human factors

Day 1: Lewis, Domino, and Sponge

Published June 9, 2015 | By Daewoong Lee

Recap of what I applied to my learning and follow-up questions:

Intro:

“Educate the young, regulate the old”
- Witty and sensible to an extent, but does it work when the young have to work under the shadow of the old? Medicine is a top-down hierarchy, and bottom-up change is not only insurmountable but also often not sustainable.
- At the same time, becoming a positive deviant has its own value that cannot be diminished. I just wonder whether there is concurrent top-down efforts.

What can I do with Institute for Healthcare Improvement (IHI)? I would like to learn more.

Movie: Lewis Blackman (patient) and Helen Haskell (mother)

The patients and families need to know that night times and weekends the level of care is not the same. It is recommended to have a caretaker at bedside, and why not admit the systemic weakness and invite them… Continue reading →

House keys and the inevitability of human error

Published June 17, 2014 | By RebeccaC

It always saddens me when a medical mistake is reported in the media, and the immediate reaction of so many people is: “Someone that careless and incompetent should be fired. There is absolutely no excuse for hurting a patient by omitting such a basic step as calculating the right dose / making sure you have the right patient / checking for allergies / etc… ”

My immediate response to this is always: “Have you ever locked yourself out of your house?” Human beings make mistakes. Human beings sometimes omit basic, crucial steps from tasks they supposedly have mastered. We make small, stupid, high-consequence mistakes so predictably, so inevitably that an entire industry (locksmithing) is dedicated to undoing the small, stupid, high-consequence mistake of not ensuring we have our keys when and where we need them.

The keys analogy is actually a great way to think about… Continue reading →