Still Not Safe

Still Not Safe

Author: Robert Wears

Publisher: Oxford University Press, USA

Published: 2019-12

Total Pages: 305

ISBN-13: 0190271264

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The term "patient safety" rose to popularity in the late nineties, as the medical community -- in particular, physicians working in nonmedical and administrative capacities -- sought to raise awareness of the tens of thousands of deaths in the US attributed to medical errors each year. But what was causing these medical errors? And what made these accidents to rise to epidemic levels, seemingly overnight? Still Not Safe is the story of the rise of the patient-safety movement -- and how an "epidemic" of medical errors was derived from a reality that didn't support such a characterization. Physician Robert Wears and organizational theorist Kathleen Sutcliffe trace the origins of patient safety to the emergence of market trends that challenged the place of doctors in the larger medical ecosystem: the rise in medical litigation and physicians' aversion to risk; institutional changes in the organization and control of healthcare; and a bureaucratic movement to "rationalize" medical practice -- to make a hospital run like a factory. If these social factors challenged the place of practitioners, then the patient-safety movement provided a means for readjustment. In spite of relatively constant rates of medical errors in the preceding decades, the "epidemic" was announced in 1999 with the publication of the Institute of Medicine report To Err Is Human; the reforms that followed came to be dominated by the very professions it set out to reform. Weaving together narratives from medicine, psychology, philosophy, and human performance, Still Not Safe offers a counterpoint to the presiding, doctor-centric narrative of contemporary American medicine. It is certain to raise difficult, important questions around the state of our healthcare system -- and provide an opening note for other challenging conversations.


Book Synopsis Still Not Safe by : Robert Wears

Download or read book Still Not Safe written by Robert Wears and published by Oxford University Press, USA. This book was released on 2019-12 with total page 305 pages. Available in PDF, EPUB and Kindle. Book excerpt: The term "patient safety" rose to popularity in the late nineties, as the medical community -- in particular, physicians working in nonmedical and administrative capacities -- sought to raise awareness of the tens of thousands of deaths in the US attributed to medical errors each year. But what was causing these medical errors? And what made these accidents to rise to epidemic levels, seemingly overnight? Still Not Safe is the story of the rise of the patient-safety movement -- and how an "epidemic" of medical errors was derived from a reality that didn't support such a characterization. Physician Robert Wears and organizational theorist Kathleen Sutcliffe trace the origins of patient safety to the emergence of market trends that challenged the place of doctors in the larger medical ecosystem: the rise in medical litigation and physicians' aversion to risk; institutional changes in the organization and control of healthcare; and a bureaucratic movement to "rationalize" medical practice -- to make a hospital run like a factory. If these social factors challenged the place of practitioners, then the patient-safety movement provided a means for readjustment. In spite of relatively constant rates of medical errors in the preceding decades, the "epidemic" was announced in 1999 with the publication of the Institute of Medicine report To Err Is Human; the reforms that followed came to be dominated by the very professions it set out to reform. Weaving together narratives from medicine, psychology, philosophy, and human performance, Still Not Safe offers a counterpoint to the presiding, doctor-centric narrative of contemporary American medicine. It is certain to raise difficult, important questions around the state of our healthcare system -- and provide an opening note for other challenging conversations.


Still Not Safe

Still Not Safe

Author: Robert L. Wears

Publisher:

Published:

Total Pages:

ISBN-13: 9780190271299

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Patient safety suddenly burst into public consciousness in the late 1990s and became a 'celebrated' cause in the 2000s. It has since gradually faltered, and little improvement has been noted over almost 20 years. Both the rise and fall of patient safety demand explanation. Medical harm had been known long before the 1990s, so why did it suddenly become popular? And why were safety efforts ineffective? The authors propose that this rise was due to a discursive shift that reframed 'medical harm' into 'medical error' in the setting of anxiety about industrialization and great change in healthcare.


