This article describes a complex system model based on human performance factors that is borrowed from other industries but can be used by clinical nurse specialists for making progress in patient safety. Traditional approaches to investigation and follow-up of errors in healthcare organizations have not resulted in improvement in patient safety. The New Look approach described in this article emphasizes the complexity in which healthcare workers make decisions about patient c are every day and how increased learning about the resiliency of healthcare workers in the face of multiple system gaps and discontinuities will lead to long-lasting improvements in safety. The article describes how the clinical nurse specialist can lead efforts using the New Look human performance-based approach in 4 areas: changing to a nonpunitive culture, learning about system complexity, learning about healthcare worker resiliency, and preparing for the complexity of introducing change.
From Indiana University School of Nursing, Indianapolis (Dr Ebright); Ohio State University and VA Midwest Patient Safety Center of Inquiry, Columbus, Ohio (Dr Patterson); and The College of Medicine, University of Cincinnati, and VA Midwest Patient Safety Center of Inquiry, Columbus, Ohio (Dr Render).
Editor’s Note: In 2002, we will publish 6 articles for which 1 to 3 credit hours may be earned as part of a CNS’s learning activities. Examination questions are provided at the end of this article for your consideration. See the answer/enrollment form after the article for additional information regarding the program.
This article has been designated for CE credit. A closed-book multiple-choice examination follows this article, which tests your knowledge of the following objectives:
Corresponding author: Patricia R. Ebright, DNS, CNS, RN, 329 Spring Ridge Ct, Carmel, IN 46032 (e-mail: firstname.lastname@example.org).