Monday, August 10, 2009

Interrupting Harm

Here you can find The San Francisco Chronicle's "Dead by Mistake", a series dedicated to exploring the profound effects of harm caused by medical error. On the site they highlight the Institute for Healthcare Improvement's (IHI) Global Trigger Tool- a tool used for measuring adverse events. You can read more about the GTT here.

Remember, to count is only part of our work. We must find harm, understand where our defects are, make predictions, test our theories/changes, and ultimately interrupt the cycle of harm before it ever occurs. We must use design science to eliminate needless death, pain and human suffering, unwanted waiting, helplessness and waste, and we must do it in a way that no one is left behind (

Many of you have asked to learn more about measurement. As promised, I will begin a series of weekly learning sessions with an aim to demystify quality improvement.

Please join me for next week's session: Understanding Variation on Thursday August 20th at 9:00 AM at CCRMC in Building One, Conference Room One.

Be well,


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