Zero Suicide Sidney Dekker: Responses to failure

Healthcare systems exist in a changing world. Too often they are under severe resource and performance pressures and the environment, economics, technology and regulatory context all change over time.
In complex systems when adverse events happen they are not linear. However, hindsight bypasses the circumstances of the moment and does not seek to understand why people made the decision they made at the time. It inevitably leads you to the outcome which you already know.

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Wow! Excellent presentation. I’m not a manager but this has made me rethink how I respond to errors (mine and others) in my workplace and constructive changes I can make in my response. Thank you.