ABSTRACT
Learning about the limits and dif‹culties of improving patient safety is one thing, it is necessary. The previous chapters have discussed a host of issues-from the problems of the medical competence hierarchy to local rationality to the complexities and capabilities of new technology and the administrative and managerial origin of organizational adverse events. Knowing what to do with that knowledge can be something else. What to do now? This chapter discusses a number of human factors interventions that have proven worthwhile in both healthcare and other industries. It begins with safety reporting and organizational learning, then moves to adverse event investigations and resource management training, and ‹nishes with a human factors consideration of checklists as tools for improving safety.
