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This succinct but absorbing book covers the main way stations on James Reason’s 40-year journey in pursuit of the nature and varieties of human error. He presents an engrossing and very personal perspective, offering the reader exceptional insights, wisdom and wit as only James Reason can. A Life in Error charts the development of his seminal and hugely influential work from its original focus on individual cognitive psychology through the broadening of scope to embrace social, organizational and systemic issues.
This succinct but absorbing book covers the main way stations on James Reason’s 40-year journey in pursuit of the nature and varieties of human error. In it he presents an engrossing and very personal perspective, offering the reader exceptional insights, wisdom and wit as only James Reason can. The journey begins with a bizarre absent-minded action slip committed by Professor Reason in the early 1970s - putting cat food into the teapot - and continues up to the present day, conveying his unique perceptions into a variety of major accidents that have shaped his thinking about unsafe acts and latent conditions. A Life in Error charts the development of his seminal and hugely influential work from its original focus into individual cognitive psychology through the broadening of scope to embrace social, organizational and systemic issues. The voyage recounted is both hugely entertaining and educational, imparting a real sense of how James Reason’s ground-breaking theories changed the way we think about human error, and why he is held in such esteem around the world wherever humans interact with technological systems. This book is essential reading for students, academics and safety professionals of all kinds who are interested in avoiding breakdowns that can cause serious damage to people, assets and the environment.
This succinct but absorbing book covers the main way stations on James Reason’s 40-year journey in pursuit of the nature and varieties of human error. In it he presents an engrossing and very personal perspective, offering the reader exceptional insights, wisdom and wit as only James Reason can. The journey begins with a bizarre absent-minded action slip committed by Professor Reason in the early 1970s - putting cat food into the teapot - and continues up to the present day, conveying his unique perceptions into a variety of major accidents that have shaped his thinking about unsafe acts and latent conditions. A Life in Error charts the development of his seminal and hugely influential work from its original focus into individual cognitive psychology through the broadening of scope to embrace social, organizational and systemic issues. The voyage recounted is both hugely entertaining and educational, imparting a real sense of how James Reason’s ground-breaking theories changed the way we think about human error, and why he is held in such esteem around the world wherever humans interact with technological systems. This book is essential reading for students, academics and safety professionals of all kinds who are interested in avoiding breakdowns that can cause serious damage to people, assets and the environment.
Whether you are a doctor, nurse, student, or otherwise interested reader, the stories here will help you to understand how medicine works and how medical error can happen. The lifelong process of learning that is a medical career requires healthcare workers to find a way to live through these setbacks without either becoming too adept at putting them 'down to experience' and forgetting their social significance, or 'burning out' and leaving medicine. The stories and discussions here present detailed narratives, analyses, and reflections on medical errors through actions, omissions, and misunderstandings. They offer a uniquely honest perspective on the social implications of medical error and will enable healthcare workers at all levels to analyse and learn from it without losing sight of its impact.
Institute of Medicine,Committee on Quality of Health Care in America
Author : Institute of Medicine,Committee on Quality of Health Care in America Publisher : National Academies Press Page : 312 pages File Size : 52,8 Mb Release : 2000-03-01 Category : Medical ISBN : 9780309068376
To Err Is Human by Institute of Medicine,Committee on Quality of Health Care in America Pdf
Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine
Behind Human Error by David D. Woods,Sidney Dekker,Richard Cook,Leila Johannesen,Nadine Sarter Pdf
Human error is cited over and over as a cause of incidents and accidents. The result is a widespread perception of a 'human error problem', and solutions are thought to lie in changing the people or their role in the system. For example, we should reduce the human role with more automation, or regiment human behavior by stricter monitoring, rules or procedures. But in practice, things have proved not to be this simple. The label 'human error' is prejudicial and hides much more than it reveals about how a system functions or malfunctions. This book takes you behind the human error label. Divided into five parts, it begins by summarising the most significant research results. Part 2 explores how systems thinking has radically changed our understanding of how accidents occur. Part 3 explains the role of cognitive system factors - bringing knowledge to bear, changing mindset as situations and priorities change, and managing goal conflicts - in operating safely at the sharp end of systems. Part 4 studies how the clumsy use of computer technology can increase the potential for erroneous actions and assessments in many different fields of practice. And Part 5 tells how the hindsight bias always enters into attributions of error, so that what we label human error actually is the result of a social and psychological judgment process by stakeholders in the system in question to focus on only a facet of a set of interacting contributors. If you think you have a human error problem, recognize that the label itself is no explanation and no guide to countermeasures. The potential for constructive change, for progress on safety, lies behind the human error label.
