Making Healthcare Safe : The Story of the Patient Safety Movement. Lucian L.Leape

Format:

Book

Author/Creator:

Leape, Lucian L.

Language:

English

Physical Description:

1 online resource (450 pages)

Edition:

1st ed.

Place of Publication:

Cham : Springer International Publishing AG, 2021.

Language Note:

English

Summary:

This unique and engaging open access title provides a compelling and ground-breaking account of the patient safety movement in the United States, told from the perspective of one of its most prominent leaders, and arguably the movement’s founder, Lucian L. Leape, MD. Covering the growth of the field from the late 1980s to 2015, Dr. Leape details the developments, actors, organizations, research, and policy-making activities that marked the evolution and major advances of patient safety in this time span. In addition, and perhaps most importantly, this book not only comprehensively details how and why human and systems errors too often occur in the process of providing health care, it also promotes an in-depth understanding of the principles and practices of patient safety, including how they were influenced by today’s modern safety sciences and systems theory and design. Indeed, the book emphasizes how the growing awareness of systems-design thinking and the self-education and commitment to improving patient safety, by not only Dr. Leape but a wide range of other clinicians and health executives from both the private and public sectors, all converged to drive forward the patient safety movement in the US. Making Healthcare Safe is divided into four parts: I. In the Beginning describes the research and theory that defined patient safety and the early initiatives to enhance it. II. Institutional Responses tells the stories of the efforts of the major organizations that began to apply the new concepts and make patient safety a reality. Most of these stories have not been previously told, so this account becomes their histories as well. III. Getting to Work provides in-depth analyses of four key issues that cut across disciplinary lines impacting patient safety which required special attention. IV. Creating a Culture of Safety looks to the future, marshalling the best thinking about what it will take to achieve the safe care we all deserve. Captivatingly written with an “insider’s” tone and a major contribution to the clinical literature, this title will be of immense value to health care professionals, to students in a range of academic disciplines, to medical trainees, to health administrators, to policymakers and even to lay readers with an interest in patient safety and in the critical quest to create safe care.

Contents:

Intro

Foreword

Preface

Acknowledgments

Contents

About the Author

Part I: In the Beginning

Chapter 1: The Hidden Epidemic: The Harvard Medical Practice Study

References

Chapter 2: It's Not Bad People: Error in Medicine

The Causes of Errors

Application of Systems Thinking to Healthcare

Error in Medicine

Response to Error in Medicine

Chapter 3: Changing the System: The Adverse Drug Events Study

BWH Center for Patient Safety Research and Practice

Chapter 4: Coming Together: The Annenberg Conference

Chapter 5: A Home of Our Own: The National Patient Safety Foundation

Part II: Institutional Responses

Chapter 6: We Can Do This: The Institute for Healthcare Improvement Adverse Drug Events Collaborative

What Is a Collaborative?

How It Works

The Reducing Adverse Drug Events Collaborative

Results

Lessons Learned

Use of Collaboratives

Subsequent IHI Initiatives

Conclusion

Chapter 7: Who Will Lead? The Executive Session

First Meeting, January 22-24, 1998

Second Meeting: June 25-27, 1998

Third Meeting: January 21-23, 1999

Fourth Meeting: June 17-19, 1999

Fifth Meeting: January 27-29, 2000

Appendix 7.1: Executive Session Members

CEOs of Healthcare Delivery Organizations

Leaders of Health-Related Organizations

Others

Chapter 8: A Community of Concern: The Massachusetts Coalition for the Prevention of Medical Errors

Medication Consensus Group

Leadership Forum

Regulatory Consensus Group

Restraint Consensus Group

DPH Project

Surveys

Implementing Best Practices

The Reconciling Medications Project

Communicating Critical Test Results

Impact of the Coalition

Appendix 8.1: Initial Coalition Member Organizations.

Appendix 8.2: Communicating Critical Test Results

Chapter 9: When the IOM Speaks: IOM Quality of Care Committee and Report

To Err Is Human

Postscript

Appendix 9.1: Committee on Quality Of Health Care In America

Chapter 10: The Government Responds: The Agency for Healthcare Research and Quality

Response to the IOM Report

AHRQ Programs

Impact of AHRQ Programs

Chapter 11: Setting Standards: The National Quality Forum

Serious Reportable Events

Safe Practices for Better Healthcare

Performance Measures

New Leadership

Conflict of Interest Scandal

Appendix 11.1: Serious Reportable Events Steering Committee [11]

Appendix 11.2: NQF Serious Reportable Events [11]

Appendix 11.3: NQF Safe Practices [15]

Chapter 12: Enforcing Standards: The Joint Commission

History of the Joint Commission [1]

The Agenda for Change

Changing Accreditation

Focus on Patient Safety: Sentinel Events

Sentinel Event Alerts

Patient Safety Goals

Core Measures

Public Policy Initiative

Accreditation Process Improvement

Chapter 13: Partners in Progress: Patient Safety in the UK

A National Commitment

The Patient Safety Movement

The National Patient Safety Agency (NPSA)

Additional Safety Efforts

Patient Safety in Scotland

Reorganization

Chapter 14: Going Global: The World Health Organization

The World Alliance for Patient Safety

Guidelines for Adverse Event Reporting and Learning Systems

Patient and Consumer Involvement-Patients for Patient Safety (P4PS)

Support of Patient Safety Research

The Global Patient Safety Challenge

Later Years

Appendix 14.1: The London Declaration

References.

