Understanding Patient Safety

Understanding Patient Safety

Authors: Robert M. Wachter

Published: October 2007

eISBN: 9780071594332 0071594337 | ISBN: 9780071482776

Contents

Preface

Section I: An Introduction to Patient Safety and Medical Errors

Chapter One: 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 Two: 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

General Principles of Patient Safety Improvement Strategies

Key Points

References and Additional Readings

Chapter Three: Safety Versus Quality

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 Safety

Key Points

References and Additional Readings

Section II: Types of Medical Errors

Chapter Four: Medication Errors

Some Basic Concepts, Terms, and Epidemiology

Strategies to Decrease Medication Errors

Key Points

References and Additional Readings

Chapter Five: Surgical Errors

Some Basic Concepts and Terms

Volume-Outcome Relationships

Patient Safety in Anesthesia

Wrong-Site/Wrong-Patient Surgery

Retained Sponges and Instruments

Key Points

References and Additional Readings

Chapter Six: Diagnostic Errors

Some Basic Concepts and Terms

Missed Myocardial Infarction: A Classic Diagnostic Error

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

Improving Diagnostic Reasoning

Key Points

References and Additional Readings

Chapter Seven: Human Factors and Errors at the Person-Machine Interface

Introduction

Human Factors Engineering

Usability Testing and Heuristic Analysis

Key Points

References and Additional Readings

Chapter Eight: Transition and Handoff Errors

Some Basic Concepts and Terms

Best Practices for Person-to-Person Handoffs

Best Practices for Site-to-Site Handoffs

Key Points

References and Additional Readings

Chapter Nine: Teamwork and Communication Errors

Some Basic Concepts and Terms

The Role of Teamwork in Healthcare

Fixed Versus Fluid Teams

Teamwork and Communication Strategies

Key Points

References and Additional Readings

Chapter Ten: Nosocomial Infections

General Concepts and Epidemiology

Surgical Site Infections

Ventilator-Associated Pneumonia

Catheter-Related Bloodstream Infections

Healthcare-Associated Urinary Tract Infections

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

Key Points

References and Additional Readings

Chapter Eleven: Other Complications of Healthcare

General Concepts

Venous Thromboembolism Prophylaxis

Preventing Pressure Ulcers

Preventing Falls

Key Points

References and Additional Readings

Chapter Twelve: Patient Safety in the Ambulatory Setting

General Concepts and Epidemiology

Hospital Versus Ambulatory Environments

Key Points

References and Additional Readings

Section III: Solutions

Chapter Thirteen: Information Technology

Healthcare's Information Problem

Electronic Medical Records

Computerized Provider Order Entry

Other IT-Related Safety Solutions

Computerized Decision Support

IT Solutions for Improving Diagnostic Accuracy

The Challenges of Computerization

Key Points

References and Additional Readings

Chapter Fourteen: Reporting Systems, Incident Investigations, and Other Methods of Understanding Safety Issues

Overview

Reporting Systems

Hospital Incident Reporting Systems

Reports to Entities Outside the Healthcare Organization

Root Cause Analysis and Other Incident Investigation Methods

Morbidity and Mortality Conferences

Other Methods of Capturing Safety Problems

Key Points

References and Additional Readings

Chapter Fifteen: Creating a Culture of Safety

Overview

The Culture of Low Expectations

Rapid Response Teams

Other Methods to Promote Culture Change

Key Points

References and Additional Readings

Chapter Sixteen: Workforce Issues

Overview

Nursing Workforce Issues

Housestaff Duty Hours

Key Points

References and Additional Readings

Chapter Seventeen: Training Issues

Overview

Autonomy versus Oversight

The Role of Simulation

Key Points

References and Additional Readings

Chapter Eighteen: The Malpractice System

Overview

Tort Law and the Malpractice System

No-Fault Systems: An Alternative to Tort-Based Malpractice

Key Points

References and Additional Readings

Chapter Nineteen: Accountability

Overview

Accountability

The Role of the Media

Reconciling "No Blame" and Accountability

Key Points

References and Additional Readings

Chapter Twenty: Laws and Regulations

Overview

Regulations and Accreditation

Other Levers to Promote Safety

Problems with Regulatory and Other Prescriptive Solutions

Key Points

References and Additional Readings

Chapter Twenty One: The Role of Patients

Overview

Language Barriers and Health Literacy

"What Can Patients do to Protect Themselves?"

Apologies: Physicians' and Healthcare Systems' Obligations to Patients and Families After a Medical Error

Patient Engagement as a Safety Strategy

Key Points

References and Additional Readings

Chapter Twenty Two: Organizing a Safety Program

Overview

Structure and Function

Managing the Incident Reporting System

Dealing with Data

Strategies to Connect Senior Leadership with Frontline Personnel

Strategies to Generate Front Line Activity to Improve Safety

Dealing with Major Errors and Sentinel Events

Failure Mode Effects Analyses

Qualifications and Training of the Patient Safety Officer

The Role of the Patient Safety Committee

Board Engagement in Patient Safety

Research in Patient Safety

Patient Safety Meets Evidence-Based Medicine

Key Points

References and Additional Readings

Conclusion

Section IV: Appendices

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

Appendix II. Glossary of Selected Terms in Patient Safety

A

B

C

D

E

F

H

I

J

L

M

N

P

R

S

T

U

W

Appendix III. Selected Milestones in the Field of Patient Safety

Appendix IV. The Joint Commission's National Patient Safety Goals (Hospital Version, 2007)

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

Appendix VI. The National Quality Forum's List of 28 "Never Events"

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

Index