In the fall of 2005 the environmental groups, Friends of the River, the Sierra Club and the South Yuba Citizens League tried to convince the Federal Energy Regulatory Commission to fortify the earthen emergency spillway of Oroville Dam.* The California Department of Water Resources denied the risk, and the FERC denied the petitioners’ request for […]
Author: Jared Padgett
Enhancing Patient Safety through Organizational Learning: Are Patient Safety Indicators a Step in the Right Direction?
The authors noted increasing use of Patient Safety Indicators (PSIs), and evaluated whether analysis of PSIs contributes to improved patient safety. PSIs are calculated through administrative data, and the authors suggested that without organizational learning, PSIs and other measurements may not be as effective. They describe a process for using PSIs to improve organizational learning. […]
Creating High Reliability in Health Care Organizations
This article describes the creation of a patient safety model, and the results of the model’s test in intensive care units. The model was developed using elements of HRO theory, including development of standard processes, and improved communication. Emphasis was placed on improving organizational learning through application of lessons learned, so that future errors could […]
Assessing NASA’s Safety Culture: The Limits and Possibilities of High‐Reliability Theory
This article provides alternative viewpoints for what an HRO should look like. It contrasts normal accident theory with High Reliability Theory (HRT). It also shows how some organizations cannot become HROs, though they should continue striving to do so. HRO is a process, not an achievement. The authors suggest that NASA cannot become an HRO, […]
Relationship of Safety Climate and Safety Performance in Hospitals
This study found that frontline personnel’s understanding of the safety climate was a better predictor of safety than supervisors’ understanding of the safety climate. It explored how patient safety indicators are affected by the overall safety climate. This supports the HRO principle of authority migration, where frontline, knowledgeable employees are empowered to prevent errors. Singer, S., […]