Unintended Consequences

In Patient Safety on April 28, 2015 at 7:37 am

I live in an 18 floor building and ride the elevator often. When there are older gentlemen riding with me they usually step aside to let me out first.  While this appears chivalrous it actually lens me to be the one to open the garage door which is usually fairly difficult due to the wind pattern.Sometimes’s it hurts my arm.
When I realized this, I began to motion to let the men out first. Most often I am greeted by a smile and a slight bow “oh no ladies first”. I have been hesitant to say anything as the men are often quite pleased with their chivalry.

How often in health care are we pleased with ourselves for doing the right thing or following best practices when in fact we might have made things more difficult or even harmful for a patient? If they think we are nice and mean well will they even tell us?

Watch for unintended consequences.If you don’t look or ask you won’t find them and you might just be doing more harm than good

Chorhexidine injected into leg 2013

In Human Factors on March 29, 2015 at 5:47 pm

The Human Factor: Learning from Gina’s Story’ which has been shown to NHS staff and organisations to show how lessons can be learned from local investigations.
A powerful video. Anyone in healthcare will cringe as soon as you see the team proceed to fill open bowls with unlabeled fluids.

Organizational justice

In organizational justice, safety on March 27, 2015 at 5:26 pm

There some in organizational psychology who feel just culture isnt enough to promote a culture of safety. Where just culture deals with response to behavior directly related to safety, organizational justice refers to employees overall perception of fairness in the workplace. Safety culture may be more influenced by this as hypothesized by Weiner, et al (2008). It isnt known how different groups who work in the healthcare environment perceive justice in the workplace. IF doctors are treated differently than nurses does that impact safety culture? If one group has a better supervisor than another does that impact safety culture?

Weiner Hobgood and Lewis Highly recommended reading
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How do leaders factor into this? Walk the walk and talk the talk have never been more important. Check out this recent study about hypocritical leadership


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