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Quality Thinking About Quality – Part Three: Scientific Revolutions, Rarely Occurring Events

In Part Two, I discussed the Joint Commission’s Universal Protocol, explained why it hasn’t worked at preventing wrong-site surgery, and proposed a better approach.  I also discussed the problem of airway disasters and suggested that it is time for a new approach to airway management.  Here I’d like to discuss how revolutions in science (including the clinical sciences) often occur, …

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Quality Thinking About Quality – Part Two: Wrong-Site Errors, Airway Disasters

In Part One, I explored the concept of quality, discussed performance demands and the choices workers face when system demands exceed performance capabilities.  Let us consider well-intentioned efforts to prevent wrong-site surgery, as well the bugaboo of airway mishaps. Wrong-site, wrong-implant, wrong-patient errors occur at an alarming rate in the U.S.  The Joint Commission came up with a safety procedure …

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Quality Thinking About Quality – Part One: What is Quality?

Now that’s an odd title.  “Quality Thinking About Quality”.   We typically don’t think of the attribute of quality as having anything to do with the act of thinking.  There’s a good reason for this.  Because it doesn’t.  Using the noun quality as modifier of the gerund thinking is simply incongruous.  It makes no sense. What is quality?  How do we …