By Michael St.Pierre
This ebook addresses all concerns correct to blunders prevention and secure perform within the acute and emergency health-care environment. It starts with the fundamental ideas of human habit and selection making after which walls into 3 sections the place the person, the workforce, and the organizational impacts in the health-care procedure are mentioned in better intensity. Case studies and confirmed ideas support to flooring mental conception in day-by-day perform. This publication has emerged from a long-standing cooperation among clinicians and psychologists and blends the strengths of either professions right into a effectively available textual content.
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Additional info for Crisis Management in Acute Care Settings: Human Factors and Team Psychology in a High Stakes Environment
The point of interest is why a planned activity did not result in its intended outcome. In this conceptual framework the focus is shifted toward possible psychological precursors and systemic interactions which led to the wrong action. ” If only one person seems to be involved in the medication error, a clear causeand-effect attribution seems justified: His or her wrong actions led to the undesired result. If even in such simple cases such an assessment is doubtful, it becomes difficult when accidents occur in a dynamic setting with multiple healthcare providers involved.
Since Sigmund Freud’s “Psychopathology of Everyday Life” (Freud 1901), which searched for the roots of error in the subconscious, the unconscious, and the psycho-sexual state of the individual, many different taxonomies on error have been proposed (for an overview: Reason 1990; Senders and Moray 1991; Dekker 2002, 2005; Strauch 2002). There is still no one conceptual framework, however, which gives us a comprehensive picture of human error. This is not surprising, because different classifications serve different needs; however, there is widespread agreement that speaking of an “error” implies that there was (a) an intentional action, (b) aiming at a goal, and (c) at least one alternative so that it could have been done differently.
5 The nonapplication of a “good” rule, because the healthcare provider was unfamiliar with the rule or unable to remember it in time. 3 The resident’s decision to inject lidocaine for the treatment of PVCs would be an example for the misapplication of a “good” rule for antiarrhythmic therapy, because he missed the specifics of the situation: Not the patient’s cardiac status, but rather the excessive (but short-lived) plasma level of epinephrine was responsible for the electrophysiological alterations.