Book Synopsis Still Not Safe by : Robert L. Wears

Download or read book Still Not Safe written by Robert L. Wears and published by . This book was released on with total page pages. Available in PDF, EPUB and Kindle. Book excerpt: Patient safety suddenly burst into public consciousness in the late 1990s and became a 'celebrated' cause in the 2000s. It has since gradually faltered, and little improvement has been noted over almost 20 years. Both the rise and fall of patient safety demand explanation. Medical harm had been known long before the 1990s, so why did it suddenly become popular? And why were safety efforts ineffective? The authors propose that this rise was due to a discursive shift that reframed 'medical harm' into 'medical error' in the setting of anxiety about industrialization and great change in healthcare.


Still Not Safe

Still Not Safe

Author: Robert Wears

Publisher: Oxford University Press

Published: 2019-11-01

Total Pages: 256

ISBN-13: 0190271280

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The term "patient safety" rose to popularity in the late nineties, as the medical community -- in particular, physicians working in nonmedical and administrative capacities -- sought to raise awareness of the tens of thousands of deaths in the US attributed to medical errors each year. But what was causing these medical errors? And what made these accidents to rise to epidemic levels, seemingly overnight? Still Not Safe is the story of the rise of the patient-safety movement -- and how an "epidemic" of medical errors was derived from a reality that didn't support such a characterization. Physician Robert Wears and organizational theorist Kathleen Sutcliffe trace the origins of patient safety to the emergence of market trends that challenged the place of doctors in the larger medical ecosystem: the rise in medical litigation and physicians' aversion to risk; institutional changes in the organization and control of healthcare; and a bureaucratic movement to "rationalize" medical practice -- to make a hospital run like a factory. If these social factors challenged the place of practitioners, then the patient-safety movement provided a means for readjustment. In spite of relatively constant rates of medical errors in the preceding decades, the "epidemic" was announced in 1999 with the publication of the Institute of Medicine report To Err Is Human; the reforms that followed came to be dominated by the very professions it set out to reform. Weaving together narratives from medicine, psychology, philosophy, and human performance, Still Not Safe offers a counterpoint to the presiding, doctor-centric narrative of contemporary American medicine. It is certain to raise difficult, important questions around the state of our healthcare system -- and provide an opening note for other challenging conversations.


Book Synopsis Still Not Safe by : Robert Wears

Download or read book Still Not Safe written by Robert Wears and published by Oxford University Press. This book was released on 2019-11-01 with total page 256 pages. Available in PDF, EPUB and Kindle. Book excerpt: The term "patient safety" rose to popularity in the late nineties, as the medical community -- in particular, physicians working in nonmedical and administrative capacities -- sought to raise awareness of the tens of thousands of deaths in the US attributed to medical errors each year. But what was causing these medical errors? And what made these accidents to rise to epidemic levels, seemingly overnight? Still Not Safe is the story of the rise of the patient-safety movement -- and how an "epidemic" of medical errors was derived from a reality that didn't support such a characterization. Physician Robert Wears and organizational theorist Kathleen Sutcliffe trace the origins of patient safety to the emergence of market trends that challenged the place of doctors in the larger medical ecosystem: the rise in medical litigation and physicians' aversion to risk; institutional changes in the organization and control of healthcare; and a bureaucratic movement to "rationalize" medical practice -- to make a hospital run like a factory. If these social factors challenged the place of practitioners, then the patient-safety movement provided a means for readjustment. In spite of relatively constant rates of medical errors in the preceding decades, the "epidemic" was announced in 1999 with the publication of the Institute of Medicine report To Err Is Human; the reforms that followed came to be dominated by the very professions it set out to reform. Weaving together narratives from medicine, psychology, philosophy, and human performance, Still Not Safe offers a counterpoint to the presiding, doctor-centric narrative of contemporary American medicine. It is certain to raise difficult, important questions around the state of our healthcare system -- and provide an opening note for other challenging conversations.


