Still Not Safe最新文献

Institutionalization 制度化

Still Not Safe Pub Date : 2019-11-21 DOI: 10.1093/oso/9780190271268.003.0009

R. Wears, K. Sutcliffe

引用次数: 21

Beginnings 开始

Still Not Safe Pub Date : 2019-11-21 DOI: 10.1093/oso/9780190271268.003.0002

R. Wears, K. Sutcliffe

{"title":"Beginnings","authors":"R. Wears, K. Sutcliffe","doi":"10.1093/oso/9780190271268.003.0002","DOIUrl":"https://doi.org/10.1093/oso/9780190271268.003.0002","url":null,"abstract":"The To Err is Human report rests upon a series of historical episodes—the early development of safety thinking in healthcare, the evolution of safety thinking in the safety sciences, and accumulating stories of personal suffering and tragedy experiences by patients. Concerns about the safety of healthcare date at least as far back as the Code of Hammurabi. Early efforts at improving safety appeared sporadically in the eighteenth and nineteenth centuries, but these were isolated and not sustained. Malpractice concerns were also entangled with safety, and the first malpractice crisis in the United States came about due to advances, rather than deficiencies, in care. Public and governmental interest in safety more generally developed out of railway accidents in the nineteenth century. Notions of accidents evolved over time, moving from accident proneness to the domino model, to more complex models such as Reason’s Swiss cheese model. Libby Zion's death results in New York state legislation regulating medical trainees’ supervision and duty hours, marking a change from a self-regulating profession to a more typical service industry. Recognition that health professionals involved in adverse events are also, in a sense, victims begins to grow.","PeriodicalId":113540,"journal":{"name":"Still Not Safe","volume":"55 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127771666","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

The Future of Patient Safety 病人安全的未来

Still Not Safe Pub Date : 2019-11-21 DOI: 10.1093/oso/9780190271268.003.0012

R. Wears, K. Sutcliffe

引用次数: 0

Reflection 反射

Still Not Safe Pub Date : 2019-11-21 DOI: 10.1093/oso/9780190271268.003.0011

R. Wears, K. Sutcliffe

{"title":"Reflection","authors":"R. Wears, K. Sutcliffe","doi":"10.1093/oso/9780190271268.003.0011","DOIUrl":"https://doi.org/10.1093/oso/9780190271268.003.0011","url":null,"abstract":"Reviewing the evolution of patient safety over time, we see a discursive shift from harm to “error.” The “error” framing is used to advance the authority of scientific-bureaucratic managerial medicine and to diminish the traditional authority of clinical expertise. Psychologist Sidney Dekker noted that four different voices appear in patient safety discourses: epistemological (what happened?), preventative (how can it be prevented?), boundary-maintaining (were there violations or impermissible activities?), and existential (what is the reason for this suffering?). Discussions in one voice tend to be dissatisfying for the others, but the “error” framing addresses all four: an error occurred, errors can be prevented, violators should be punished, moral wrong leads to suffering. In summary, patient safety’s rise resulted from five factors: a general decrease in risk tolerance, the industrialization of healthcare, reframing harm as “error,” brief input from safety sciences holding out potential for improvement, and medicine’s effort to retain control of healthcare internally. Ironically, these factors also tended to make patient safety activity ineffective since they bounded out insights, skills, and theories from the safety sciences.","PeriodicalId":113540,"journal":{"name":"Still Not Safe","volume":"24 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"130425710","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0