Human Error : Crew Resource Management

This book identifies three standards of employees which each may require a different method of leadership form the same leader. These employees

There are two common ways to handle a medical error. One is by blaming the individual or things when the error occurs, called it the “culture of blame”. The other one is by focusing on the safety goal using effective systems and teamwork, called “culture of safety". We may say that one is more applicable than the other, or maybe one is more beneficial than the other. In real life though, only one can be applied in a healthcare system, the one that is proven effective regardless its origin, pragmatic, or .

Identify hazards, assess risks and risk control measures. Any kind of business you are, there is always the possibility of an accident or damage to someone's health. All work exposes people to hazards. Loads which have to be manually handled; dangerous machinery; toxic substances; electricity; working with display screen equipment or even psychological hazards such as stress. The reason there’s not even more accidents and diseases caused in the work place is because systems of prevention which are in place which have been built up over generations. Most accidents happen because they have not been prevented. Essentially you have to ensure absence of risk to safety and health of employees and others 'so far as is reasonably practicable'.

It is estimated that nearly 100,000 people die each year from medical errors in hospitals, with an estimated cost of between $17 and $29 billion per year. Finding a solution to this crisis has become a priority for every healthcare organization, with the realization that most errors are not caused by reckless staff, but by poor systems and processes (Institute of Medicine, 2000). Consequently, healthcare has begun to look to outside organizations in order to find solutions, by examining industries that are considered highly reliable, despite operating in hazardous situations. The lessons learned by these Highly Reliable Organizations (HROs) can be used to promote safe and reliable performance, which in turn should improve patient and staff

The Health Care Industry is complex and is responsible for the health of the country (The Hospital & Healthsystem Association of Pennsylvania; Outcome Engineering, 2010), and ultimately of the world. Unfortunately, according to the Institute of Medicine's comprehensive report, "To Err Is Human," avoidable medical errors annually kill 44,000 - 98,000 hospital patients (Reiling, Knutzen, & Stoecklein, 2003). In addition, as of March 31, 2010, the ten most frequently reported sentinel events within U.S. healthcare organizations are: "wrong site surgery; suicide; operative/post-operative complication; delay in treatment; medical error; patient fall; unintended retention of a foreign body; assault, rape or homicide; perinatal death or loss of function; patient death or injury in restraints" (HealthLeaders Media, 2010). Clearly, many of these

The Institute of Medicine (IOM) report To Err is Human (2000) defines patient safety, "as the prevention of harm caused by errors" (IOM, 2000, p. 57). Errors as defined by the IOM (2000) is the "failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim" (IOM, 2000, p. 57). Although not stated in the definition, errors are unintentional and do not have to result in harm of fatalities.

First is collective mindfulness. These means everyone within is expected to understand that issues may arise that can cause serious safety concerns. Safety is everyone’s responsibility as well as collective and shared responsibility (Ratwani, Hettinger and Fairbanks, 2014, p. 3). Second factor is dealing with reporting. There are processes in place that will report safety issues if one arises. The organization makes sure that the reports are easily accessible and useable as well as followed-up with. Lastly, is creating a culture that understands mistakes happen. Staff may not go around blaming others when something is interrupted, it is a team and events take place when humans are involved. This type of culture helps individuals know there are processes in place, provided by leadership to handle these type of serious safety events (Ratwani, Hettinger and Fairbanks, 2014). A major role to implement patient safety is by the use of health IT

The business success of most companies relies on the strategies they develop in order to manage their human resources. These strategies are based on policies that companies establish as rules that must be followed in order to ensure the flow of the activity in accordance with the standards established by the industry in case. However, these strategies and policies are developed in accordance with the type of activity of each company. The activity of Lockheed Martin is of great interest because of the implications it has on several industry sectors. The company must reach high quality standards. This is an objective that can be reached with the help of employees by developing different strategies intended to manage them.

The human factor approach of Reason defines errors according to two types of failure: active and latent failure, with adverse events at times involving a combination of the two. Active failures are defines as “unsafe acts (i.e. errors and violations) committed by those at the human system interface”.20-22 Active errors occur at the level of the operator, and their effects are felt almost immediately. This is sometimes called the sharp end.20-22 Staff actions at the (sharp end) of patient care may involve slips (e.g. picking up the wrong syringe), cognitive failure (e.g. memory lapses or misreading of information), and violation (deviation from standard procedures or processes). Latent failures stem from decisions, essentially made by management and more senior clinicians within the healthcare setting, which provide conditions in which unsafe acts occur (e.g. inadequate system of communication; poor rostering of staff; inadequate supervision; understaffing) and also weakness in defenses (e.g.

Safety First is a phrase most have heard throughout their career, but what impact does that have when there is an increase of safety incidents on base? Newly appointed safety officers inherit any outstanding safety challenges as well as any benchmark programs that brings safety to light. However, if the program is broken the safety officer must utilize the skills harbored within assigned personnel to make a difference for the betterment of the wing. As the new wing safety officer, I have been tasked to eradicate the trends in safety mishaps and make sure there is a process in place to prevent future occurrences. This paper will outline an

The Qantas Airways is the largest airline in Australia. Its Human Resource Management operates in the company in four major areas, which are business segments, corporate, shared services, development, and learning. This report gives limelight to the Qantas airways HRM and its role in ensuring perfect operations of the company. It further discusses change management and job analysis and design. The company has undergone intensive change management such as cutting of prices and labor costs in order to ensure high productivity, moderation of wages as well as the introduction of flexible structures through a versatile and motivated workforce. Moreover, the HRM is also responsible of ensuring that right people are hired and

The incident with the Northwest flight (NY Times 2009) crew is an ideal example of this. The pilots had a combined flying experience of over 30,000 hours, yet they committed an error that resulted in a major embarrassment and which could have cost lives. The main cause cited for this blunder is that the pilots were distracted during flight because they were engaged in personal matters on their laptops, which is a violation of airline safety guidelines. Is the root reason for this incident just poor judgment and misbehavior of the pilots or perhaps not enough emphasis on responsibility in their training?

A continuous concern that continues to present itself within the healthcare environment is adequate staffing on nursing units. Most hospital organizations try their very best to accommodate staffing needs, though many units remain understaffed for an unspecified amount of time. Inadequate staffing can negatively affect patient outcomes, lead to nurse burnout, and decrease patient satisfaction scores. Combating this issue will require a great deal of effort, as many geographical face nursing shortages when seeking new graduates and qualified candidates. Employees may begin to feel that they are unable to pursue personal goals within a healthcare organization, due to inability to transfer as a result of staffing shortages. This often results in nursing seeking employment or career advancement outside of the organization or geographical area, which further intensifies ramification associated with inadequate staffing.

The style of leadership varies with every individual. It has been stated that today’s successful leaders have created in their organizations an atmosphere where every employee believes in management, their strategy and the importance of their individual contributions in achieving the organizations goal. Blake Mouton’s Managerial Grid is a model using in identifying leadership style that is based on the concept that there are two behavioural dimensions: concern for people which can be defined as the degree to which leaders are aware of and consider the needs of their staff, their skill sets and development potential when making decisions about specific tasks to be completed. The

Human error is a primary factor that makes organisational accidents unavoidable. Human error is defined as a human decision or action in which