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













Engineering a Safer World


Book Description

A new approach to safety, based on systems thinking, that is more effective, less costly, and easier to use than current techniques. Engineering has experienced a technological revolution, but the basic engineering techniques applied in safety and reliability engineering, created in a simpler, analog world, have changed very little over the years. In this groundbreaking book, Nancy Leveson proposes a new approach to safety—more suited to today's complex, sociotechnical, software-intensive world—based on modern systems thinking and systems theory. Revisiting and updating ideas pioneered by 1950s aerospace engineers in their System Safety concept, and testing her new model extensively on real-world examples, Leveson has created a new approach to safety that is more effective, less expensive, and easier to use than current techniques. Arguing that traditional models of causality are inadequate, Leveson presents a new, extended model of causation (Systems-Theoretic Accident Model and Processes, or STAMP), then shows how the new model can be used to create techniques for system safety engineering, including accident analysis, hazard analysis, system design, safety in operations, and management of safety-critical systems. She applies the new techniques to real-world events including the friendly-fire loss of a U.S. Blackhawk helicopter in the first Gulf War; the Vioxx recall; the U.S. Navy SUBSAFE program; and the bacterial contamination of a public water supply in a Canadian town. Leveson's approach is relevant even beyond safety engineering, offering techniques for “reengineering” any large sociotechnical system to improve safety and manage risk.




Building Safer Communities


Book Description







Making America Green and Safe


Book Description

Since history is a critical part of future planning, the eight chapters of this book offer both academics and the general public a historical perspective of the evolution of science and policy actions on climate change and steps toward building a resilient and sustainable society, especially at the Environmental Protection Agency (EPA). Reflecting the world today, especially at the EPA, the author, who is a long-time academic and government policy maker and researcher, acknowledges that as David Barry once said (March 22, 1999) “We live in troubled times, but I feel good about myself, about my homeland and about all nations, and yes, about the future of humanity. And I will tell you why; I am on painkillers.” Pain killers are not what we want for the future. Given the pressures of many megatrends, business and government must take bipartisan actions to move toward a resilient and sustainable world. The book provides detailed insights into how best to deal with the nexus of environmental, social and economic problems and how to ensure strong economic growth while protecting the environment.




Sooner Safer Happier


Book Description

"This is one of the most important Agile books since The Phoenix Project." —Charles Betz, Principle Analyst, Forrester Research It's no secret that we are living in the Digital Age. Technology companies make up seven of the world's ten largest firms by market capitalization. And the key to their success is the key to all modern organizations. Jonathan Smart, business agility practitioner, thought leader, and coach, reveals the patterns and antipatterns that will help organizations from every industry deliver better value sooner, safer, and happier through high levels of engagement, inclusion, and empowerment. Through his decades of experience in the technology world, Smart provides business leaders with a blueprint for creating a world-class organization of the future. Through Agile and Lean ways of working, business leaders can empower teams to improve production, grow together, and create better services for their customers. These better ways of working have overflowed from the IT department to every corner of successful organizations, taking root in every industry from aerospace to accounting, insurance to shipping. This book is not about software development. It is not a book about the computer industry. This book is about applying agility across the entire organization. It's a book that will put you at the front of change and ahead of the competition. "A true business-wide perspective on Digital Transformation and the need for whole business agility." —Adam Banks, Non Executive Director and Former CTIO of AP Moller Maersk **Note from the Authors: Purchases will result in the planting of trees and empowerment of women, in countries with the lowest scores on the IUCN's gender and environment index. It's not just carbon neutral, purchases in any format will result in, on average, 10x greater carbon offset.




Parliamentary Papers


Book Description