Case Studies in Patient Safety by
This book offers a series of case studies on patient safety - specifically errors that lead to preventable patient harm -- told from the perspective of the patient and family. The reader is guided through a structured analysis of the events, eliciting lessons learned and strategies for preventing similar events in the future. Learning objectives for each case facilitate the reader's development of a set of core competencies related to improving safety and quality of health care. Students of the health professions (medical, nursing, pharmacy, health administration, public health) as well as practicing professionals (patient safety officers, chief quality officers, risk managers, health service researchers) will gain valuable insight into the real-world of medical errors and a better understanding of how they can be prevented through practical, actionable methods.
Avoiding Common Errors in the Emergency Department by
Selected as a Doody's Core Title for 2021 and 2023! In a conversational, easy-to-read style, Avoiding Common Errors in the Emergency Department, 2nd Edition , discusses 365 errors commonly made in the practice of emergency medicine and gives practical, easy-to-remember tips for avoiding these pitfalls. Chapters are brief, approachable, and evidence-based, suitable for reading immediately before the start of a rotation, used for quick reference on call, or read daily over the course of one year for personal assessment and review. ?Key Features: Coverage includes psychiatry, pediatrics, poisonings, cardiology, obstetrics and gynecology, trauma, general surgery, orthopedics, infectious diseases, gastroenterology, renal, anesthesia and airway management, urology, ENT, and oral and maxillofacial surgery. Completely revised and rewritten by many new authors, as well as returning authors who bring a fresh perspective to new subjects. New key points at the end of each chapter present must-know information in an easy-access, bulleted format. Ideal for emergency medicine physicians, residents, and attendings; emergency nurse practitioners, PAs who practice in the ED, and primary care physicians in urgent care centers. Your book purchase includes a complimentary download of the enhanced eBook for iOS, Android, PC & Mac. Take advantage of these practical features that will improve your eBook experience: The ability to download the eBook on multiple devices at one time -- providing a seamless reading experience online or offline Powerful search tools and smart navigation cross-links allow you to search within this book, or across your entire library of VitalSource eBooks Multiple viewing options offer the ability to scale images and text to any size without losing page clarity as well as responsive design The ability to highlight text and add notes with one click
Patient Safety Ethicss : How Vigilance, Mindfulness, Compliance, and Humility Can Make Healthcare Safer by
Developing best practices and ethical systems to protect and enhance patient safety. Human errors occur all too frequently in medical practice settings. One sobering recent report claimed that medical errors are the third leading cause of death in the United States. Hoping to reverse this disturbing trend but wondering why it is that things usually go well despite errors, John D. Banja's Patient Safety Ethics lays out a model that advocates vigilance, mindfulness, compliance, and humility as core ethical principles of patient safety. Arguing that the safe provision of healthcare is one of the most fundamental moral obligations of clinicians, Banja surveys the research literature on harm-causing medical errors to explore the ethical foundations of patient safety and to reduce the severity and frequency of medical error. Drawing on contemporary scholarship on quality improvement, risk management, and medical decision making, Banja also relies on a novel source of information to illustrate patient safety ethics: medical malpractice suits. Providing professional perspective with insights from prominent patient safety experts, Patient Safety Ethics identifies hazard pitfalls and suggests concrete ways for clinicians and regulators to improve patient safety through an ethically cultivated program of "hazard awareness."
Health Program Planning, Implementation, and Evaluation : Creating Behavioral, Environmental, and Policy Change by
A time-tested, landmark approach to health promotion and communication projects and everything that goes into making them successful. For more than 40 years, the PRECEDE-PROCEED model, developed in the early 1970s by Lawrence W. Green and first published as a text in 1980 with Marshall W. Kreuter, Sigrid G. Deeds, and Kay B. Partridge, has been effectively applied worldwide to address a broad range of health issues: risk factors like tobacco and lack of exercise, social determinants of health such as lack of access to transportation and safe housing, and major disease challenges like heart disease and guinea worm disease. In Health Program Planning, Implementation, and Evaluation, Green and his team of senior editors and chapter authors combine their expertise to offer a high-level guide to public health programming. This guide