Professor James Reason, University of Manchester
http://swazilandforum.com/?n=option-builder-broker option builder broker Problems and Perils of Prescription Medicines
Thursday 22 May 2003
Royal College of Physicians
Stumbling at every step
Tadalafil Oral Strip In the last 5 or 6 years something remarkable has happened in medicine and healthcare, a kind of glasnost and error has come out of the closet. But there hasnâ€™t been a big bang or catastrophe. There has been the Bristol Royal infirmary, but all of this has been brought about by a flurry of high-level reports, the chief medical officers report and organisation with a memory and various other documents that raised errors very high on the agenda. The great pioneers say we should look to aviation, as a model for safety in healthcare and indeed there are many good lessons to be learned.
broker forex Aviation is predicated on the assumption that people screw-up. You (healthcare professionals) on the other hand are extensively educated to get it right and so you donâ€™t have a culture where you share readily the notion of error. So it is something of a big sea change. We are able almost at every meeting that crops up hear some discussion of error.
notizie trading tempo reale My original title was "Stumbling at every step". I wanted to start with the notion of error management.
binäre optionen endlich mit gewinn download A lot of the past ways of managing error have been fashion driven and atheoretical. I want to give you a principled view of how one might go about it. Errors canâ€™t be eliminated but they can be managed. That isnâ€™t something that springs to the lips of most managers, they see it as some sort of divine curse. Error is extremely adaptive and comes from cognitive roots that are the very basis of human behaviour. Our ability to delegate our actions to non-intentional control or automatic control is essential for normal life, but it also leads to actions take on a life of their own without any intention. I think one needs to understand the nature of error and the variety of error before we can manage it.
opciones binarias estrategias trading Error is not random, it is not out of the blue, and it is largely predictable. You can predict it using the uncertainty principle. In order to be performed correctly any cognitive action needs to be specified in a number of ways and where there is under specification, which takes a variety of forms like the failure to attend at some particular point in an action sequence or having degraded sensory data, or forgetting something, or having incomplete knowledge then the cognitive system does something very clever. It moves into a state where it will adopt the response that is most useful in that situation. It is very contextual. It is hinged upon frequency and familiarity.