Archive for the ‘Behavior change’ Category

Back to the Future…

In Behavior change, High Reliability Orgs, Resiliency, Root cause analysis on January 28, 2012 at 8:08 am

ISMP newsletter, 1998

“Currently, there is no consistent process among healthcare organizations for detecting and reporting errors. Since many medication errors cause no harm to patients, they remain undetected or unreported. Still, organizations frequently depend on spontaneous voluntary error reports alone to determine a medication error rate. The inherent variability of determining an error rate in this way invalidates the measurement, or benchmark. A high error rate may suggest either unsafe medication practices or an organizational culture that promotes error reporting. Conversely, a low error rate may suggest either successful error prevention strategies or a punitive culture that inhibits error reporting. Also, the definition of a medication error may not be consistent among organizations or even between individual practitioners in the same organization. Thus, spontaneous error reporting is a poor method of gathering “benchmarks;”it is not designed to measure medication error rates.” Read the full newletter here

Hey McFly, why have we made so little progress?


Human Error? Nice try Rolling Hills…

In Behavior change, culture, human error on December 23, 2011 at 9:08 am

Article by J. St Amand: Rolling Hills Hospital in Franklin, Tenn., recently refused a lesbian woman the right to visit her partner, reported the Tennessean in a Dec. 21 article. Franklin is located about 20 miles south of downtown Nashville.

The psychiatric hospital went against new federal anti-discrimination laws when Val Burke was not allowed to visit her partner who was in facility’s residential unit. The U.S. Department of Health and Human Services created the rules, which include equal visitation and representation rights, in September.

It was human error,” said Richard Bangert, chief executive officer of Rolling Hills. “They made a mistake. When I learned of it, I immediately met with my staff on Monday. We immediately made the change in terms of making sure that our policy was very clear.”

Bangert plans to apologize to Burke

While it is nice to see the hospital endeavoring to comply with Federal regulations, this was not a case of HUMAN ERROR. Does labeling this as human error contribute to our understanding of it? This is another incident of blame and train. “we met with the staff and made sure our policy was clear.” Is the spirit of the policy “DON’T discriminate against federally protected groups?” Read the rest of this entry »

More Fogg….

In Behavior change, Human Factors, usability on November 7, 2011 at 7:20 am

Caroline Jones over at used BJ Fogg’s B=MAT method to describe a simple change around the office.   It is a great read and shows the Fogg behavior model in action.

“People are creatures of habit and this can introduce challenges should you want them to adopt a new behaviour. We all start forming and evolving our behaviours from the time we are born, and each of us will respond to different stimuli in our own unique way. Some of us can’t start their day without our morning coffee whereas others will reach for a cigarette as a first port of call. Some can’t fall asleep without a book in their hands and others like to leave their T.V. switched on. These behavioural differences are a big part of what makes us human….Read More

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