All about my books – Alles over mijn boeken
“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
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
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
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