Understanding patient safety / Robert M. Wachter.

Format:

Book

Author/Creator:

Wachter, Robert M.

Series:

McGraw-Hill's AccessMedicine

Language:

English

Subjects (All):

Medical errors--Prevention.

Medical errors.

Patients--Safety measures.

Patients.

Risk Management.

Safety.

Organization and Administration.

Health Services.

Investigative Techniques.

Analytical, Diagnostic and Therapeutic Techniques and Equipment.

Health Services Administration.

Accident Prevention.

Health Care Facilities Workforce and Services.

Delivery of Health Care.

Accidents.

Public Health.

Environment and Public Health.

Safety Management.

Methods.

Medical Errors.

Medical Subjects:

Risk Management.

Safety.

Organization and Administration.

Health Services.

Investigative Techniques.

Analytical, Diagnostic and Therapeutic Techniques and Equipment.

Health Services Administration.

Accident Prevention.

Health Care Facilities Workforce and Services.

Delivery of Health Care.

Accidents.

Public Health.

Environment and Public Health.

Safety Management.

Methods.

Medical Errors.

Physical Description:

1 online resource (320 p. ) col. ill.

Edition:

2nd ed.

Place of Publication:

New York : McGraw-Hill Medical ; London : McGraw-Hill [distributor], 2012.

Language Note:

English

Summary:

This title delivers key insights on patient safety and quality to help understand and prevent a broad range of errors, including those related to medications, surgery, diagnosis, infections, and nursing care. Gain a thorough understanding of the key principles of patient safety with the subject's pioneer text -- Now in full color "This highly readable yet comprehensive book will appeal to every member of the healthcare team. It is a must for every physician's bookshelf." -- Abraham Verghese, MD, Professor, Stanford University andauthor of the bestselling Cutting for Stone "Bob Wachter's quest to improve the safety of American healthcare represents the very essence of a physician's duty to put the patient first. His unflinching candor about the nature and magnitude of our current safety problems is matched only by his passion forimprovement." -- Mark R. Chassin, MD, MPP, MPH, President, The Joint Commission "Amazingly readable for such a wealth of important information. This book should be required reading for every health professional and every healthcare executive." -- Christine Cassel, MD, President and CEO, American Board of Internal Medicine "In a single volume, Wachter accomplishes the seemingly impossible: furnishing the novice with a highly accessible, easy-to-read introduction to patient safety, while providing a comprehensive, fully annotated reference for the experienced patient safety practitioner. All of the important issues are addressed in individual chapters, each with a lively and relevant clinical example and a "key points" summary at the end bracketing full, balancedand lucid descriptions. A true gem, destined to be a close companion for all of us who strive to make healthcare safe." -- Lucian Leape, MD, Professor, Harvard School of Public Health and Chair, Lucian Leape Institute of the National Patient Safety Foundation "There's no more prominent authority on patient safety than Bob Wachter. And there's no more effective primer on patient safety than this one." -- Atul Gawande, MD, MPH, Associate Professor, Harvard Medical School, staff writer for the New Yorker, and bestselling author of Complications and The Checklist Manifesto "Compelling: a must read for all concerned with patient safety. Bob Wachter has a unique voice, incorporating clinical experience, research expertise, and policy implications.all with the patient front and center." -- Peter J. Pronovost, MD, PhD, Professor and Director of the Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine Understanding Patient Safety , Second Edition is the essential book for anyone seeking to learn the core clinical, organizational, and systems issues of patient safety. Written in an engaging and accessible style by one of the world's leading authorities on patient safety and quality, Understanding Patient Safety is filled with valuable cases and analyses, as well as tables, graphics, references, and tools. This classic reference is designed to make the patient safety field understandable to medical, nursing, pharmacy, hospital administration, and other trainees, and to be the go-to book for experienced clinicians and non-clinicians alike. The second edition has been revised to include coverage of the latest issues and trends, including: Information technology Measurements of safety, errors, and harm Checklist-based interventions Safety targets Policy issues in patient safety Balancing "no blame" and accountability Understanding Patient Safety , Second Edition delivers key insights to help you understand and prevent aa broad range of errors, including those related to medications, surgery, diagnosis, infections, and nursing care. The crucial contextual issues -- including errors at the person-machine interface, the role of culture, patient engagement in their own safety, and workforce and trainee considerations, are also well covered. Finally, the book provides a practical overview of how to organize an effective safety program, in both hospitals and clinics. Gain a thorough understanding of the key principles of patient safety with the subject's pioneer text -- Now in full color "This highly readable yet comprehensive book will appeal to every member of the healthcare team. It is a must for every physician's bookshelf." -- Abraham Verghese, MD, Professor, Stanford University andauthor of the bestselling Cutting for Stone "Bob Wachter's quest to improve the safety of American healthcare represents the very essence of a physician's duty to put the patient first. His unflinching candor about the nature and magnitude of our current safety problems is matched only by his passion forimprovement." -- Mark R. Chassin, MD, MPP, MPH, President, The Joint Commission "Amazingly readable for such a wealth of important information. This book should be required reading for every health professional and every healthcare executive." -- Christine Cassel, MD, President and CEO, American Board of Internal Medicine "In a single volume, Wachter accomplishes the seemingly impossible: furnishing the novice with a highly accessible, easy-to-read introduction to patient safety, while providing a comprehensive, fully annotated reference for the experienced patient safety practitioner. All of the important issues are addressed in individual chapters, each with a lively and relevant clinical example and a "key points" summary at the end bracketing full, balancedand lucid descriptions. A true gem, destined to be a close companion for all of us who strive to make healthcare safe." -- Lucian Leape, MD, Professor, Harvard School of Public Health and Chair, Lucian Leape Institute of the National Patient Safety Foundation "There's no more prominent authority on patient safety than Bob Wachter. And there's no more effective primer on patient safety than this one." -- Atul Gawande, MD, MPH, Associate Professor, Harvard Medical School, staff writer for the New Yorker, and bestselling author of Complications and The Checklist Manifesto "Compelling: a must read for all concerned with patient safety. Bob Wachter has a unique voice, incorporating clinical experience, research expertise, and policy implications.all with the patient front and center." -- Peter J. Pronovost, MD, PhD, Professor and Director of the Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine Understanding Patient Safety , Second Edition is the essential book for anyone seeking to learn the core clinical, organizational, and systems issues of patient safety. Written in an engaging and accessible style by one of the world's leading authorities on patient safety and quality, Understanding Patient Safety is filled with valuable cases and analyses, as well as tables, graphics, references, and tools. This classic reference is designed to make the patient safety field understandable to medical, nursing, pharmacy, hospital administration, and other trainees, and to be the go-to book for experienced clinicians and non-clinicians alike. The second edition has been revised to include coverage of the latest issues and trends, including: Information technology Measurements of safety, errors, and harm Checklist-based interventions Safety targets Policy issues in patient safety Balancing "no blame" and accountability Understanding Patient Safety , Second Edition delivers key insights to help you understand and prevent aa broad range of errors, including those related to medications, surgery, diagnosis, infections, and nursing care. The crucial contextual issues -- including errors at the person-machine interface, the role of culture, patient engagement in their own safety, and workforce and trainee considerations, are also well covered. Finally, the book provides a practical overview of how to organize an effective safety program, in both hospitals and clinics.