aligns with foundational public health competencies required by increasingly rigorous certification and accreditation standards. Driven by the coronavirus pandemic and a looming climate crisis, the book addresses the rapid changes in modern-day conceptions of disease prevention and health promotion. Today's public health practitioners and researchers are often called upon to address a complex web of factors, including population inequities, that influence health status, from biology to social and structural determinants. Program and policy solutions to population health challenges require systematic planning, implementation, and evaluation. Providing students with knowledge, skills, and a range of tools, the book recognizes new approaches to communication and fresh methods for reaching a greater diversity of communities. The authors highlight the importance of starting the population health planning process with an inclusive assessment of the social needs and quality-of-life concerns of the community. They explain how to assess health problems systematically in epidemiological terms and address the behavioral and environmental determinants of the most important and changeable health problems. They also cover procedures for assessing and developing the capacity of communities and organizations to implement and evaluate programs. Drawing on more than 1,200 published applications of the PRECEDE-PROCEED model, Health Program Planning, Implementation, and Evaluation features numerous case studies and contributions from internationally recognized experts, including governmental, academic, and community public health leaders, giving readers a thorough and well-rounded view of the subject. Ultimately, it is an up-to-date powerhouse for community and global health promotion at all levels. Contributors: Faten Ben Abdelaziz, John P. Allegrante, Patricia Chalela, Cam Escoffery, Maria E. Fernandez, Jonathan E. Fielding, Robert S. Gold, Shelly Golden, Holly Hunt, Vanya C. Jones, Michelle C. Kegler, Gerjo Kok, Lloyd J. Kolbe, Chris Y. Lovato, Rodney Lyn, Guy Parcel, Janey C. Peterson, Nico Pronk, Amelie G. Ramirez, Paul Terry
Laboratory Test Requesting Appropriateness and Patient Safety by
The global medical process is a chain of different medical multidisciplinary procedures. The success in global Patient Safety will depend on the Safety of the consecutive medical processes that intervene in this complex system. Laboratory data is an essential part of health care, indeed it is used in 70% of clinical decisions. Inappropriate laboratory test over requesting is extremely frequent. The prevalence of under requesting has been less studied. The consequences of under requesting are clear, we are missing a diagnosis. Inappropriate over requesting can result not only in a problem of cost but also in a problem regarding patient safety. Additionally, another important consequence of inappropriate tests over requesting is that such amount of unnecessary tests has probably contributed to a significant increase in the volume of those over the last years. In all, there is general consensus that the inadequacy of test requesting must be corrected through strategies and monitored over time through indicators to assure the optimal laboratory contribution to clinical decision-making and patient safety.
Five Disciplines for Zero Patient Harm : How High Reliability Happens by
Safe care for every patient, in every setting, every time. Is this really an achievable goal for all healthcare organizations? Yes, it is. The vast majority of occurrences of harm to patients during their care are preventable. But simply aiming for improvement won't do; healthcare organizations must reset their patient safety goal to zero patient harm. Five Disciplines for Zero Patient Harm: How High Reliability Happens offers real-world, how-to guidance for driving fundamental change that consistently achieves safe patient care. Drawing on best practices from high-hazard industries such as aviation, nuclear power, and air traffic control, this book details the safety habits and disciplines that are ingrained in such organizations' cultures and behaviors. Specifically, five disciplines of performance excellence, when consistently applied to healthcare organizations, can save lives and protect patients from harm: Prepare for excellent performance through simulation, deliberate practice, and training.Apply proven offensive strategies that exhibit consistent, excellent individual and team performance.Minimize both individual and team errors through immediate feedback and coach interventions.Employ strong defensive strategies that effectively block the potential negative effects of errors, latent hazards, and emerging threats.Coach individuals and teams to achieve consistent, excellent performance in the first four disciplines.Zero preventable patient harm can be the norm, not the stretch goal, when the practices and action steps in this comprehensive resource are implemented. Five Disciplines for Zero Patient Harm provides an evidence-based guide for hospitals and healthcare systems to transform unsafe behaviors into safe behaviors and safe behaviors into safe habits. That's how high reliability happens.
