Designing Safer Systems

“War Gaming” for Patient Safety

“War Gaming” for Patient Safety

Posted by  | Designing Safer Systems, Organizational and Cultural Change

Over a decade ago, I consulted on a project for the U.S. Air Force involving very large-scale simulations. These "war games" involved more than 1,500 participants around the world — some in simulators and some using real equipment in training mode. In a warehouse-sized building, a wall of gigantic screens captured the mock battle, as a(...)

Read More

How We Can Engineer a Less Costly Health Care System

How We Can Engineer a Less Costly Health Care System

Posted by  | Designing Safer Systems, Patient-Centered Care, Preventing Patient Harm

If we want to rein in the costs of the U.S. health-care system — now equal to nearly 18 percent of the nation's gross domestic product — we cannot ignore the fragmented technologies used to help heal and save lives. At first glance, the devices, monitors, electronic health records and machines found in today's hospitals(...)

Read More

How the Flint Water Crisis Is a Cautionary Tale for Health Care

How the Flint Water Crisis Is a Cautionary Tale for Health Care

Posted by  | Designing Safer Systems, Organizational and Cultural Change, Preventing Patient Harm

There has been no shortage of blame for the poisoning of Flint, Michigan's water supply. In March, a governor-appointed task force issued a report that rebuked local, state and federal authorities for their actions — and inactions — that created the public health crisis. Then, in late April, state prosecutors announced the first charges in the(...)

Read More

Seeking the Right Stuff for Teams: In the Hospital or Distant Space

Seeking the Right Stuff for Teams: In the Hospital or Distant Space

Posted by  | Designing Safer Systems, Measurement of Safety and Quality, Organizational and Cultural Change

Wanted: Talented, highly driven individuals to take on multiyear work assignment with potential for benefiting humankind. Requires the highest levels of technical skill, teamwork and adaptability. Must be able to tolerate social isolation, mental and physical fatigue, demanding and uneven work schedules, days and nights away from home. Risk of depression and burnout. Must be(...)

Read More

Patient Safety at 15: How Much Have We Grown?

Patient Safety at 15: How Much Have We Grown?

Posted by  | Designing Safer Systems, Measurement of Safety and Quality, Organizational and Cultural Change, Preventing Patient Harm

Fifteen-year anniversaries often come and go without fuss, overlooked in favor of those we can mark in full decades. Yet recently, at Johns Hopkins and nationally, we've crossed that mark for a couple of events in patient safety that merit both celebration and reflection. In January 2001, a series of lapses at Johns Hopkins led(...)

Read More

New Ebola Training Modules Will Help Safeguard Patients, Providers, and the Public

New Ebola Training Modules Will Help Safeguard Patients, Providers, and the Public

Posted by  | Designing Safer Systems, Preventing Patient Harm

Your body is covered from head to toe in protective equipment, and it’s 115 degrees Fahrenheit inside your outfit. Your hands sweat under two pairs of gloves. An ill-fitting hood creeps down your forehead and nearly covers your eyes, but you cannot touch your head to shift it back up. To top it off, the(...)

Read More

Re-engineering health care for safety and cost savings

Posted by  | Designing Safer Systems, Preventing Patient Harm

Despite spending $800 billion on technology last year, health care productivity is flat and preventable patient harm remains the third leading cause of death in the U.S. One reason is that health care is grossly under-engineered: medical devices don't talk to each other, treatments are not specified and ensured, and outcomes are largely assumed rather(...)

Read More