Apresentação de Stephen Muething durante o SIMPÓSIO EINSTEIN-IHI: Implantação e Disseminação de Programas de Segurança do Paciente aconteceu de 3 a 5 de novembro de 2013, em São Paulo - Brasil.
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Getting To Zero Harm: Cincinnati Children's Hospital Story
1. What Is Possible In A Hospital?
Getting To Zero Harm
Cincinnati Children’s Story
November 4, 2013
Stephen E. Muething, MD
Vice President for Safety
James M. Anderson Center
8. High Reliability Organizations (HROs)
Kathleen M. Sutcliffe, MSN, PhD
Karl E. Weick, PhD
High Reliability Organizations
Environment rich with potential for errors
Unforgiving social and political environment
Learning through experimentation difficult
Complex processes
Complex technology
9. Characteristics of
High Reliability Organizations
1. Preoccupation with failure
Regarding small, inconsequential errors as a symptom that
something is wrong; finding the half-event
2. Sensitivity to operations
Paying attention to what’s happening on the front-line
3. Reluctance to simplify
Encouraging diversity in experience, perspective, and opinion
4. Commitment to resilience
Developing capabilities to detect, contain, and bounce-back
from events that do occur
5. Deference to expertise
Pushing decision making down and around to the person
with the most related knowledge and expertise