Change Leadership in Nursing : How Change Occurs in a Complex Hospital System by
Recommended."--Choice: Current Reviews for Academic Libraries Brigham and Women's Hospital, a high-profile, complex, academic medical center in Boston, MA, is a founding member of the Partners HeathCare Sytem and is associated with Harvard Medical School and Dana Farber Cancer Institute. This truly unique volume chronicles the systemic efforts of the nursing department to make an already outstanding system even better. It provides access to a compelling story of institute-wide nursing practice today and how the opportunity for major change was embraced and successfully accomplished. Told from the perspective of ninety administrative and staff nurses, it serves as a model for change in similar institutions everywhere. Key Features Provides "real world" system level description of hospital-wide change initiated and implemented by nurses committed to safe quality patient care Serves as a roadmap for institution-wide change for aspiring nurse leaders, including values to support, tools to develop or use, resources to be managed, key personnel to employ, and more Offers nurse executives an array of catalytic ideas they can adapt to their own settings Acts as a model for administrators and students in Masters and Doctoral Programs who are interested in seeing how change occurs in complex systems through personal engagement at all levels"
Patient Safety and Hospital Accreditation : A Model for Ensuring Success by
Improving the culture of safety in our health care institutions is an essential component of preventing or reducing errors as well as improving overall health care quality. This book presents the clinically tested Myer's Patient Safety Model for health care system leaders, middle managers, and administrators to build their patient safety program and to help sustain, renew, or obtain accreditation. The author provides detailed explanations of why medical errors still occur in accredited hospitals, and provides the much needed organization-wide steps to prevent these errors and enhance patient safety for improved outcomes. Current patient safety challenges are discussed with an emphasis on the concept of reliability. The Myers Model is examined in detail, along with current evidence for its three interrelated levels of organizational structure-the leadership (system) level, the unit (microsystem) level, and the individual level. The text includes interviews about key aspects of patient safety with three leaders of major health care accreditation programs in the U.S., Canada, and Australia. Additionally, it provides an overview of reporting systems within the U.S. and covers two essential tools for patient safety-root cause analysis and failure mode and effect analysis. The book links all aspects of patient safety with accreditation standards at the national level, and also discusses efforts to globalize accreditation criteria and procedures. Key Features: Presents a clinically tested model for building a patient safety program and helping to sustain, renew, or obtain accreditation Provides tools for use in ensuring patient safety and accreditation, including root cause analysis and failure mode and effect analysis Discusses how aggregate data inform patient safety documentation and accreditation through integrated perspectives Offers a global view of accreditation and patient safety Includes techniques to improve communication among members of health care teams
Effective Communication in Clinical Handover : From Research to Practice by
Based on detailed multi-disciplinary analyses of more than 800 recorded handover interactions, audits of written handover documentation, interviews and survey responses, the contributing authors identify features of effective and ineffective clinical handovers in diverse hospital contexts. The authors then translate their descriptive findings into practical protocols, communication strategies and checklists that clinicians, managers and policy makers can apply to improve the safety and quality of clinical handovers. All the contributors are affiliated with the International Research Centre for Communication in Healthcare (IRCCH), an international multidisciplinary organisation of over 90 healthcare professionals from more than 17 countries committed to improving improving communication in healthcare systems around the world. 'The authors have created a new and tightly woven systems safety net that will, if implemented, significantly reduce the occurrence of errors resulting from cumulative communication failures.' -H. Esterbrook Longmaid III, MD, FACR, President of Medical Staff, Beth Israel Deaconess-Milton Hospital, Milton, MA USA 'Uncommonly valuable for the rigorous, original communication research it reports and for the careful translation of the research findings into practical strategies that actually improve clinical handovers in the real world of practice.' -Professor Suzanne Kurtz, Washington State University 'This clear, plain English book is an outstanding resource for the training of all involved in healthcare.' -Elizabeth Trickett, (Former) Director of Safety and Quality, ACT Health, Australia
Health Care Quality Management : Tools and Applications by
In today's challenging health care environment, health care organizations are faced with improving patient outcomes, redesigning business processes, and executing quality and risk management initiatives. Health Care Quality Management offers an introduction to the field and practice of quality management and reveals the best practices and strategies health care organizations can adopt to improve patient outcomes and program quality. Filled with illustrative case studies that show how business processes can be restructured to achieve improvements in quality, risk reduction, and other key business results and outcomes Clearly demonstrates how to effectively use process analysis tools to identify issues and causes, select corrective actions, and monitor implemented solutions Includes vital information on the use of statistical process control to monitor system performance (variables) and outcomes (attributes) Also contains multiple data sets that can be used to practice the skills and tools discussed and reviews examples of where and how the tools have been applied in health care Provides information on root cause analysis and failure mode effects analysis and offers, as discussion, the clinical tools and applications that are used to improve patient care By emphasizing the tools of statistics and information technology, this book teaches future health care professionals how to identify opportunities for quality improvement and use the tools to make those improvements.
New Horizons in Patient Safety : Understanding Communication : Case Studies for Physicians by
This case studies book is a unique, practical, cutting-edge, and indispensable go-to resource for front-line practitioners and educators in medicine. Each case study (chapter) is framed by a set of introductory learning objectives, an evaluation section, thought-provoking discussion questions, and references to further readings. Furthermore, the book is conveniently organized along the continuum of medical care delivery, providing quick access to ad-hoc solutions in safety- and quality-compromised situations, illustrating how skillful communication can be the key to a more effective prevention, intervention, and response to "close calls" and adverse events. The case studies book is unique and innovative in its interdisciplinary integration of the contemporary literature in communication science with current "hot buttons" of patient safety. It manifests a valuable interdisciplinary collaboration by translating the basic tenets of human communication science for practitioners of medicine, providing a conceptual, evidence-based foundation for formulating communication-based practice guidelines to advance patient safety and quality of care. The case studies put communication theory into practice to facilitate experiential learning, granting insights into the breadth and diverse aspects of safe and high quality healthcare delivery. Thought-provoking discussion questions and references for further reading make this book a valuable reference for medical practitioners across the world.
