Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDS--three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems.
To Err Is Human breaks the silence that has surrounded medical errors and their consequence--but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agenda--with state and local implications--for reducing medical errors and improving patient safety through the design of a safer health system.
Human Error James Reason Epub Downloadl
Perhaps the most significant contribution of Reason's work was his development of a model for the dynamics of accident causation, sometimes referred to as the Swiss cheese model (Figure 1). The author identified what he describes as latent failures at the managerial level before the possibility for human error is even involved. As described by Reason, latent errors are those
11. The sexual activity, in which husband and wife are intimately and chastely united with one another, through which human life is transmitted, is, as the recent Council recalled, "noble and worthy.'' (11) It does not, moreover, cease to be legitimate even when, for reasons independent of their will, it is foreseen to be infertile. For its natural adaptation to the expression and strengthening of the union of husband and wife is not thereby suppressed. The fact is, as experience shows, that new life is not the result of each and every act of sexual intercourse. God has wisely ordered laws of nature and the incidence of fertility in such a way that successive births are already naturally spaced through the inherent operation of these laws. The Church, nevertheless, in urging men to the observance of the precepts of the natural law, which it interprets by its constant doctrine, teaches that each and every marital act must of necessity retain its intrinsic relationship to the procreation of human life. (12)
14. Therefore We base Our words on the first principles of a human and Christian doctrine of marriage when We are obliged once more to declare that the direct interruption of the generative process already begun and, above all, all direct abortion, even for therapeutic reasons, are to be absolutely excluded as lawful means of regulating the number of children. (14) Equally to be condemned, as the magisterium of the Church has affirmed on many occasions, is direct sterilization, whether of the man or of the woman, whether permanent or temporary. (15)
16. Now as We noted earlier (no. 3), some people today raise the objection against this particular doctrine of the Church concerning the moral laws governing marriage, that human intelligence has both the right and responsibility to control those forces of irrational nature which come within its ambit and to direct them toward ends beneficial to man. Others ask on the same point whether it is not reasonable in so many cases to use artificial birth control if by so doing the harmony and peace of a family are better served and more suitable conditions are provided for the education of children already born. To this question We must give a clear reply. The Church is the first to praise and commend the application of human intelligence to an activity in which a rational creature such as man is so closely associated with his Creator. But she affirms that this must be done within the limits of the order of reality established by God.
21. The right and lawful ordering of birth demands, first of all, that spouses fully recognize and value the true blessings of family life and that they acquire complete mastery over themselves and their emotions. For if with the aid of reason and of free will they are to control their natural drives, there can be no doubt at all of the need for self-denial. Only then will the expression of love, essential to married life, conform to right order. This is especially clear in the practice of periodic continence. Self-discipline of this kind is a shining witness to the chastity of husband and wife and, far from being a hindrance to their love of one another, transforms it by giving it a more truly human character. And if this self-discipline does demand that they persevere in their purpose and efforts, it has at the same time the salutary effect of enabling husband and wife to develop to their personalities and to be enriched with spiritual blessings. For it brings to family life abundant fruits of tranquility and peace. It helps in solving difficulties of other kinds. It fosters in husband and wife thoughtfulness and loving consideration for one another. It helps them to repel inordinate self-love, which is the opposite of charity. It arouses in them a consciousness of their responsibilities. And finally, it confers upon parents a deeper and more effective influence in the education of their children. As their children grow up, they develop a right sense of values and achieve a serene and harmonious use of their mental and physical powers.
27. Likewise we hold in the highest esteem those doctors and members of the nursing profession who, in the exercise of their calling, endeavor to fulfill the demands of their Christian vocation before any merely human interest. Let them therefore continue constant in their resolution always to support those lines of action which accord with faith and with right reason. And let them strive to win agreement and support for these policies among their professional colleagues. Moreover, they should regard it as an essential part of their skill to make themselves fully proficient in this difficult field of medical knowledge. For then, when married couples ask for their advice, they may be in a position to give them right counsel and to point them in the proper direction. Married couples have a right to expect this much from them.
Although times change and knowledge increases, it is possible to discern a core of philosophical insight within the history of thought as a whole. Consider, for example, the principles of non-contradiction, finality and causality, as well as the concept of the person as a free and intelligent subject, with the capacity to know God, truth and goodness. Consider as well certain fundamental moral norms which are shared by all. These are among the indications that, beyond different schools of thought, there exists a body of knowledge which may be judged a kind of spiritual heritage of humanity. It is as if we had come upon an implicit philosophy, as a result of which all feel that they possess these principles, albeit in a general and unreflective way. Precisely because it is shared in some measure by all, this knowledge should serve as a kind of reference-point for the different philosophical schools. Once reason successfully intuits and formulates the first universal principles of being and correctly draws from them conclusions which are coherent both logically and ethically, then it may be called right reason or, as the ancients called it, orthós logos, recta ratio.
5. On her part, the Church cannot but set great value upon reason's drive to attain goals which render people's lives ever more worthy. She sees in philosophy the way to come to know fundamental truths about human life. At the same time, the Church considers philosophy an indispensable help for a deeper understanding of faith and for communicating the truth of the Gospel to those who do not yet know it.
8. Restating almost to the letter the teaching of the First Vatican Council's Constitution Dei Filius, and taking into account the principles set out by the Council of Trent, the Second Vatican Council's Constitution Dei Verbum pursued the age-old journey of understanding faith, reflecting on Revelation in the light of the teaching of Scripture and of the entire Patristic tradition. At the First Vatican Council, the Fathers had stressed the supernatural character of God's Revelation. On the basis of mistaken and very widespread assertions, the rationalist critique of the time attacked faith and denied the possibility of any knowledge which was not the fruit of reason's natural capacities. This obliged the Council to reaffirm emphatically that there exists a knowledge which is peculiar to faith, surpassing the knowledge proper to human reason, which nevertheless by its nature can discover the Creator. This knowledge expresses a truth based upon the very fact of God who reveals himself, a truth which is most certain, since God neither deceives nor wishes to deceive.6
14. From the teaching of the two Vatican Councils there also emerges a genuinely novel consideration for philosophical learning. Revelation has set within history a point of reference which cannot be ignored if the mystery of human life is to be known. Yet this knowledge refers back constantly to the mystery of God which the human mind cannot exhaust but can only receive and embrace in faith. Between these two poles, reason has its own specific field in which it can enquire and understand, restricted only by its finiteness before the infinite mystery of God.
28. The search for truth, of course, is not always so transparent nor does it always produce such results. The natural limitation of reason and the inconstancy of the heart often obscure and distort a person's search. Truth can also drown in a welter of other concerns. People can even run from the truth as soon as they glimpse it because they are afraid of its demands. Yet, for all that they may evade it, the truth still influences life. Life in fact can never be grounded upon doubt, uncertainty or deceit; such an existence would be threatened constantly by fear and anxiety. One may define the human being, therefore, as the one who seeks the truth. 2ff7e9595c
Yorumlar