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Close calls, narrow escapes, or near hits. History has shown repeatedly that these "near-miss" incidents often precede loss producing events, but are largely ignored or go unreported because nothing (no injury, damage or loss) happened. Thus, many opportunities to prevent the accidents that the organization has not yet had are lost. Recognizing and
Americans should be able to count on receiving health care that is safe. To achieve this, a new health care delivery system is needed â€" a system that both prevents errors from occurring, and learns from them when they do occur. The development of such a system requires a commitment by all stakeholders to a culture of safety and to the development of improved information systems for the delivery of health care. This national health information infrastructure is needed to provide immediate access to complete patient information and decision-support tools for clinicians and their patients. In addition, this infrastructure must capture patient safety information as a by-product of care and use this information to design even safer delivery systems. Health data standards are both a critical and time-sensitive building block of the national health information infrastructure. Building on the Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm, Patient Safety puts forward a road map for the development and adoption of key health care data standards to support both information exchange and the reporting and analysis of patient safety data.
Near Miss Reporting as a Safety Tool arises from a meeting of safety professionals, academicians, and consultants from Western-Europe and Canada held in Eindhoven, the Netherlands, in September 1989. The book deals with near-miss reporting in various systems, mostly in the context of errors and accidents. The book begins by discussing the effects of bad management decisions in the design phase and a framework that will describe or manage these near misses through reporting, description, analysis, interpretation, and suggestions. Seven modules that compose this framework, called the Near Miss Management System (NMMS), along with pertinent cases, are explained. The book notes that near misses are ignored because of technical myopia, action-oriented organizations, event-focused organizations, consequence driven, and variables in quality of reporting. The organizational and management aspects of the NMMS are then analyzed within the commonly accepted culture and experience of the company. The book also presents comparative application of near miss information systems covering a wide range of industrial and transport environment. Such presentation allows differences and similarities to come into view more easily. The text will prove valuable for safety professionals in the nuclear and chemical industry and in road, railway, and air traffic management. Professors and students in safety management will likewise appreciate this book.
Because close calls, often termed near misses, don't raise the same concerns about malpractice liability and may be less emotionally charged than errors that cause serious harm, they are a unique source of learning for individuals and organizations striving to keep patients safe. This book tells how to take advantage of these lessons to prevent today's close call from turning into tomorrow's catastrophic event. Special Features: * Foreword by human error expert James Reason, Ph.D. * Authoritative tutorials on what the literature tells us about the concept of close calls and their identification, relationship with errors, and use in assessing and improving the safety and reliability of health care. * 15 detailed case studies from a variety of clinical disciplines and specialties to show how health care organizations use close calls to identify and solve patient safety problems
Displaced international consultant Dayle Standish heads for the Caribbean, following a losing battle involving corporate intrigue and blackmail. Diving Cozumel's azure waters, Dayle photographs a mysterious encounter inside a deep underwater cave. Soon after, a deadly assassin working for a foreign intelligence service starts targeting Cozumel dive operator Terry Manetta's customers. But Dayle is determined not to become the next victim, keeping one step ahead of a relentless killer pursuing her across the Atlantic and back to the Mexican Caribbean. Terry and her husband, former New York City detective Joe Manetta, team up with old friends at the NYPD, FBI, and CIA, to solve this international caper. Throw in the Washington DC PD and the alphabet soup gets even thicker, as spies, treasure hunters, and Cozumel scuba divers collide in this Caribbean adventure. It's been several years since Terry and Joe Manetta accidentally embroiled themselves in a Caribbean mystery thriller. Their latest adventure covers an international triangle anchored in New York City, Havana, and Cozumel with brief stopovers in Washington D.C., Madrid, and Cadiz.
This book provides a valuable reference tool for technical and management personnel who lead or are a part of incident investigation teams. This second edition focuses on investigating process-related incidents with real or potential catastrophic consequences. It presents on-the-job information, techniques, and examples that support successful investigations. The methodologies, tools, and techniques described in this book can also be applied when investigating other types of events such as reliability, quality, occupational health, and safety incidents. The accompanying CD-ROM contains the text of the book for portability as well as additional supporting tools for on-site reference and trouble shooting. Note: CD-ROM/DVD and other supplementary materials are not included as part of eBook file.
Leading the way in this field, the Encyclopedia of Quantitative Risk Analysis and Assessment is the first publication to offer a modern, comprehensive and in-depth resource to the huge variety of disciplines involved. A truly international work, its coverage ranges across risk issues pertinent to life scientists, engineers, policy makers, healthcare professionals, the finance industry, the military and practising statisticians. Drawing on the expertise of world-renowned authors and editors in this field this title provides up-to-date material on drug safety, investment theory, public policy applications, transportation safety, public perception of risk, epidemiological risk, national defence and security, critical infrastructure, and program management. This major publication is easily accessible for all those involved in the field of risk assessment and analysis. For ease-of-use it is available in print and online.
Dr. Cătălin Bărboianu, a recognized authority in gaming mathematics, philosopher of science, and problem-gambling researcher, proposes in this practical guide for both problem and non-problem gamblers a new pragmatic, conceptual approach of gambling mathematics. The primary aim of this guide is the adequate understanding of the essence and complexity of gambling through its mathematical dimension. The author starts from the premise that formal gambling mathematics, which is hardly even digestible for the non-math-inclined gamblers, is ineffective alone in correcting the specific cognitive distortions associated with gambling. By applying the latest research results in this field, the author blends the gambling-mathematics concepts with the epistemology of applied mathematics and cognitive psychology for providing gamblers the knowledge required for rational and safe gambling. It is not a standard book of gambling mathematics. The essential mathematical concepts are explained in a conceptual mode for the non-math reader, limited to their context of application and including their precise relationship with the real world of gambling. The entire mathematical dimension of gambling is reduced to seven general principles, explained at large in the seven main chapters, each generating a set of general recommendations applicable in general or in particular situations. These recommendations cover both the technical play, including objective and optimal strategies, and responsible, safe gambling. The guide has entire sections dedicated to roulette, blackjack, slots, poker, and sport betting; however, the principles and the associated advice are applicable in general to all games of chance. A major focus of the work is on explaining, making aware of, demounting, and correcting the classical gambling cognitive distortions (misconceptions, subjective estimations of probabilities, the Monte Carlo fallacy, conjunction and disjunction fallacies, the near-miss effect, illusion of control, and the misunderstanding of gambling language). The guide provides the required cognitive tools for correcting these distortions with the help of the mathematical concepts and addresses not only gamblers, but also gambling experts, including counselors.