Chapter 15: Just Do It: The Surgical Checklist

Chapter 16: Spreading the Word: The Salzburg Seminar

Appendix 16.1: History of the Salzburg Global Seminars

Appendix 16.2: Participants in Salzburg Seminar 386 Patient Safety and Medical Error

Reference

Chapter 17: Publish or Perish: British Medical Journal Theme Issue, New England Journal of Medicine Series

NEJM Series on Patient Safety

Reporting of Adverse Events

Patient Safety and Quality Journals

Joint Commission Journal on Quality Improvement and Safety

BMJ's Quality and Safety in Health Care

The Journal of Patient Safety

Part III: Getting to Work: Key Issues and How They were Dealt with

Chapter 18: Sleepy Doctors: Work Hours and the Accreditation Council for Graduate Medical Education

Residency Training

Early History-What Happened After Zion

2003 ACGME Regulations

The Duty Hours Debate

What Happened: 2003-2008

The IOM Panel

ACGME Duty Hour Task Force

Harvard Conference on Duty Hours

The ACGME Response

CLER

Milestones

Duty Hours

Chapter 19: A Conspiracy of Silence: Disclosure, Apology, and Restitution

Malpractice

The Contrarians

Doing It Right

When Things Go Wrong-The Disclosure Project

When Things Go Wrong

The Patient and Family Experience

The Caregiver Experience

Management of the Event

Getting Support

National Progress in Communication and Resolution

Chapter 20: Who Can I Trust? Ensuring Physician Competence

The System We Have

What's the Problem?

Why Doctors Fail

Who Is Responsible for Ensuring Physician Competence and Safety?

American Board of Medical Specialties

Accreditation Council for Graduate Medical Education

The Joint Commission.

State Licensing Boards

Federation of State Medical Boards

New York Cardiac Advisory Committee

The Civil Justice System-Malpractice Litigation

Hospital Responsibility for Physician Performance

Multisource Feedback

Support of Physicians with Problems

How Should it Work? The Ideal System

Nonregulatory Approaches to Improving Competence

National Surgical Quality Improvement Program

Analysis of Patient Complaints

National Alliance for Physician Competence

The Coalition for Physician Accountability

Chapter 21: Everyone Counts: Building a Culture of Respect

A Group of Leaders

"Champions"

The Problem

A Culture of Respect

A Culture of Respect, Part 1: The Nature and Causes of Disrespectful Behavior by Physicians [4]

A Culture of Respect, Part 2: Creating a Culture of Respect [12]

A Strange Twist

Response

Part IV: Creating a Culture of Safety

Chapter 22: Make No Little Plans: The Lucian Leape Institute

Unmet Needs [4]

Teaching Physicians to Provide Safe Patient Care

Workshop Leaders: Dennis O'Leary and Lucian Leape

Summary of Recommendations (Table 22.1)

Progress

Remaining Challenges

Order from Chaos [5]

Accelerating Care Integration

Workshop Leaders: David Lawrence and Richard Bohmer

Summary of Recommendations (Table 22.2)

Through the Eyes of the Workforce [6]

Creating Joy, Meaning, and Safer Health Care

Workshop Leaders: Julie Morath and Paul O'Neill

Vulnerable Workplaces

What Can Be Done?

Developing Effective Organizations

Summary of Recommendations (Table 22.3)

Safety Is Personal [7]

Partnering with Patients and Families for the Safest Care

Workshop Leaders: Susan Edgman-Levitan and James Conway.

Summary of Recommendations (Table 22.4)

Shining a Light [8]

Safer Health Care Through Transparency

Workshop Leaders: Gary Kaplan and Robert Wachter

Summary of Recommendations (Table 22.5)

Transforming Health Care: A Compendium

Members

Later Work

The "Must Do" List

Financial Costs of Patient Safety

Collaboration with American College of Healthcare Executives

Chapter 23: Now the Hard Part: Creating a Culture of Safety

What Is Culture?

A Culture of Safety

Characteristics of a Safe Culture

A Just Culture

High-Reliability Organizations

Why Changing Culture Is so Hard to Do

How to Do It

Examples of Success

Virginia Mason Medical Center

Secrets of Success

Cincinnati Children's Hospital

Denver Health

Safe and Reliable Health Care

Making It Happen

A Role for Government?

A "Burning Platform"?

Correction to: Everyone Counts: Building a Culture of Respect

Index.

Notes:

Description based on publisher supplied metadata and other sources.

ISBN:

3-030-71123-4

9783030711221

OCLC:

1253475905