Health IT and Patient Safety : Building Safer Systems for Better Care by
Irving Berlin (1888#150;1989) was unable to read or write music and could only play the piano in the key of F-sharp major; yet, for the first half of the twentieth century he was America's most successful and most representative songwriter, composing such hits as "Alexander's Ragtime Band," "Cheek to Cheek," "Let's Face the Music and Dance," "Puttin' on the Ritz," "White Christmas," "Anything You Can Do," "There's No Business Like Show Business," and "God Bless America." As Thousands Cheer, winner of the Ralph J. Gleason Music Book Award, explores with precision and sensitivity Berlin's long, prolific career; his self-doubt and late-blooming misanthropy; and the tyrannical control he exerted over his legacy of song. From his immigrant beginnings through Tin Pan Alley, Broadway, and Hollywood to his reclusive and bitter final years, this definitive biography reveals the man who wrote 1500 songs but could never quash the fear that, for all his success, he wasn't quite good enough.
Building a Culture of Ownership in Healthcare by
Using construction as their metaphor, authors Joe Tye and Bob Dent make a compelling case that a healthcare organization's invisible architecture--a foundation of core values, a superstructure of organizational culture, and the interior finish of workplace attitude--is no less important than its visible architecture. Further, they assert that culture will not change unless people change, and people will not change unless they are inspired to do so and given the right tools. This fully updated second edition of Building a Culture of Ownership in Healthcare takes readers on a journey from accountability to ownership--providing a proven model, strategies, and practical solutions to help improve organizational culture in the healthcare setting. Learn how investing in your organization and your people can enable a significant, successful change in productivity; employee engagement; nurse satisfaction, recruitment, and retention; quality of care; patient satisfaction; and financial outcomes. New to this edition: - Expanded coverage of the importance of culture assessment, including details on the validated VCI-17 Culture Assessment Survey - A deep dive into the four dimensions of transformational leadership - New examples of values and culture in action - Updated chapter questions to facilitate discussion at the unit level
Practical Patient Safety by
Following recent high profile cases of surgical error in the UK and USA, patient safety has become a key issue in healthcare, now placed at heart of junior doctor's training. Errors made by doctors are very similar to those made in other high risk organisations, such as aviation, nuclear and petrochemical industries. Practical Patient Safety aims to demonstrate how core principles of safety from these industries can be applied in surgical and medical practice, in particular through training for health care professionals and healthcare managers.Whilst theoretical aspects of risk management form the backdrop, the book focuses on key techniques and principles of patient safety in a practical way, giving the reader practical advice on how to avoid personal errors, and more importantly how to start patient safety training within his or her department or hospital.
The Complete Guide to Physician Relationships by
The Complete Guide to Physician Relationships Kriss Barlow, RN, MBA What Physicians Want Research-based insights into the best physician communications strategies In the wake of healthcare reform and a growing emphasis on accountable care, healthcare organizations are looking for ways to align more closely with physicians. Given the highly competitive physician recruiting and referral market, having an effective physician communication strategy has never been more vital. Based on extensive research and an in-depth survey of nearly 200 physicians, The Complete Guide to Physician Relationships outlines exactly what information physicians want and how they want to receive it from healthcare leaders, peers, marketing executives, and physician relations representatives. Get the critical data that you need to succeed with your physician relations, referral, and communication efforts. Get powerful, researched strategies and insight to: Communicate the information physicians want in the manner they want to receive it Engage physicians in quality and patient satisfaction improvement efforts Determine the most effective way to promote services Strengthen your relationship with specialists, primary care doctors, and new recruits Improve the effectiveness of physician sales Take a look at the table of contentsIntroduction Chapter 1: What Do Physicians Want to Hear from Leadership? Medical staff support Beyond doing, communicating Business models Real involvement Summary Chapter 2: How Does Your Hospital Compete? Conversations about cost, technology Patient satisfaction Recruitment and retention Understand first Aligning for the future Summary Chapter 3: ACOs, PHOs: Industry Change and Physicians'' Priorities in the Relationship ACO aware Shared savings and quality incentives Physician performance measurement Summary Chapter 4: What Do Physicians Want to Hear from Their Peers? Who gets picked? Demonstrating quality in a peer-to-peer setting Consistent communication Making it easy for patients Tangled twine of priorities Summary Chapter 5: Do Physicians on the Medical Staff Know Each Other? Knowing and referring Ease of referral Elements that impact referral decisions Summary Chapter 6: Communication When a Referral Is Sent Care delivery post-discharge Managing expectations Messages show value Summary Chapter 7: What Do Physicians Want to Hear from Marketing? How do physicians like to receive marketing information? What this means for you Opportunity for action Summary Chapter 8: Promoting Services Managing our "we know best" attitude Active support of physician-to-physician connections Social media and web innovations Summary Chapter 9: Supporting Specialists Talk is not cheap Avoid only one option