Healthcare is not a machine to be oiled. It is not something that can be shaved, and tweaked, and optimized to a point of lean flawlessness.
Rather, healthcare is a complex-adaptive system. As such, it’s models for safety and efficiency cannot (indeed must not) rely on the “retrospectoscope” of hindsight. And it certainly, must not name-blame-shame-and-train when handling error or inefficiency. Resilience Engineering may well be the cutting edge of patient safety science. Here’s how you can participate… More