A small-town lawyer has been searching for his daughter for eighteen years. Now a local girl has gone missing, and he’s determined to find them both—no matter the cost. Buddy Smith built his law practice around tracking down missing children. After all, he knows the agony of being separated from a child. Not long after his daughter’s birth, her mother took her and ran away. Buddy hasn’t seen either since. Gracie Blaylock has known Buddy her entire life, and now that she is clerk of court for the county, their paths cross frequently. When Gracie hears that a teenager is missing, she knows Buddy is the one for the case. The missing girl’s parents are desperate for answers. Together with Gracie and Mayleah—the new detective in town—Buddy chases every lead, hoping to reach the missing teen before it’s too late. While he pursues one girl, he uncovers clues that could bring him closer to the daughter he thought he’d lost forever. Master storyteller Robert Whitlow will keep you guessing in this gripping legal drama while also reminding you of the power of God’s restoration. Gripping, stand-alone legal drama Full-length novel at approximately 120,000 words Includes discussion questions for book clubs Also by Robert Whitlow: The Trial, The Confession, and The Witnesses
Reports of Cases Argued and Determined in the Supreme Court of Errors of the State of Connecticut by Connecticut. Supreme Court,Connecticut. Supreme Court of Errors Pdf
ONE OF THE YEAR'S BEST BOOKS The Wall Street Journal • Slate • Kansas City Star • Flavorwire • Policy Mic • Buzzfeed “Necessary Errors is a very good novel, an enviably good one, and to read it is to relive all the anxieties and illusions and grand projects of one’s own youth.”—James Wood, The New Yorker The exquisite debut novel by the author of Overthrow that brilliantly captures the lives and romances of young expatriates in newly democratic Prague It’s October 1990. Jacob Putnam is young and full of ideas. He’s arrived a year too late to witness Czechoslovakia’s revolution, but he still hopes to find its spirit, somehow. He discovers a country at a crossroads between communism and capitalism, and a picturesque city overflowing with a vibrant, searching sense of possibility. As the men and women Jacob meets begin to fall in love with one another, no one turns out to be quite the same as the idea Jacob has of them—including Jacob himself. Necessary Errors is the long-awaited first novel from literary critic and journalist Caleb Crain. Shimmering and expansive, Crain’s prose richly captures the turbulent feelings and discoveries of youth as it stretches toward adulthood—the chance encounters that grow into lasting, unforgettable experiences and the surprises of our first ventures into a foreign world—and the treasure of living in Prague during an era of historic change.
National Academies of Sciences, Engineering, and Medicine,Institute of Medicine,Board on Health Care Services,Committee on Diagnostic Error in Health Care
Author : National Academies of Sciences, Engineering, and Medicine,Institute of Medicine,Board on Health Care Services,Committee on Diagnostic Error in Health Care Publisher : National Academies Press Page : 473 pages File Size : 42,7 Mb Release : 2015-12-29 Category : Medical ISBN : 9780309377720
Improving Diagnosis in Health Care by National Academies of Sciences, Engineering, and Medicine,Institute of Medicine,Board on Health Care Services,Committee on Diagnostic Error in Health Care Pdf
Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€"has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.
"An ambitious and meticulous foray into the nature of being." -- The Boston Globe A landmark exploration of the relationship between emotion and reason Since Descartes famously proclaimed, "I think, therefore I am," science has often overlooked emotions as the source of a person’s true being. Even modern neuroscience has tended, until recently, to concentrate on the cognitive aspects of brain function, disregarding emotions. This attitude began to change with the publication of Descartes’ Error in 1995. Antonio Damasio—"one of the world’s leading neurologists" (The New York Times)—challenged traditional ideas about the connection between emotions and rationality. In this wondrously engaging book, Damasio takes the reader on a journey of scientific discovery through a series of case studies, demonstrating what many of us have long suspected: emotions are not a luxury, they are essential to rational thinking and to normal social behavior.