Contents:

Intro

Contents

Preface

SECTION I: AN INTRODUCTION TO PATIENT SAFETY AND MEDICAL ERRORS

Chapter 1 The Nature and Frequency of Medical Errors and Adverse Events

Adverse Events, Preventable Adverse Events, and Errors

The Challenges of Measuring Errors and Safety

The Frequency and Impact of Errors

Key Points

References and Additional Readings

Chapter 2 Basic Principles of Patient Safety

The Modern Approach to Patient Safety: Systems Thinking and the Swiss Cheese Model

Errors at the Sharp End: Slips Versus Mistakes

Complexity Theory and Complex Adaptive Systems

General Principles of Patient Safety Improvement Strategies

Chapter 3 Safety, Quality, and Value

What is Quality?

The Epidemiology of Quality Problems

Catalysts for Quality Improvement

The Changing Quality Landscape

Quality Improvement Strategies

Commonalities and Differences Between Quality and Patient Safety

Value: Connecting Quality (and Safety) to the Cost of Care

SECTION II: TYPES OF MEDICAL ERRORS

Chapter 4 Medication Errors

Some Basic Concepts, Terms, and Epidemiology

Strategies to Decrease Medication Errors

Chapter 5 Surgical Errors

Some Basic Concepts and Terms

Volume-Outcome Relationships

Patient Safety in Anesthesia

Wrong-Site/Wrong-Patient Surgery

Retained Sponges and Instruments

Surgical Fires

Safety in Nonsurgical Bedside Procedures

Chapter 6 Diagnostic Errors

Missed Myocardial Infarction: A Classic Diagnostic Error

Cognitive Errors: Iterative Hypothesis Testing, Bayesian Reasoning, and Heuristics

Improving Diagnostic Reasoning.

Communication and Information Flow Issues in Diagnostic Errors

Overdiagnosis

The Policy Context for Diagnostic Errors

Chapter 7 Human Factors and Errors at the Person-Machine Interface

Introduction

Human Factors Engineering

Usability Testing and Heuristic Analysis

Applying Human Factors Engineering Principles

Chapter 8 Transition and Handoff Errors

Best Practices for Person-to-Person Handoffs

Site-to-Site Handoffs: The Role of the System

Best Practices for Site-to-Site Handoffs Other Than Hospital Discharge

Preventing Readmissions: Best Practices for Hospital Discharge

Chapter 9 Teamwork and Communication Errors

The Role of Teamwork in Healthcare

Fixed Versus Fluid Teams

Teamwork and Communication Strategies

Chapter 10 Healthcare-Associated Infections

General Concepts and Epidemiology

Surgical Site Infections

Ventilator-Associated Pneumonia

Central Line-Associated Bloodstream Infections

Catheter-Associated Urinary Tract Infections

Methicillin-Resistant S. Aureus Infection

C. Difficile Infection

What Can Patient Safety Learn from the Approach to Hospital-Associated Infections?

