Practical patient safety / by John Reynard, John Reynolds, Peter Stevenson.

Format:

Book

Author/Creator:

Reynard, John.

Contributor:

Reynolds, John, Dr.

Stevenson, Peter.

Language:

English

Subjects (All):

Medical errors--Prevention.

Medical errors.

Patients--Safety measures.

Patients.

Physical Description:

xviii, 300 p. : ill.

Edition:

1st ed.

Place of Publication:

Oxford ; New York : Oxford University Press, 2009.

Summary:

Practical Patient Safety demonstrates how core principles of safety from industries such as aviation, nuclear and petrochemical can be applied in surgical and medical practice, giving the reader practical advice on how to start patient safety training within his or her department or hospital.

Contents:

Intro

Contents

Preface

Acknowledgements

1 Clinical error: the scale of the problem

The Harvard Medical Practice Study 1984

The Quality in Australian Healthcare Study 1992

The University College London Study 2001

Danish, New Zealand, Canadian, and French studies

The frequency and costs of adverse drug events

Accuracy of retrospective studies

Error rates revealed in retrospective studies are of the same order of magnitude as those found in observational studies

Error rates according to type of clinical activity

Deaths from adverse events

Extra bed days as a consequence of error

Criminal prosecutions for medical errors

Reliability: other industries

Reliability: healthcare

References

2 Clinical errors:What are they?

Sources of error in primary care and office practice

Sources of error along the patient pathway in hospital care and potential methods of error prevention

Errors in dealing with referral letters

Errors of identification

Errors in note keeping

Errors with medical records in general

Other slips in letters that you have dictated

Errors as a consequence of patients failing to attend appointments for investigations or for outpatient consultations

Washing your hands between patients and attention to infection control

Admission to hospital

Diagnostic errors in general

Errors in drug prescribing and administration

Reducing errors in blood transfusion

Intravenous drug administration

Errors in the operating theatre

The use of diathermy

Harm related to patient positioning

Leg supports that give way

Generic safety checks prior to any surgical procedure

Failure to give DVT prophylaxis

Failure to give antibiotic prophylaxis

Errors in the postoperative period

Shared care

Medical devices

References.

3 Safety culture in high reliability organizations

High reliability organizations: background

High reliability organizations: common features

The consequences of failure

'Convergent evolution' and its implication for healthcare

Learning from accidents: overview of basic high reliability organizational culture

Elements of the safety culture

Counter-intuitive aspects of high reliability organization safety culture

4 Case studies

Case study 1: wrong patient

Case study 2: wrong blood

Case study 3: wrong side nephrectomy

Case study 4: another wrong side nephrectomy

Case study 5: yet another wrong side nephrectomy case

Case study 6: medication error-wrong route (intrathecal vincristine)

Case study 7: another medication error-wrong route (intrathecal vincristine)

Case study 8: medication error-wrong route (intrathecal vincristine)

Case study 9: medication error-miscalculation of dose

Case study 10: medication error-frequency of administration mis-prescribed as 'daily' instead of 'weekly'

Case study 11: medication error-wrong drug

Case study 12: miscommunication of path lab result

Case study 13: biopsy results for two patients mixed up

Case study 14: penicillin allergy death

Case study 15: missing X-ray report

Case study 16: medication not given

Case study 17: oesophageal intubation

Case study 18: tiredness error

Case study 19: inadequate training

Case study 20: patient fatality-anaesthetist fell asleep

5 Error management

How accidents happen: the person approach versus the systems approach

Error chains

System failures

'Catalyst events'

Human error

Error classification

How experts and novices solve problems

Three error management opportunities

Detecting and reversing incipient adverse events in real time: 'Red flags'.

Red flags: the symptoms and signs of evolving error chains

Speaking up protocols

Error management using accident and incident data

6 Communication failure

The prevalence of communication failures in adverse events in healthcare

Communication failure categories

Whose fault: message sender or receiver?

Safety-critical communications (SCC) protocols

How to prevent communication errors in specific healthcare situations

Composing an 'abnormal' (non-routine) safety-critical message

Written communication/documentation communication failures

7 Situation awareness

Situation awareness: definitions

Three levels of situation awareness

Catastrophic loss of situation awareness and the associated syndrome: 'mind lock'

Understanding loss of situation awareness

Cognitive failures: the role of mental models/the psychology of mistakes

Mental models: the problems

Ensuring high situation awareness

Two special cases involving loss of situation awareness

8 Professional culture

Similarities between two professions

Negative aspects of professional cultures

Steep hierarchy

Changing the pilots' professional culture

Team resource management/non-technical skills

9 When carers deliberately cause harm

10 Patient safety toolbox

Practical ways to enhance the safety of your patients

11 Conclusions

Glossary

A

B

C

E

F

H

I

L

M

N

O

P

R

S

T

U

W

Appendices

Appendix 1: Initiating a safety-critical (verbal) communication (STAR)

Appendix 2: I-SBAR-to describe a (deteriorating) patient's condition

Appendix 3: General patient safety tools

Appendix 4: Red flags (the symptoms and signs of an impending error)

Index

D

G

J

K.

L

Q

V

W.

Notes:

Includes bibliographical references and index.

Description based on publisher supplied metadata and other sources.

ISBN:

0-19-157540-2

1-283-58109-4

0-19-176856-1

9786613893543

OCLC:

801363490