Education beyond CME Summary Chapter 10: What Do Physicians Want to Hear from Physicians Relations? Measuring the value Resource role Managing concerns Helping them grow their practice Leveraging education On-boarding What''s happening at the hospital Summary Chapter 11: Physician Relations Attributes That Matter The relationship is about physicians Personal development for this role What''s in it for me Managing internal perception Summary Chapter 12: Physician Relations'' Voice Expanding the role Gather data, use data, show your impact with data Listen to differentiate Knowledge is an obligation Internal coordination, collaboration, integration Summary Appendix Who will benefit from this book? VPs of advertising VPs of marketing VPs of communications VPs of public relations Chief marketing officers Advertising directors Directors of marketing Directors of communications Marketing managers Advertising managers Chief medical officers CEOs CNOs COOs Medical staff coordinators Practice administrators Physicians Physician relations representatives
The Strategic Management of Health Care Organizations by
A comprehensive guide to effective strategic management of health care organizations. Strategic Management of Health Care Organizations provides essential guidance for leading health care organizations through strategic management. This structured approach to strategic management examines the processes of strategic thinking, consensus building and documentation of that thinking into a strategic plan, and creating and maintaining strategic momentum - all essential for coping with the rapidly evolving health care industry. Strategic Management of Health Care Organizations fully explains how strategic managers must become strategic thinkers with the ability to evaluate a changing industry, analyze data, question assumptions, and develop new ideas. The book guides readers through the strategic planning process demonstrating how to incorporate strategic thinking and create and document a clear and coherent plan of action. In addition, the all-important processes of creating and maintaining the strategic momentum of the organization are fully described. Finally, the text demonstrates how strategic managers in carrying out the strategic plan, must evaluate its success, learn more about what works, and incorporate new strategic thinking into operations and subsequent planning. This strategic management approach has become the de facto standard for health care management as leadership and strategic management are more critical than ever in coping with an industry in flux. This book provides heath care management students as well as health care administrators with foundational guidance on strategic management concepts and practices, tailored to the unique needs of the health care industry. Included are a clear discussion of health services external analysis, organizational internal analysis, the development of directional strategies, strategy alternative identification and evaluation, and the development and management of implementation strategies providing an informative and insightful resource for anyone in the field. This new eighth edition has been fully updated to reflect new insights into strategic thinking, new methods to conceptualize and document critical environmental issues, practical steps for carrying out each of the strategic management processes, industry and management essentials for strategic thinkers , and new case studies for applying the strategic management processes. More specifically, readers of this edition will be able to: Create a process for developing a strategic plan for a health care organization. Map and analyze external issues, trends, and events in the general environment, the health care system, and the service area. Conduct a comprehensive service area competitor analysis. Perform an internal analysis and determine the competitive advantages and competitive disadvantages. Develop directional strategies. Identify strategic alternatives and make rational strategic decisions for a health care organization. Develop a comprehensive strategy for a health care organization. Create effective value-adding service delivery and support strategies. Translate service delivery and support plans into specific action plans. The health care industry's revolutionary change remains ongoing and organizational success depends on leadership. Strategic management has become the single clearest manifestation of effective leadership of health care organizations and the strategic management framework's strengths are needed now more than ever. The Strategic Management of Health Care Organizations provides comprehensive guidance and up-to-date practices to help leaders keep their organizations on track.
Managing Care : How Clinicians Can Lead Change and Transform Healthcare by
Healthcare systems worldwide are swamped with demand, short of resources, and ill-equipped to respond to global health crises like COVID-19. This book is a guide for reforming healthcare delivery. The way we organize care matters, and the people best positioned to drive this are the clinicians who deliver care. The book offers a framework for transforming healthcare delivery that covers operational design, change management, long-term learning, and organizational environment. It describes the work of leading local operational change; identifies key decisions to be made, actions to be taken, and factors that must be taken into account; and gives clinicians the tools and perspectives they need to lead change. The challenge of modern healthcare is to develop better organizations capable of delivering compassionate and individualized care on a grand scale while preserving the personal relationship between clinician and patient and the quality of care at the ward, operating room, clinic, or practice. Informed by extensive research and experience with systems all over the world, Richard Bohmer shows how organizations may transform by deploying a new workforce of clinical change leaders and how clinicians can take greater control over their own working environments.