Chapter 11 Other Complications of Healthcare

General Concepts

Venous Thromboembolism Prophylaxis

Preventing Pressure Ulcers

Preventing Falls

Preventing Delirium

Chapter 12 Patient Safety in the Ambulatory Setting

Hospital Versus Ambulatory Environments.

Improving Ambulatory Safety

SECTION III: SOLUTIONS

Chapter 13 Information Technology

Healthcare's Information Problem

Electronic Health Records

Computerized Provider Order Entry

Other IT-Related Safety Solutions

Computerized Clinical Decision Support Systems

IT Solutions for Improving Diagnostic Accuracy

The Policy Environment for HIT

Chapter 14 Reporting Systems, Root Cause Analysis, and Other Methods of Understanding Safety Issues

Overview

General Characteristics of Reporting Systems

Hospital Incident Reporting Systems

The Aviation Safety Reporting System

Reports to Entities Outside the Healthcare Organization

Patient Safety Organizations

Root Cause Analysis and Other Incident Investigation Methods

Morbidity and Mortality Conferences

Other Methods of Capturing Safety Problems

Chapter 15 Creating a Culture of Safety

An Illustrative Case

Measuring Safety Culture

Hierarchies, Speaking Up, and the Culture of Low Expectations

Production Pressures

Teamwork Training

Checklists and Culture

Rules, Rule Violations, and Workarounds

Some Final Thoughts on Safety Culture

Chapter 16 Workforce Issues

Nursing Workforce Issues

Rapid Response Teams

House Staff Duty Hours

The "July Effect"

Nights and Weekends

"Second Victims": Supporting Caregivers After Major Errors

Chapter 17 Education and Training Issues

Autonomy Versus Oversight

Simulation Training

Teaching Patient Safety

References and Additional Readings.

Chapter 18 The Malpractice System

Tort Law and the Malpractice System

Error Disclosure, Apologies, and Malpractice

No-Fault Systems and "Health Courts": An Alternative to Tort-Based Malpractice

Medical Malpractice Cases as a Source of Safety Lessons

Chapter 19 Accountability

Accountability

Disruptive Providers

The "Just Culture"

Reconciling "No Blame" and Accountability

The Role of the Media

Chapter 20 Accreditation and Regulations

Accreditation

Regulations

Other Levers to Promote Safety

Problems with Regulatory, Accreditation, and Other Prescriptive Solutions

Chapter 21 The Role of Patients

Patients with Limited English Proficiency

Patients with Low Health Literacy

Errors Caused by Patients Themselves

Patient Engagement as a Safety Strategy

Chapter 22 Organizing a Safety Program

Structure and Function

Managing the Incident Reporting System

Dealing with Data

Strategies to Connect Senior Leadership with Frontline Personnel

Strategies to Generate Frontline Activity to Improve Safety

Dealing with Major Errors and Sentinel Events

Failure Mode and Effects Analyses

Qualifications and Training of the Patient Safety Officer

The Role of the Patient Safety Committee

Engaging Physicians in Patient Safety

Board Engagement in Patient Safety

Research in Patient Safety

Patient Safety Meets Evidence-Based Medicine

Conclusion

SECTION IV: APPENDICES

Appendix I. Key Books, Reports, Series, and Web Sites on Patient Safety.

Appendix II. The AHRQ Patient Safety Network (AHRQ PSNet) Glossary of Selected Terms in Patient Safety

Appendix III. Selected Milestones in the Field of Patient Safety

Appendix IV. The Joint Commission's National Patient Safety Goals (Hospital Version, 2011)

Appendix V. Agency for Healthcare Research and Quality's (AHRQ) Patient Safety Indicators (PSIs)

Appendix VI. The National Quality Forum's List of Serious Reportable Events, 2011

Appendix VII. The National Quality Forum's List of "Safe Practices for Better Healthcare-2010 Update"

Appendix VIII. Medicare's "No Pay for Errors" List

Appendix IX. Things Patients and Families Can Do, and Questions They Can Ask, to Improve Their Chances of Remaining Safe in the Hospital

Index.

Notes:

Bibliographic Level Mode of Issuance: Monograph

Description based on publisher supplied metadata and other sources.

ISBN:

0-07-180812-4

0071765787

1-280-68559-X

0-07-180694-6

9786613662538

OCLC:

1024273685