But the data show that: The probability of Never Events is as low as for any complex task in any industry (human reliability doesn’t get much better than 99.997%) Resources are often suboptimal/not as designed/imagined (e.g. checklist implementation, staffing, workload, pressure)
Indeed it is and indeed it does. Any threat to your planned career is a serious one, when you start out with a £50k+ student loan. It's not the healthiest environment for candour to thrive. Or patients, for that matter.
-
-
It seems that the problem is, the system is set up for retributive justice first, not restorative justice. Both have a role, but in most cases of unintended harm, restorative justice must at least come first, and be fully embraced.
-
I'd say you're right. There's an argument to suggest a contradiction between professional guidelines and the law, when it comes to candour in medicine. Robert Francis recognised that and recommended a fix. Sadly, the fix we actually got was perverted by gov so as to be useless.
-
‘Fixes that fail’ - very common in social systems. https://en.m.wikipedia.org/wiki/Fixes_that_fail … It sounds to me like some protected time and space is needed to apply some restorative justice.
-
We certainly need something. Not sure that Wikipedia definition is ideal for this situation? Seems to describe a fix that starts out working, but later fails? This fix never worked - as intended.
-
Problem, as with checklists, is failure in implementation. Inadequate analysis of context and how a fix affects (or does not account for) the context to create secondary problems or just embed problem further.
-
Like Plan-Do-Study-Act cycles...often forgotten that this is only implementation phase. Study-Plan-Do cycle would be simpler, work better, and remind everyone to study the problem situation and context deeply first, from multiple perspectives.
End of conversation
New conversation -
Loading seems to be taking a while.
Twitter may be over capacity or experiencing a momentary hiccup. Try again or visit Twitter Status for more information.