All about my books – Alles over mijn boeken
An organisation learns about its own risks in two very different ways, and most organisations are quietly excellent at one of them and have barely tried the other. The first way begins after something goes wrong. An event occurs, someone is harmed or nearly so, and the organisation investigates: what happened, why, and how do … Read more
“No harm done.” Three words that end more safety conversations than any others, and almost always in the wrong place. The dose was caught before it reached the patient. The wrong-site marking was spotted at the time-out. The specimen with no label was noticed before it was run. Relief goes round the room, the moment … Read more
Every facilitator hears the objection within the first week, usually from the busiest and most credible person in the room. We do not have time for this. It deserves a straight answer, because the people saying it are not being obstructive. They are describing their week accurately. So let me concede the whole of it … Read more
“Human error” is the most reassuring phrase in the whole language of safety, which is exactly what makes it dangerous. It closes the file. Once we have decided that a competent person simply erred, there is nothing left to examine except the person, and the person, being competent, will promise to try harder. Then the … Read more
Every serious safety event arrives with the same quiet feeling attached, the sense that somewhere in the building, someone already knew. Not the day it would happen, and not the patient. The weak spot. Someone knew that the shift-change handoff ran on one nurse’s memory, that the infusion alarm had been overridden so often it … Read more