Sort weak signals into high-reliability habits
Match unit safety observations to the high-reliability habit they call for.
Match each unit observation to the high-reliability habit it most calls for. Preoccupation with failure Reluctance to simplify Sensitivity to operations Deference to expertise Two bed alarms found off after transport, no patient harmed Medication delays blamed on "careless nurses" before checking pharmacy batching Charge nurse scans current acuity, hallway holds, and isolation rooms before assignments A wound-care nurse questions a dressing order and the team pauses for her expertise A near miss is reviewed even though the patient was fine Manager asks what changed in the work system instead of accepting "night shift is weak" Team adjusts assignments after…
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