All about my books – Alles over mijn boeken
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
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
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
Every automated dispensing cabinet keeps a log of its overrides, the times a nurse pulled a medication before a pharmacist reviewed the order. In the imagined version of the process, this pathway is rare, urgent, and justified, an emergency valve for the moments when waiting for review would itself be dangerous. Then you open the … 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