Fig. 13.1 Threat and error model proposed by Helmreich [8]. Immediate threats are factors outside the control of the cockpit crew that act to increase the complexity of the situation…
Fig. 36.1 The foundation of this evolution in pediatric and congenital cardiac care is a solid understanding of the inter-relationships of the domains of outcomes analysis, quality improvement, and patient…
5. Department of Health. An organisation with a memory: report of an expert group on learning from adverse events in the NHS. London: HMSO; 2000. 6. McGlynn EA, Asch SM,…
Fig. 29.1 SEIPS Model of Systems in Healthcare: safety and harm are emergent properties of systems (Redrawn with permission from Carayon Qual Saf Health Care 2006) There are two important…
© Springer-Verlag London 2015Paul R. Barach, Jeffery P. Jacobs, Steven E. Lipshultz and Peter C. Laussen (eds.)Pediatric and Congenital Cardiac Care10.1007/978-1-4471-6566-8_26 26. Resilience and Systems Engineering Karen Harrington1 and Peter C. Laussen3, 2 (1) Departments of Pediatrics and Critical Care,…
Fig. 15.1 Antenatal Funnel plot by UK region for the financial year 2010–2011 A funnel plot showing performance by UK regions suggests that the London region is performing better but…
Safe Avoiding preventable injuries, reducing medical errors Effective Providing services based on scientific knowledge (clinical guidelines) Patient centered Care that is respectful and responsive to individuals Efficient Avoiding wasting time…
Is the team the right size and composition? Are there adequate levels of complementary skills? Is there a shared goal for the team? Does everyone understand the goals of the…
Fig. 22.1 Translational research phases Although definitions and views about the scope of implementation science vary, a key feature is its approach to the problem of persisting quality gaps from…
Fig. 9.1 Methodological overview of POCA registry (Reproduced from BMJ Quality and Safety; Posner et al. [4], copyright 2002 with permission from BMJ Publishing Group Ltd) For each case, an…