To Err Is Human

To Err Is Human

Author: Institute of Medicine

Publisher: National Academies Press

Published: 2000-03-01

Total Pages: 312

ISBN-13: 0309068371

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Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine


Book Synopsis To Err Is Human by : Institute of Medicine

Download or read book To Err Is Human written by Institute of Medicine and published by National Academies Press. This book was released on 2000-03-01 with total page 312 pages. Available in PDF, EPUB and Kindle. Book excerpt: Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine


Keeping Patients Safe

Keeping Patients Safe

Author: Institute of Medicine

Publisher: National Academies Press

Published: 2004-03-27

Total Pages: 485

ISBN-13: 0309187362

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Building on the revolutionary Institute of Medicine reports To Err is Human and Crossing the Quality Chasm, Keeping Patients Safe lays out guidelines for improving patient safety by changing nurses' working conditions and demands. Licensed nurses and unlicensed nursing assistants are critical participants in our national effort to protect patients from health care errors. The nature of the activities nurses typically perform â€" monitoring patients, educating home caretakers, performing treatments, and rescuing patients who are in crisis â€" provides an indispensable resource in detecting and remedying error-producing defects in the U.S. health care system. During the past two decades, substantial changes have been made in the organization and delivery of health care â€" and consequently in the job description and work environment of nurses. As patients are increasingly cared for as outpatients, nurses in hospitals and nursing homes deal with greater severity of illness. Problems in management practices, employee deployment, work and workspace design, and the basic safety culture of health care organizations place patients at further risk. This newest edition in the groundbreaking Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety.


Book Synopsis Keeping Patients Safe by : Institute of Medicine

Download or read book Keeping Patients Safe written by Institute of Medicine and published by National Academies Press. This book was released on 2004-03-27 with total page 485 pages. Available in PDF, EPUB and Kindle. Book excerpt: Building on the revolutionary Institute of Medicine reports To Err is Human and Crossing the Quality Chasm, Keeping Patients Safe lays out guidelines for improving patient safety by changing nurses' working conditions and demands. Licensed nurses and unlicensed nursing assistants are critical participants in our national effort to protect patients from health care errors. The nature of the activities nurses typically perform â€" monitoring patients, educating home caretakers, performing treatments, and rescuing patients who are in crisis â€" provides an indispensable resource in detecting and remedying error-producing defects in the U.S. health care system. During the past two decades, substantial changes have been made in the organization and delivery of health care â€" and consequently in the job description and work environment of nurses. As patients are increasingly cared for as outpatients, nurses in hospitals and nursing homes deal with greater severity of illness. Problems in management practices, employee deployment, work and workspace design, and the basic safety culture of health care organizations place patients at further risk. This newest edition in the groundbreaking Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety.


Patient Safety and Quality

Patient Safety and Quality

Author: Ronda Hughes

Publisher: Department of Health and Human Services

Published: 2008

Total Pages: 592

ISBN-13:

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"Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043)." - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/


Book Synopsis Patient Safety and Quality by : Ronda Hughes

Download or read book Patient Safety and Quality written by Ronda Hughes and published by Department of Health and Human Services. This book was released on 2008 with total page 592 pages. Available in PDF, EPUB and Kindle. Book excerpt: "Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043)." - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/


Crossing to Safety

Crossing to Safety

Author: Wallace Stegner

Publisher: Modern Library

Published: 2007-12-18

Total Pages: 370

ISBN-13: 0307430863

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Introduction by Terry Tempest Williams Afterword by T. H. Watkins Called a “magnificently crafted story . . . brimming with wisdom” by Howard Frank Mosher in The Washington Post Book World, Crossing to Safety has, since its publication in 1987, established itself as one of the greatest and most cherished American novels of the twentieth century. Tracing the lives, loves, and aspirations of two couples who move between Vermont and Wisconsin, it is a work of quiet majesty, deep compassion, and powerful insight into the alchemy of friendship and marriage.


