Can Healthcare Investigations Learn from the Aviation Industry?
At the apex of the 1970s, the aviation industry found itself at the tail end of a 10-year path of negligence that culminated in the deaths of nearly 17,000 airline passengers worldwide. Amidst...
View ArticleImproving Diagnosis – Modulating “Hidden” Factors, Human and Otherwise
When we try to dissect through the various confounding factors that contribute to delays and errors in diagnosis, it is important to understand that only by delving deeply can one realize opportunities...
View ArticleIs it Possible to Modernize How Guidelines and Policies are Stored?
Considering the ubiquity of modern technology and computers, it seems an archaic notion that information such as patient records, healthcare policies, and guidelines would be stored by means of paper...
View ArticleHow to improve incident reporting rates
The core purpose of incident reporting is to learn from what happened in order to make improvements to future healthcare processes and systems and protect patients from harm. However, research1,2 shows...
View Article“Actionability” – the Appropriate and Necessary Outcome of Investigations
In the previous commentary in this series about enhancing the value of investigations, I discussed the findings of an investigation involving missed/delayed diagnosis of acute leukemia. The original...
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