Leading in Health Care Organizations : Improving Safety, Satisfaction, and Financial Performance by
Health care organizations around the world are judged in terms of a health care triple bottom line: ensuring employee and patient safety, maximizing employee and patient satisfaction, and meeting financial goals. Given the increasing burden of chronic diseases, the increasing complexity of medical interventions, and the increasing costs of care, innovative leadership is required to achieve this triple bottom line. The 14th volume of the Advances in Health Care Management research series addresses the links between leadership and safety, satisfaction or financial performance in health care management by exploring questions such as the following: (1) How does leadership impact employee safety? (2) How does leadership affect patient safety? (3) How does leadership impact employee satisfaction? (4) How does leadership affect patient satisfaction? (5) How does leadership affect financial performance? (6) How do health care organizations deploy multi-level leadership to achieve safety goals? Satisfaction goals? Financial goals? Multiple goals? (7) How do health care organization leaders establish and maintain a safety culture? A patient-centered culture? A high performance culture? Combined cultures?"
Accountability and Responsibility in Health Care : Issues In Addressing An Emerging Global Challenge by
Serious scholarly analyses of the types and roles of accountability in health care first appeared in the late 1980s. That issue, along with the related issue of responsibility in health care, has continued to interest policymakers, analysts and scholars ever since. Indeed, there has been a renewed surge of interest in recent years, with growing attention to the notion of accountable care organizations in the US, clinical audits in the UK, and governance as stewardship in many other countries. Accountability and responsibility in health care was also the theme of a major international conference organized by the Israel National Institute for Health Policy Research, which was held in Jerusalem in 2009.This book is a collection of scholarly articles on the themes of accountability and responsibility in health care and seeks to be the premier book in that field. It includes selected papers from the 2009 Jerusalem Conference, analytic essays on how accountability and responsibility are playing out in eight different countries, and reprints of some of the classic articles in the field.The book will interest policymakers, managers, researchers and students, and many of the ideas presented here will help shape the development of this field in the years ahead. Some of these ideas have appeared in other forums; the unique contribution of this volume is that it is the first to bring together so many different perspectives on accountability and responsibility in health care. This volume will both acquaint readers with some of the latest thinking on accountability and responsibility in health care, and will serve as a catalyst for future reflection, research and writing in this area.
High Reliability Organizations : A Healthcare Handbook for Patient Safety & Quality, Second Edition by
Awarded second place in the 2021 AJN Book of the Year Awards in Professional Issues! Nurses represent the majority of healthcare workers and are on the front lines of delivery and provision of safe and effective care. As a result, nurses are ideally situated to drive the mission to achieve high reliability in healthcare. We expect the primary audience of this text to be frontline nursing staff, nurses in administration, quality and patient safety professionals, advanced practice nurses, and nurse educators. The healthcare professional who purchases this book will do so with the desire to learn more about the application of HRO principles to patient safety and quality problems. This book is unique in that it uses HRO principles as an organizing framework for practical application. The intent of the editors is to provide a quality and patient safety book that is useful to professionals doing the work of healthcare. Healthcare professionals are constantly seeking practical tools and descriptions of practices that will improve and enhance patient safety and quality outcomes. High reliability is a current goal for hospitals, and the principles are sound. However, there is little in the literature that discusses how to apply the principles at the front lines of care to improve outcomes. This text addresses this gap by placing the need for high reliability concepts into our current climate in healthcare through illustrative discussion (theory and research) of each of the five concepts of HRO, along with a description of a current best practice and/or tool that applies to the model. The goal of this book is to stimulate organizations to embrace high reliability concepts while striving to improve the quality and safety of care delivered to patients and families. We all benefit from a safer healthcare environment. The book is divided into eight parts: Part 1: This part provides background for the current safety and quality climate. Parts 2-6: These parts offer HRO concepts as a framework for the new model with examples. The first of these HRO concepts is that HROs have a preoccupation with failure. The second of these HRO concepts is that HROs restrain the impulse to view events through a single lens and are reluctant to simplify. The third HRO concept is that HROs demonstrate sensitivity to operations by making strong responses to weak signs. The fourth HRO concept is that HROs shift decision making away from formal authority and apply deference to expertise. The final HRO concept is that HROs have a commitment to resilience. Part 7: This part puts it all together and provides the reader with examples of how HRO concepts are assimilated into practice across the care continuum.Part 8: This part provides the reader with real-world examples of HRO principles employed in a variety of patient care areas. Comprehensive Instructor's Guide and Student Workbook are available for this book.