Book Synopsis Crossing to Safety by : Wallace Stegner

Download or read book Crossing to Safety written by Wallace Stegner and published by Modern Library. This book was released on 2007-12-18 with total page 370 pages. Available in PDF, EPUB and Kindle. Book excerpt: Introduction by Terry Tempest Williams Afterword by T. H. Watkins Called a “magnificently crafted story . . . brimming with wisdom” by Howard Frank Mosher in The Washington Post Book World, Crossing to Safety has, since its publication in 1987, established itself as one of the greatest and most cherished American novels of the twentieth century. Tracing the lives, loves, and aspirations of two couples who move between Vermont and Wisconsin, it is a work of quiet majesty, deep compassion, and powerful insight into the alchemy of friendship and marriage.


The Giver

The Giver

Author: Lois Lowry

Publisher: Houghton Mifflin Harcourt

Published: 2014

Total Pages: 257

ISBN-13: 054434068X

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The Giver, the 1994 Newbery Medal winner, has become one of the most influential novels of our time. The haunting story centers on twelve-year-old Jonas, who lives in a seemingly ideal, if colorless, world of conformity and contentment. Not until he is given his life assignment as the Receiver of Memory does he begin to understand the dark, complex secrets behind his fragile community. This movie tie-in edition features cover art from the movie and exclusive Q&A with members of the cast, including Taylor Swift, Brenton Thwaites and Cameron Monaghan.


Book Synopsis The Giver by : Lois Lowry

Download or read book The Giver written by Lois Lowry and published by Houghton Mifflin Harcourt. This book was released on 2014 with total page 257 pages. Available in PDF, EPUB and Kindle. Book excerpt: The Giver, the 1994 Newbery Medal winner, has become one of the most influential novels of our time. The haunting story centers on twelve-year-old Jonas, who lives in a seemingly ideal, if colorless, world of conformity and contentment. Not until he is given his life assignment as the Receiver of Memory does he begin to understand the dark, complex secrets behind his fragile community. This movie tie-in edition features cover art from the movie and exclusive Q&A with members of the cast, including Taylor Swift, Brenton Thwaites and Cameron Monaghan.


Safety-I and Safety-II

Safety-I and Safety-II

Author: Erik Hollnagel

Publisher: CRC Press

Published: 2018-04-17

Total Pages: 167

ISBN-13: 1317059794

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Safety has traditionally been defined as a condition where the number of adverse outcomes was as low as possible (Safety-I). From a Safety-I perspective, the purpose of safety management is to make sure that the number of accidents and incidents is kept as low as possible, or as low as is reasonably practicable. This means that safety management must start from the manifestations of the absence of safety and that - paradoxically - safety is measured by counting the number of cases where it fails rather than by the number of cases where it succeeds. This unavoidably leads to a reactive approach based on responding to what goes wrong or what is identified as a risk - as something that could go wrong. Focusing on what goes right, rather than on what goes wrong, changes the definition of safety from ’avoiding that something goes wrong’ to ’ensuring that everything goes right’. More precisely, Safety-II is the ability to succeed under varying conditions, so that the number of intended and acceptable outcomes is as high as possible. From a Safety-II perspective, the purpose of safety management is to ensure that as much as possible goes right, in the sense that everyday work achieves its objectives. This means that safety is managed by what it achieves (successes, things that go right), and that likewise it is measured by counting the number of cases where things go right. In order to do this, safety management cannot only be reactive, it must also be proactive. But it must be proactive with regard to how actions succeed, to everyday acceptable performance, rather than with regard to how they can fail, as traditional risk analysis does. This book analyses and explains the principles behind both approaches and uses this to consider the past and future of safety management practices. The analysis makes use of common examples and cases from domains such as aviation, nuclear power production, process management and health care. The final chapters explain the theoret


