To Err Is Human


Book Description

Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine




Blundering for a Change


Book Description

Tassoni and Thelin examine how much classroom disruptions, failures, and resistance can tell us about the limits and possibilities of progressive teaching.




Better By Mistake


Book Description

New York Times columnist Alina Tugend delivers an eye-opening big idea: Embracing mistakes can make us smarter, healthier, and happier in every facet of our lives. In this persuasive book, journalist Alina Tugend examines the delicate tension between what we’re told—we must make mistakes in order to learn—and the reality—we often get punished for them. She shows us that mistakes are everywhere, and when we acknowledge and identify them correctly, we can improve not only ourselves, but our families, our work, and the world around us as well. Bold and dynamic, insightful and provocative, Better by Mistake turns our cultural wisdom on its head to illustrate the downside of striving for perfection and the rewards of acknowledging and accepting mistakes and embracing the imperfection in all of us.




WAC and Second Language Writers


Book Description

Editors and contributors pursue the ambitious goal of including within WAC theory, research, and practice the differing perspectives, educational experiences, and voices of second-language writers. The chapters within this collection not only report new research but also share a wealth of pedagogical, curricular, and programmatic practices relevant to second-language writers. Representing a range of institutional perspectives—including those of students and faculty at public universities, community colleges, liberal arts colleges, and English-language schools—and a diverse set of geographical and cultural contexts, the editors and contributors report on work taking place in the United States, Asia, Europe, and the Middle East.




The Book of Fatal Errors


Book Description

Award-winning author Dashka Slater spins a tale of friendship, magic, and eternal life in The Book of Fatal Errors, an evocative and witty middle-grade fantasy. Rufus doesn’t just make mistakes – he makes fatal errors. Clumsy and awkward, he feels entrapped by his teasing classmates and their constant laughter. But now it is summer. Rufus is free. He roams the wildlands of his grandfather’s mysterious homestead, blissfully unaware of the danger up ahead. And there is much danger. Rufus and his snooty cousin Abigail soon become entangled in the tantalizing world of the feylings, mischievous fairly-like creatures desperate to find their way home. In helping the feylings, Rufus tumbles down a dark path rich with age-old secrets and difficult truths. Any move he makes might be his final fatal error. Or perhaps, his most spectacular beginning.




The Field Guide to Human Error Investigations


Book Description

This title was first published in 2002: This field guide assesses two views of human error - the old view, in which human error becomes the cause of an incident or accident, or the new view, in which human error is merely a symptom of deeper trouble within the system. The two parts of this guide concentrate on each view, leading towards an appreciation of the new view, in which human error is the starting point of an investigation, rather than its conclusion. The second part of this guide focuses on the circumstances which unfold around people, which causes their assessments and actions to change accordingly. It shows how to "reverse engineer" human error, which, like any other componant, needs to be put back together in a mishap investigation.




Expectations


Book Description

A group of friends dealing with diverse triumphs and tribulations meets one beautiful autumn afternoon in 1965. They have longings, hopes, and dreams. But is God's plan for them something far beyond their expectations?




Improving Diagnosis in Health Care


Book Description

Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€"has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.




Learning and Expectations in Macroeconomics


Book Description

A crucial challenge for economists is figuring out how people interpret the world and form expectations that will likely influence their economic activity. Inflation, asset prices, exchange rates, investment, and consumption are just some of the economic variables that are largely explained by expectations. Here George Evans and Seppo Honkapohja bring new explanatory power to a variety of expectation formation models by focusing on the learning factor. Whereas the rational expectations paradigm offers the prevailing method to determining expectations, it assumes very theoretical knowledge on the part of economic actors. Evans and Honkapohja contribute to a growing body of research positing that households and firms learn by making forecasts using observed data, updating their forecast rules over time in response to errors. This book is the first systematic development of the new statistical learning approach. Depending on the particular economic structure, the economy may converge to a standard rational-expectations or a "rational bubble" solution, or exhibit persistent learning dynamics. The learning approach also provides tools to assess the importance of new models with expectational indeterminacy, in which expectations are an independent cause of macroeconomic fluctuations. Moreover, learning dynamics provide a theory for the evolution of expectations and selection between alternative equilibria, with implications for business cycles, asset price volatility, and policy. This book provides an authoritative treatment of this emerging field, developing the analytical techniques in detail and using them to synthesize and extend existing research.




The Book of Mistakes


Book Description

Zoom meets Beautiful Oops! in this memorable picture book debut about the creative process, and the way in which "mistakes" can blossom into inspiration One eye was bigger than the other. That was a mistake. The weird frog-cat-cow thing? It made an excellent bush. And the inky smudges… they look as if they were always meant to be leaves floating gently across the sky. As one artist incorporates accidental splotches, spots, and misshapen things into her art, she transforms her piece in quirky and unexpected ways, taking readers on a journey through her process. Told in minimal, playful text, this story shows readers that even the biggest “mistakes” can be the source of the brightest ideas—and that, at the end of the day, we are all works in progress, too. Fans of Peter Reynolds’s Ish and Patrick McDonnell’s A Perfectly Messed-Up Story will love the funny, poignant, completely unique storytelling of The Book of Mistakes. And, like Oh, The Places You’ll Go!, it makes the perfect graduation gift, encouraging readers to have a positive outlook as they learn to face life’s obstacles.