WORK/LIFE: Fixing the system

April 2004 
Volume 34  Number 4
Pages 74 - 74
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    With patient safety a major initiative, this is a good time to reexamine patient-safety practices at your facility. To promote a culture of safety, you must recognize that human nature and the complexity of clinical practice guarantee that preventing mistakes entirely is impossible. Here are a few reasons why:

    * A person's short-term memory can hold only five pieces of information.

    * Stress significantly degrades human performance.

    * Fatigue decreases the ability to process complex information.

    * Interruptions take the focus off important tasks.

    * Multitasking multiplies the risk of error.

    Lasting change calls for improving the system rather than penalizing individuals for errors. To make meaningful changes, the risk managers in your organization should invite input from the people doing the work—you and your colleagues. Staff members involved in change will “own” it, and improvements ...

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