Best ste to play regular timecontrol chessess

BEST STE TO PLAY REGULAR TIMECONTROL CHESSESS FREE

They arise from decisions made by designers, builders, procedure writers, and top level management. Latent conditions are the inevitable вЂњresident pathogensвЂќ within the system. But, as discussed below, virtually all such acts have a causal history that extends back in time and up through the levels of the system. Followers of the person approach often look no further for the causes of an adverse event once they have identified these proximal unsafe acts. At Chernobyl, for example, the operators wrongly violated plant procedures and switched off successive safety systems, thus creating the immediate trigger for the catastrophic explosion in the core. 6 Active failures have a direct and usually shortlived impact on the integrity of the defences. They take a variety of forms: slips, lapses, fumbles, mistakes, and procedural violations. Nearly all adverse events involve a combination of these two sets of factors.ДЄctive failures are the unsafe acts committed by people who are in direct contact with the patient or system. The holes in the defences arise for two reasons: active failures and latent conditions. Usually, this can happen only when the holes in many layers momentarily line up to permit a trajectory of accident opportunity-bringing hazards into damaging contact with victims (figure). The presence of holes in any one вЂњsliceвЂќ does not normally cause a bad outcome. In reality, however, they are more like slices of Swiss cheese, having many holes-though unlike in the cheese, these holes are continually opening, shutting, and shifting their location. In an ideal world each defensive layer would be intact. Mostly they do this very effectively, but there are always weaknesses. Their function is to protect potential victims and assets from local hazards. High technology systems have many defensive layers: some are engineered (alarms, physical barriers, automatic shutdowns, etc), others rely on people (surgeons, anaesthetists, pilots, control room operators, etc), and yet others depend on procedures and administrative controls. The Swiss cheese model of system accidentsДefences, barriers, and safeguards occupy a key position in the system approach. The pursuit of greater safety is seriously impeded by an approach that does not seek out and remove the error provoking properties within the system at large. The same set of circumstances can provoke similar errors, regardless of the people involved. Secondly, far from being random, mishaps tend to fall into recurrent patterns. Firstly, it is often the best people who make the worst mistakes-error is not the monopoly of an unfortunate few. As a result, two important features of human error tend to be overlooked. 5 Engineering a just culture is an essential early step in creating a safe culture.ДЄnother serious weakness of the person approach is that by focusing on the individual origins of error it isolates unsafe acts from their system context. 4 Trust is a key element of a reporting culture and this, in turn, requires the existence of a just culture-one possessing a collective understanding of where the line should be drawn between blameless and blameworthy actions. The complete absence of such a reporting culture within the Soviet Union contributed crucially to the Chernobyl disaster.

3 Without a detailed analysis of mishaps, incidents, near misses, and вЂњfree lessons,вЂќ we have no way of uncovering recurrent error traps or of knowing where the вЂњedgeвЂќ is until we fall over it. 2 Effective risk management depends crucially on establishing a reporting culture. In aviation maintenance-a hands-on activity similar to medical practice in many respects-some 90% of quality lapses were judged as blameless. Indeed, continued adherence to this approach is likely to thwart the development of safer healthcare institutions.ДЄlthough some unsafe acts in any sphere are egregious, the vast majority are not.

Nevertheless, the person approach has serious shortcomings and is ill suited to the medical domain. It is also legally more convenient, at least in Britain. Seeking as far as possible to uncouple a person's unsafe acts from any institutional responsibility is clearly in the interests of managers. If something goes wrong, it seems obvious that an individual (or group of individuals) must have been responsible.

BEST STE TO PLAY REGULAR TIMECONTROL CHESSESS FREE

People are viewed as free agents capable of choosing between safe and unsafe modes of behaviour. Blaming individuals is emotionally more satisfying than targeting institutions. From some perspectives it has much to commend it. The person approach remains the dominant tradition in medicine, as elsewhere.

Best ste to play regular timecontrol chessess