which system ca be recommended for automated storage and retrieval…

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The five principles of high-reliability organizations are described in The Milbank Quarterly as pre-occupation of failure, resist the temptation to simplify, sensitivity to operations, commitment to resilience, and a deference to expertise (CHASSIN & LOEB, 2013). In the situation described by the prompt, more information is necessary to determine if this happened at a high-reliability organization. There are some things that indicate that the principles were followed, such as the problems being identified, and the team replacing glucose monitors with what was believed to be higher quality equipment. These two facts seem to follow the pre-occupation of failure and sensitivity to operations. The pre-occupation of failure may have been considered when the machines were changed, in an effort to improve data management in glucose monitoring. The sensitivity to operations happened when the problems were found and reported. A deference to expertise is difficult to judge because there is no information describing the expertise of the team. If the team was made up of people who work with the blood glucose monitoring equipment, then they did defer to expertise. It is also possible that the people working with the glucose equipment were reluctant to change in which case there was not a deference to expertise. Another factor that is unknown, is the quantity of people that were treated in the two weeks and the accuracy of the previous machines. An article in the Journal of Diabetes Science and Technology found that in continuous glucose monitoring machines true hypoglycemia was alerted 92% of the time (Bailey et al., 2014). Maybe 50 incorrectly treated patients in two weeks is still an improvement over the old system. One thing that perhaps should have been done initially is only change one machine and monitor it to watch out for problems. That would limit the number of patients who received inappropriate insulin management. Perhaps the new machine could be monitored by the old machine to ensure that no patients received the wrong care. An article in the Healthcare Management Forum describes evidence-based leadership as the driver of change to a high-reliability organization (Cochrane et al., 2017). It would be interesting to know if the change made to the machines was based on evidence of the new machine's superiority.  nothing to revise just read and give response
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