All about my books – Alles over mijn boeken
At 6:47 in the morning a chemistry analyser flags a dangerously high potassium result. The day shift arrives at seven. The night technologist has just started the handoff huddle. The result sits on a screen that, for the next hour, belongs to no one, and the call to the ward that should have followed within … Read more
Hospital process maps tend to go blank in the same places: the corridor, the elevator, the twenty minutes a patient spends between one department’s care and another’s. These are treated as connective tissue, mere transport between the parts of the map where the real work happens. They are, in fact, where a surprising share of … Read more
The senior physician says, with complete confidence, that this step never fails. Across the table, the pharmacy technician who watches it fail most Tuesdays looks down and says nothing. In that small moment of silence a risk analysis can quietly die, and produce something worse than nothing on its way out: false reassurance, stamped and … Read more
Picture the invitation list for a risk analysis of the medication process on a busy ward. The obvious names go down first: the nurse manager, a couple of staff nurses, a pharmacist. The people who own medication administration. It feels complete, and it is exactly how good analyses go quietly wrong. Here is the uncomfortable … Read more
There is a myth that proactive risk work requires a chartered project: a sponsor, a trained facilitator, eight weeks, a wall covered in sticky notes. For a high-stakes process, all of that is appropriate. For the hundred smaller moments where a little foresight would help, it is so disproportionate that the analysis simply never happens, … Read more
Two years after a genuinely good analysis, walk back to the process it fixed and you will often find the fix gone. Not rejected, not overturned in any meeting anyone remembers. Simply evaporated. A staffing change reassigned the person who did the extra check. A software update quietly dropped the alert. The workaround crept back … Read more
Watch what happens at the end of most risk analyses. The hard work is done, the hazards are named and ranked, and then, in the last forty-five minutes, the team disposes of them. The disposal, with dispiriting regularity, reads the same way. Re-educate the staff. Revise the policy. Remind everyone at the huddle. Add it … Read more
Somewhere right now a capable team is spending forty minutes deciding whether a risk scores a six or a seven. They will not resolve it, because there is nothing to resolve. The distinction does not exist outside the worksheet, and while they argue it, the hazard they agree is serious sits unaddressed. This is scoring … Read more
Ask a group to brainstorm everything that could go wrong with a process and you will get a lively hour and a partial list. Brainstorming is generous with the failures that are dramatic, recent, or personally remembered, and quietly blind to the rest. The failure that has never quite happened yet, the one nobody has … Read more
There is a particular kind of safety document that looks flawless and describes a hospital that does not exist. Its process map is clean. Every step follows the last in good order, nothing is interrupted, no one is covering two assignments, and the night shift behaves exactly like the policy says it should. It is … Read more