Medical Errors and Patient Safety : Strategies to Reduce and Disclose Medical Errors and Improve Patient Safety by
Is the reporting of medical errors changing? This book shows with real cases from health care and beyond that most errors come from flaws in the system. It also shows why they don't get reported and how medical error disclosure around the world is shifting away from blaming people, to a "no-fault" model that seeks to improve the whole system of care. The book intends to provide an introduction to medical errors that result in preventable adverse events. It will examine issues that stymie efforts made to reduce preventable adverse events and medical errors, and will moreover highlight their impact on clinical laboratories and other areas, including educational, bioethical, and regulatory issues. Varying error rates of 0.1-9.3% in clinical diagnostic laboratories have been reported in the literature. While it is suggested that fewer errors occur in the laboratory than in other hospital settings, the quantum of laboratory tests used in healthcare entails that even a small error rate may reflect a large number of errors. The interdependence of surgical specialties, emergency rooms, and intensive care units - all of which are prone to higher rates of medical errors - with clinical diagnostic laboratories entails that reducing error rates in laboratories is essential to ensuring patient safety in other critical areas of healthcare. The author maintains that many such errors are preventable provided that appropriate attention is paid to systemic factors involved in laboratory errors. This book identifies possible intelligent system approaches that can be adopted to help control and eliminate these errors. It is a valuable tool for physicians, clinical biochemists, research scientists, laboratory technologists and anyone interested in reducing adverse events at all levels of healthcare processes.
Occurrence Reporting : Building a Robust Problem Identification and Resolution Process by
Occurrence Reporting: Building a Robust Problem Identification and Resolution Process Kenneth Rohde Enhance patient care through effective occurrence reporting You already capture the data. Now use it to make real improvements in your patient care. This new resource by performance improvement expert Kenneth R. Rohde provides practical techniques to help you better analyze your occurrence reporting process, use your data to gain superior insight into why errors occur at your organization, and make improvements that decrease adverse events and enhance patient care. Benefits: Refine and improve your existing occurrence reporting system using a proven six-step approach Arm yourself with the right data to become an effective change agent in your organization Develop an occurrence reporting process that decreases adverse events and enhances patient care Improve your report screening process Easily identify trends through detailed, efficient analysis methods Organize and prioritize your reports through effective coding Implement successful corrective actions through ongoing tracking and evaluation Table of Contents: Chapter 1: Rethinking the Occurrence Reporting Process Where Does Healthcare Go Wrong? Healthcare Is Not the Only Industry That Does Problem Identification and Resolution (PIR) Recommendations for an Ideal Process Chapter 2: The PIR Process Introducing the PIR Process Six Steps in the PIR Process Chapter 3: Reporting Importance of Managing Reporting Volume and Severity Must Dance Together Reporting Thresholds Tips for Normalization Internal vs. External Identification of Issues Two Simple Goals for Reporting Volume Tips for Improving Your Reporting Chapter 4: Screening Screening Is Really Just Prioritization Establishing Screening Criteria Reporting Severity Screening Quality Control Tips for Improving Your Screening Chapter 5: Analysis A Graded Approach to Problem Analysis Individual Analysis for High-Impact Problems and Moderate-Impact Problems Aggregated Analysis for Watch/Trend Problems Aggregated Analysis of Causes: The Big Payoff Five Simple Data Questions Trending and Aggregation Methods A Typical Analysis Session What Do Your Department Managers Really Want to Know? Chapter 6: Coding The Vital Process of Coding Code Based on Data Utilization A Practical Coding Structure Coding the Event vs. Coding the Causes Initial Event Codes Code Cleanup Troubleshooting Tips to Improve Coding Chapter 7: Causing Change: Implementing Corrective Actions Designing the Right Change Getting Stuff Done Dealing With External Commitments Tips to Improve Implementation Chapter 8: Tracking and Evaluation Tracking Actions Evaluation of Actions Evaluating the Effectiveness of the PIR Process Chapter 9: Taking Your PIR Process to the Next Level Looking Toward the Future Look at the 90 occurrence reporting tools included! Aviation Safety Reporting System incident report excerpt National Transportation Safety Board incident report excerpt FDA adverse event report sample IAEA initiation report sample CPSC incident report Quick guide to avoiding weaknesses: Build strengths in your PIR process Six steps of the PIR process Self-assessment questions to evaluate reporting, screening, analysis, coding, implementation, and tracking and evaluation Reporting stability Self-reporting Reporting by department Combine volume and severity to get the best picture Example: Calculating relative activities for use in normalization Tips for improving your reporting Screening helps us know what to do next Screening work flow Expectations for screening Example of converting word severity scales to numerical scales Prioritizing performance improvement activity and corrective actions What we need to know to screen an issue Which issues should we check the severity on? NCC MERP Index for Categorizing Medication Errors Comparison of severity scales Significant event management process Model screening matrix Typical notifications worksheet Balance your analysis efforts Analysis work flow Root cause analysis work flow Expectations for the ideal root cause analysis team, and team sponsor Expectations for an ideal apparent cause analysis Typical fields in a significant event database Significant event database flow chart Five simple questions our data analysis must answer Tools to help answer the magnitude question, the direction question, and the variability question Highly variable data set example Tools to help answer the rate of change question Key considerations for effective time series graphs Time series