All about my books – Alles over mijn boeken
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
A speech-language pathologist finishes a bedside swallow assessment and writes a clear recommendation: this patient takes thickened liquids only, and nothing by mouth without supervision. The assessment was expert, the recommendation is correct, and it is about to fail, not because anyone disagrees with it, but because of how many people need it and how … Read more
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
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
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