Have you ever drained your car battery by leaving the headlights on? You probably swore you’d be extra careful and never do it again. And then, of course, you did. Sure, you messed up. But the people who designed the car should have anticipated that. In this lesson, you’ll learn how changing the system—not the person who made the mistake—is the best way to prevent most errors. You’ll also learn a four-step framework to help you think about improving a complex system.
Estimated Time of Completion: 20 minutes
After completing this lesson, you will be able to:
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1. Explain that most errors are problems of systems, not individuals.
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2. Identify Deming’s Theory of Profound Knowledge, including its four major components—systems thinking, understanding variation, understanding theories of knowledge, and psychology.
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3. Use Deming’s framework to start planning how to improve an aspect of care you identified in Lesson 3.
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You must be a registered IHI.org user
to take this lesson.
You must achieve a minimum score of
75% to successfully complete this lesson.