analysis of reporting volume and harm events Data fields for top-level time series graph Histogram analysis of events by process (one dimension) and event category (two dimensions) Four-quadrant graphs allow you to make easy value decisions Comparison/correlation analysis of volume and severity by department Model agenda for a trend meeting Key ways to improve your analysis Comparison of centralized and distributed coding approaches Coding all causes A practical coding process includes three major types of codes Typical values for "who was impacted" Typical role codes and physical location codes Examples of a process coding approach and an activity coding approach Expectation codes Culture of safety expectations Nature of impact codes Severity codes Moral patient harm severity codes Liability harm severity codes Process impact severity codes When coding is typically performed Table of codes and possible intervention Examples of permanent and transitory corrective actions Typical definitions of qualitative benefits Relationship of permanence and predictability Scope and timing characteristics of corrective actions Checklist for good corrective actions Action plan to prevent recurrence form Feeding the four outputs of action plan Additional coding to support a basic common cause analysis, a basic benefits report, a corrective actions analysis, and to support accountability tracking What can you do with the master action list? Tips for prioritization Alignment of responsibility for the most important corrective actions Quick guide to causing change and implementing corrective actions When should we consider removing a corrective action? Key indicators to evaluate the effectiveness of your PIR process Tracking and evaluation
Malpractice in Surgery : Safety Culture and Quality Management in the Hospital by
Tentative estimates suggest that one in ten patients suffers from an adverse event in hospital. In Germany, approx. 1.8 million out of approx. 18 million inpatients suffer from adverse events; 50 percent of these cases are estimated to be avoidable. In the US, nearly 100,000 people die from the consequences of mistreatment. The intensive care units record 1.7 medical errors per patient and day. The most affected disciplines are the operative disciplines, particularly general surgery. Medical errors mainly occur when the indication for surgery is being made, during surgery and post-surgery. Suspicious oncological diagnostic results and post-operative complications are also often ignored. This book deals with complications and typical medical errors in surgery. It shows solutions and ways of dealing effectively with these errors and how to establish an efficient security management system.
First, Do Less Harm : Confronting the Inconvenient Problems of Patient Safety by
Each year, hospital-acquired infections, prescribing and treatment errors, lost documents and test reports, communication failures, and other problems have caused thousands of deaths in the United States, added millions of days to patients' hospital stays, and cost Americans tens of billions of dollars. Despite (and sometimes because of) new medical information technology and numerous well-intentioned initiatives to address these problems, threats to patient safety remain, and in some areas are on the rise. In First, Do Less Harm, twelve health care professionals and researchers plus two former patients look at patient safety from a variety of perspectives, finding many of the proposed solutions to be inadequate or impractical. Several contributors to this book attribute the failure to confront patient safety concerns to the influence of the "market model" on medicine and emphasize the need for hospital-wide teamwork and greater involvement from frontline workers (from janitors and aides to nurses and physicians) in planning, implementing, and evaluating effective safety initiatives. Several chapters in First, Do Less Harm focus on the critical role of interprofessional and occupational practice in patient safety. Rather than focusing on the usual suspects?physicians, safety champions, or high level management?these chapters expand the list of "stakeholders" and patient safety advocates to include nurses, patient care assistants, and other staff, as well as the health care unions that may represent them. First, Do Less Harm also highlights workplace issues that negatively affect safety: including sleeplessness, excessive workloads, outsourcing of hospital cleaning, and lack of teamwork between physicians and other health care staff. In two chapters, experts explain why the promise of health care information technology to fix safety problems remains unrealized, with examples that are at once humorous and frightening. A book that will be required reading for physicians, nurses, hospital administrators, public health officers, quality and risk managers, healthcare educators, economists, and policymakers, First, Do Less Harm concludes with a list of twenty-seven paradoxes and challenges facing everyone interested in making care safe for both patients and those who care for them.
Listening for What Matters : Avoiding Contextual Errors in Health Care by
Effective health care requires physicians tailor care to patients' individual life contexts, including their financial situation, social support, competing responsibilities, and cognitive abilities. Physicians, however, are poorly prepared to consider patients' lives when planning their care. The result is measurably harmful to individuals and costly to society. Listening for What Matters: Avoiding Contextual Errors in Health Care covers ten years of empirical research based on hundreds of recorded doctor visits by patients and undercover actors alike, which revealed a widespread disregard of patients' individual circumstances and needs resulting in inappropriate care. These medical errors have been largely undocumented and unaddressed by the American healthcare system. This book tells the stories of patients whose care was compromised by inattention to individual context, and introduces novel methods for assessing the magnitude of the problem. It describes how these errors, termed "contextual errors," can be minimized through changes in how doctors are trained, how medicine is practiced and quality measured, and in the ways patients assert their needs during visits. The aim of this book is to open a dialog between patients, physicians, policy makers, and medical educators, about a serious quality problem that has been overlooked and understudied.
