release on 2012-10-01 with Technology & Engineering categories.
Human error is so often cited as a cause of accidents. There is perception of a 'human error problem'. Solutions are thought to lie in changing the people or their role. The label 'human error', however, is prejudicial and hides more than it reveals about how a system malfunctions. This book takes you behind the label. It explains how human error results from social and psychological judgments by the system's stakeholders that focus only on one facet of a set of interacting contributors.
Human Error In Medicine
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Author : Marilyn Sue Bogner
language : en
Publisher: CRC Press
Release Date : 2018-02-06
Human Error In Medicine written by Marilyn Sue Bogner and has been published by CRC Press this book supported file pdf, txt, epub, kindle and other format this book has been release on 2018-02-06 with Technology & Engineering categories.
This edited collection of articles addresses aspects of medical care in which human error is associated with unanticipated adverse outcomes. For the purposes of this book, human error encompasses mismanagement of medical care due to: * inadequacies or ambiguity in the design of a medical device or institutional setting for the delivery of medical care; * inappropriate responses to antagonistic environmental conditions such as crowding and excessive clutter in institutional settings, extremes in weather, or lack of power and water in a home or field setting; * cognitive errors of omission and commission precipitated by inadequate information and/or situational factors -- stress, fatigue, excessive cognitive workload. The first to address the subject of human error in medicine, this book considers the topic from a problem oriented, systems perspective; that is, human error is considered not as the source of the problem, but as a flag indicating that a problem exists. The focus is on the identification of the factors within the system in which an error occurs that contribute to the problem of human error. As those factors are identified, efforts to alleviate them can be instituted and reduce the likelihood of error in medical care. Human error occurs in all aspects of human activity and can have particularly grave consequences when it occurs in medicine. Nearly everyone at some point in life will be the recipient of medical care and has the possibility of experiencing the consequences of medical error. The consideration of human error in medicine is important because of the number of people that are affected, the problems incurred by such error, and the societal impact of such problems. The cost of those consequences to the individuals involved in medical error, both in the health care providers' concern and the patients' emotional and physical pain, the cost of care to alleviate the consequences of the error, and the cost to society in dollars and in lost personal contributions, mandates consideration of ways to reduce the likelihood of human error in medicine. The chapters were written by leaders in a variety of fields, including psychology, medicine, engineering, cognitive science, human factors, gerontology, and nursing. Their experience was gained through actual hands-on provision of medical care and/or research into factors contributing to error in such care. Because of the experience of the chapter authors, their systematic consideration of the issues in this book affords the reader an insightful, applied approach to human error in medicine -- an approach fortified by academic discipline.
The Field Guide To Understanding Human Error
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Author : Professor Sidney Dekker
language : en
Publisher: Ashgate Publishing, Ltd.
Release Date : 2014-12-28
The Field Guide To Understanding Human Error written by Professor Sidney Dekker and has been published by Ashgate Publishing, Ltd. this book supported file pdf, txt, epub, kindle and other format this book has been release on 2014-12-28 with Mathematics categories.
This latest edition of The Field Guide to Understanding ‘Human Error' will help you understand how to move beyond 'human error'; how to understand accidents; how to do better investigations; how to understand and improve your safety work. You will be invited to think creatively and differently about the safety issues you and your organization face. In each, you will find possibilities for a new language, for different concepts, and for new leverage points to influence your own thinking and practice, as well as that of your colleagues and organization.
Safety I And Safety Ii
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Author : Erik Hollnagel
language : en
Publisher: CRC Press
Release Date : 2018-04-17
Safety I And Safety Ii written by Erik Hollnagel and has been published by CRC Press this book supported file pdf, txt, epub, kindle and other format this book has been release on 2018-04-17 with Technology & Engineering categories.
Safety has traditionally been defined as a condition where the number of adverse outcomes was as low as possible (Safety-I). From a Safety-I perspective, the purpose of safety management is to make sure that the number of accidents and incidents is kept as low as possible, or as low as is reasonably practicable. This means that safety management must start from the manifestations of the absence of safety and that - paradoxically - safety is measured by counting the number of cases where it fails rather than by the number of cases where it succeeds. This unavoidably leads to a reactive approach based on responding to what goes wrong or what is identified as a risk - as something that could go wrong. Focusing on what goes right, rather than on what goes wrong, changes the definition of safety from ’avoiding that something goes wrong’ to ’ensuring that everything goes right’. More precisely, Safety-II is the ability to succeed under varying conditions, so that the number of intended and acceptable outcomes is as high as possible. From a Safety-II perspective, the purpose of safety management is to ensure that as much as possible goes right, in the sense that everyday work achieves its objectives. This means that safety is managed by what it achieves (successes, things that go right), and that likewise it is measured by counting the number of cases where things go right. In order to do this, safety management cannot only be reactive, it must also be proactive. But it must be proactive with regard to how actions succeed, to everyday acceptable performance, rather than with regard to how they can fail, as traditional risk analysis does. This book analyses and explains the principles behind both approaches and uses this to consider the past and future of safety management practices. The analysis makes use of common examples and cases from domains such as aviation, nuclear power production, process management and health care. The final chapters explain the theoret
Knowledge Management In Healthcare
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Author : Lorri Zipperer
language : en
Publisher: Routledge
Release Date : 2016-04-22
Knowledge Management In Healthcare written by Lorri Zipperer and has been published by Routledge this book supported file pdf, txt, epub, kindle and other format this book has been release on 2016-04-22 with Computers categories.
Knowledge management goes beyond data and information capture in computerized health records and ordering systems; it seeks to leverage the experiences of all who interact in healthcare to enhance care delivery, teamwork, and organizational learning. Knowledge management - if envisioned thoughtfully - takes a systemic approach to implementation that includes the embodiment of a learning culture. Knowledge is then used to support that culture and the knowledge workers within it to encourage them to share what they know, thusly enabling their peers, their organizations and ultimately their patients to benefit from their experience to proactively dismantle hierarchy and encourage sharing about what works, and what doesn’t to focus efforts on improvement. Knowledge Management in Healthcare draws on relevant business, clinical and health administration literature plus the analysis of discussions with a variety of clinical, administrative, leadership, patient and information experts. The result is a book that will inform thinking on knowledge access needs to mitigate potential failures, design lasting improvements and support the sharing of what is known to enable work towards attaining high reliability. It can be used as a general tool for leaders and individuals wishing to devise and implement a knowledge-sharing culture in their institution, design innovative activities supporting transparency and communication to strengthen existing programs intended to enhance knowledge sharing behaviours and contribute to high quality, safe care.
Official Gazette Of The United States Patent And Trademark Office
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Author : United States. Patent and Trademark Office
language : en
Publisher:
Release Date : 1998
Official Gazette Of The United States Patent And Trademark Office written by United States. Patent and Trademark Office and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 1998 with Patents categories.
Essays On Natural History Chiefly Ornithology
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Author : Charl Waterton
language : en
Publisher:
Release Date : 1844
Essays On Natural History Chiefly Ornithology written by Charl Waterton and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 1844 with Natural history categories.
Essays On Natural History Chiefly Ornithology With An Autobiography Of The Author
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Author : Charles Waterton
language : en
Publisher:
Release Date : 1838
Essays On Natural History Chiefly Ornithology With An Autobiography Of The Author written by Charles Waterton and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 1838 with Birds categories.