Book Synopsis Safety-I and Safety-II by : Erik Hollnagel

Download or read book Safety-I and Safety-II written by Erik Hollnagel and published by CRC Press. This book was released on 2018-04-17 with total page 167 pages. Available in PDF, EPUB and Kindle. Book excerpt: Safety has traditionally been defined as a condition where the number of adverse outcomes was as low as possible (Safety-I). From a Safety-I perspective, the purpose of safety management is to make sure that the number of accidents and incidents is kept as low as possible, or as low as is reasonably practicable. This means that safety management must start from the manifestations of the absence of safety and that - paradoxically - safety is measured by counting the number of cases where it fails rather than by the number of cases where it succeeds. This unavoidably leads to a reactive approach based on responding to what goes wrong or what is identified as a risk - as something that could go wrong. Focusing on what goes right, rather than on what goes wrong, changes the definition of safety from ’avoiding that something goes wrong’ to ’ensuring that everything goes right’. More precisely, Safety-II is the ability to succeed under varying conditions, so that the number of intended and acceptable outcomes is as high as possible. From a Safety-II perspective, the purpose of safety management is to ensure that as much as possible goes right, in the sense that everyday work achieves its objectives. This means that safety is managed by what it achieves (successes, things that go right), and that likewise it is measured by counting the number of cases where things go right. In order to do this, safety management cannot only be reactive, it must also be proactive. But it must be proactive with regard to how actions succeed, to everyday acceptable performance, rather than with regard to how they can fail, as traditional risk analysis does. This book analyses and explains the principles behind both approaches and uses this to consider the past and future of safety management practices. The analysis makes use of common examples and cases from domains such as aviation, nuclear power production, process management and health care. The final chapters explain the theoret


High Reliability Organizations, Second Edition

High Reliability Organizations, Second Edition

Author: Cynthia A. Oster

Publisher: Sigma Theta Tau

Published: 2020-11-02

Total Pages: 882

ISBN-13: 1948057778

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Patient safety and quality of care are critical concerns of healthcare consumers, payers, providers, organizations, health systems, and governments. Although a strong body of knowledge shows that high reliability methods enable the most efficient, safe, and effective care, these methods have yet to be completely implemented across healthcare. According to authors Cynthia Oster and Jane Braaten, nurses—who are on the frontline of providing safe and effective care—are ideally situated to drive high reliability. High Reliability Organizations: A Healthcare Handbook for Patient Safety & Quality, Second Edition, equips nurses and healthcare professionals with the tools necessary to establish an error detection and prevention system. This new edition builds on the foundation of the first book with best practices, relevant exemplars, and important discussions about cultural aspects essential to sustainability. New material focuses on: · High reliability performance during a pandemic · Organizational learning and tiered safety huddles · High reliability in infection prevention and ambulatory care · The emerging field of human factors engineering within healthcare · Creating a virtual resource toolkit for frontline staff


Book Synopsis High Reliability Organizations, Second Edition by : Cynthia A. Oster

Download or read book High Reliability Organizations, Second Edition written by Cynthia A. Oster and published by Sigma Theta Tau. This book was released on 2020-11-02 with total page 882 pages. Available in PDF, EPUB and Kindle. Book excerpt: Patient safety and quality of care are critical concerns of healthcare consumers, payers, providers, organizations, health systems, and governments. Although a strong body of knowledge shows that high reliability methods enable the most efficient, safe, and effective care, these methods have yet to be completely implemented across healthcare. According to authors Cynthia Oster and Jane Braaten, nurses—who are on the frontline of providing safe and effective care—are ideally situated to drive high reliability. High Reliability Organizations: A Healthcare Handbook for Patient Safety & Quality, Second Edition, equips nurses and healthcare professionals with the tools necessary to establish an error detection and prevention system. This new edition builds on the foundation of the first book with best practices, relevant exemplars, and important discussions about cultural aspects essential to sustainability. New material focuses on: · High reliability performance during a pandemic · Organizational learning and tiered safety huddles · High reliability in infection prevention and ambulatory care · The emerging field of human factors engineering within healthcare · Creating a virtual resource toolkit for frontline staff