All about my books – Alles over mijn boeken
Eric Sleeckx Een van de meest voorkomende denkfouten bij besluitvorming is de sunk cost fallacy, ook wel de verzonkenkostenfout genoemd. De verzonkenkostenfout ontstaat wanneer men blijft investeren in een project of activiteit enkel omdat er al een aanzienlijke tijd, geld, energie of reputatie in is gestoken. Men gaat door, niet vanwege positieve vooruitzichten, maar omdat stoppen voelt … Read more
Je kunt een goede beslissing nemen en toch een slecht resultaat krijgen. Dat klinkt misschien tegenstrijdig, maar het is een van de belangrijkste inzichten voor iedereen die met meer vertrouwen wil beslissen. We beoordelen beslissingen vaak achteraf op basis van hun uitkomst. Als het resultaat positief is, noemen we de beslissing goed. Als het resultaat … Read more
“We fix systems, not people.” It is one of the finest sentences in modern healthcare, and in a great many organisations it is a lie, not because anyone intends to deceive, but because they have made the promise without building the thing that keeps it. Just Culture, done properly, is a genuine commitment. Left as … Read more
Aviation and nuclear power get held up so often as models for healthcare that the comparison has gone slightly numb. The phrase high-reliability organisation gets printed on posters and strategy decks, admired, and left there, as if reliability were an attitude you could adopt by deciding to. It is not an attitude. It is a … Read more
The surgical safety checklist is one of the genuine success stories of modern patient safety, and it is also one of the most misunderstood, because its success has convinced a great many people that a checklist is a thing you can install. Print it, laminate it, tape it to the wall, and safety follows. Then … Read more
Some risks are too tangled to hold in the head and too important to leave that way. The bowtie diagram exists for exactly these, and its whole appeal is that it puts a complete risk story on a single page, in a shape anyone can read without training. Picture a knot in the centre, the … Read more
James Reason gave safety its most durable picture decades ago, and it has survived every fashion since because it happens to be true. Imagine the defences protecting a patient as a series of slices of Swiss cheese, stacked one behind another. Each slice is a barrier: a check, an alarm, a protocol, a second set … Read more
Root Cause Analysis is a fine tool asked, constantly, to do work it was never built for. A serious event happens and someone says, reasonably enough, let us also use this to make sure the process is safe going forward. Or, stranger and increasingly common, a team reaches for RCA to assess a process where … Read more
A patient goes home from a hospital that has, for days, surrounded every process with barriers. A second clinician’s eyes on the high-risk medication. A scanner that checks the wristband against the dose. A colleague who happens to walk past and notice something off. Then the front door closes behind them, and every one of … Read more
The most dangerous place in a hospital is not a room. It is a transition. A patient is handed from one team to another, from one unit to another, from one shift to the next, and in that handover something essential is supposed to pass along with the body: not just the facts, but the … Read more