"This volume is dedicated to creating a single source that both summarizes what we know regarding errors in organizations and provide a focused effort toward identifying future directions for research. The goal is to provide a forum for researchers who have conducted a considerable amount of research in the error domain to discuss how to extend this research, and provide researchers who have not considered the implications of errors for their domain of organizational research an outlet to do so"--
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
From the Nobel Prize-winning author of Thinking, Fast and Slow and the coauthor of Nudge, a revolutionary exploration of why people make bad judgments and how to make better ones—"a tour de force” (New York Times). Imagine that two doctors in the same city give different diagnoses to identical patients—or that two judges in the same courthouse give markedly different sentences to people who have committed the same crime. Suppose that different interviewers at the same firm make different decisions about indistinguishable job applicants—or that when a company is handling customer complaints, the resolution depends on who happens to answer the phone. Now imagine that the same doctor, the same judge, the same interviewer, or the same customer service agent makes different decisions depending on whether it is morning or afternoon, or Monday rather than Wednesday. These are examples of noise: variability in judgments that should be identical. In Noise, Daniel Kahneman, Olivier Sibony, and Cass R. Sunstein show the detrimental effects of noise in many fields, including medicine, law, economic forecasting, forensic science, bail, child protection, strategy, performance reviews, and personnel selection. Wherever there is judgment, there is noise. Yet, most of the time, individuals and organizations alike are unaware of it. They neglect noise. With a few simple remedies, people can reduce both noise and bias, and so make far better decisions. Packed with original ideas, and offering the same kinds of research-based insights that made Thinking, Fast and Slow and Nudge groundbreaking New York Times bestsellers, Noise explains how and why humans are so susceptible to noise in judgment—and what we can do about it.
From the ill-fated dot-com bubble to unprecedented merger and acquisition activity to scandal, greed, and, ultimately, recession -- we've learned that widespread and difficult change is no longer the exception. By outlining the process organizations have used to achieve transformational goals and by identifying where and how even top performers derail during the change process, Kotter provides a practical resource for leaders and managers charged with making change initiatives work.
Major accidents are rare events due to the many barriers, safeguards and defences developed by modern technologies. But they continue to happen with saddening regularity and their human and financial consequences are all too often unacceptably catastrophic. One of the greatest challenges we face is to develop more effective ways of both understanding and limiting their occurrence. This lucid book presents a set of common principles to further our knowledge of the causes of major accidents in a wide variety of high-technology systems. It also describes tools and techniques for managing the risks of such organizational accidents that go beyond those currently available to system managers and safety professionals. James Reason deals comprehensively with the prevention of major accidents arising from human and organizational causes. He argues that the same general principles and management techniques are appropriate for many different domains. These include banks and insurance companies just as much as nuclear power plants, oil exploration and production companies, chemical process installations and air, sea and rail transport. Its unique combination of principles and practicalities make this seminal book essential reading for all whose daily business is to manage, audit and regulate hazardous technologies of all kinds. It is relevant to those concerned with understanding and controlling human and organizational factors and will also interest academic readers and those working in industrial and government agencies.
Conquer the most essential adaptation to the knowledge economy The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth offers practical guidance for teams and organizations who are serious about success in the modern economy. With so much riding on innovation, creativity, and spark, it is essential to attract and retain quality talent—but what good does this talent do if no one is able to speak their mind? The traditional culture of "fitting in" and "going along" spells doom in the knowledge economy. Success requires a continuous influx of new ideas, new challenges, and critical thought, and the interpersonal climate must not suppress, silence, ridicule or intimidate. Not every idea is good, and yes there are stupid questions, and yes dissent can slow things down, but talking through these things is an essential part of the creative process. People must be allowed to voice half-finished thoughts, ask questions from left field, and brainstorm out loud; it creates a culture in which a minor flub or momentary lapse is no big deal, and where actual mistakes are owned and corrected, and where the next left-field idea could be the next big thing. This book explores this culture of psychological safety, and provides a blueprint for bringing it to life. The road is sometimes bumpy, but succinct and informative scenario-based explanations provide a clear path forward to constant learning and healthy innovation. Explore the link between psychological safety and high performance Create a culture where it’s “safe” to express ideas, ask questions, and admit mistakes Nurture the level of engagement and candor required in today’s knowledge economy Follow a step-by-step framework for establishing psychological safety in your team or organization Shed the "yes-men" approach and step into real performance. Fertilize creativity, clarify goals, achieve accountability, redefine leadership, and much more. The Fearless Organization helps you bring about this most critical transformation.
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.
Despite the significance and prevalence of errors in organizations, there has been no attempt within the field of Industrial and Organizational Psychology to create a single source summarizing what we know regarding errors in organizations and providing a focused effort toward identifying future directions of research. This volume answers that need and provides contributions by researchers who have conducted a considerable amount of research on errors occurring in the work context. Students, academics and practitioners in a wide range of disciplines, i.e., industrial organizational psychology, medicine, aviation, human factors and systems engineering, will find this book of interest.
The guide for all leaders and senior managers, offering the answers to critical questions on organizational design and management. Every year, over 10,000 business books are published-and that's before you add in the hundreds of thousands of articles, blogs, and video lectures that are produced. Leaders can't possibly hope to digest it all, and writers increasingly sensationalize and spin their ideas in order to be noticed. The result? Put quite simply, the field of management thinking is in danger of losing the plot. In this new book, Scott Keller and Mary Meaney-Senior Partners at McKinsey & Company, the world's preeminent management consultancy-cut to the chase by answering the 10 most important and timeless questions that every leader needs to answer in order to maximize the performance and health of their organization. What's more, the authors recognize that great leaders may not have time for long-winded business books. In Leading Organizations, answers are kept to the essentials-hard facts, counter-intuitive insights, and practical steps-all presented in an accessible and highly visual format. If there's one essential business book you should read-ever-it's this one.
