Pete's Talk Notes
Below 10,000 Medical
Surgery Stat! The Game
Fatigue: An Organisational Policy
Fatigue ACORN References
Fatigue Mitigation Frameworks
Executive Level Recommendations 1
NUM's Role in Fatigue Management
Tectonic Plate Tetris Workload Theory
High Performance Health Care Teams
Antus Benner psychologica
Human Factors Study
The Art of BTT
BTT Honour Roll
BTTM Brag Board
Steve Bolsin's Letter of Recommendation
Dr Amutha Samuel's Recommendation
November 8, 2019
The interesting thing about the weather is that it is a non intelligent non linear sensitively dependent and highly reactive system.
One thing we know abour the weather is that it behaves according to the theories of chaos, making accurate prediction a remote possibility.
Despite all this we can't help attributing emotional value to the climactic conditions of the day.
And we expect the weather to cooperate with our expectations.
That's a big ask for a non intelligent non linear sensitive and reactive fluid system when in fact all we can do is get lucky.
We could say the same about healthcare.
The care experience is sensitively dependent on initial conditions.
Safety precipitates in reaction to production pressure, fatigue, systems of work and the sum total of the team behaviours and skills of those enacting your care.
Considering these metrics, the system may be no more intelligent than the weather,
The patient care outcome lies somewhere on Chaos Theory's Lorenz Attractor butterfly graph.
We are all familiar with that graph's well worn rhetoric that a butterfly flapping its wings in the Amazon can cause a hurricane in Florida.
If we seek safety as an important outcome from the mechanics of a chaotic system.....
.....then when you enter a hospital with the intention of coming out unharmed, maybe it's best to take an umbrella.
Patient Safety Learning Awards
September 27, 2018
October 18, 2015
Letter to John Gibbs
October 17, 2018
June 1, 2020
Weather or not
October 27, 2019
October 23, 2019
October 19, 2019
October 18, 2019
October 17, 2019
October 15, 2019
October 13, 2019
October 12, 2019