The Value of Close Calls in Improving Patient Safety

The Value of Close Calls in Improving Patient Safety
Author: Joint Commission Resources, Inc
Publisher: Joint Commission Resources
Total Pages: 206
Release: 2011
Genre: Health & Fitness
ISBN: 159940415X

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Because close calls, often termed near misses, don't raise the same concerns about malpractice liability and may be less emotionally charged than errors that cause serious harm, they are a unique source of learning for individuals and organizations striving to keep patients safe. This book tells how to take advantage of these lessons to prevent today's close call from turning into tomorrow's catastrophic event. Special Features: * Foreword by human error expert James Reason, Ph.D. * Authoritative tutorials on what the literature tells us about the concept of close calls and their identification, relationship with errors, and use in assessing and improving the safety and reliability of health care. * 15 detailed case studies from a variety of clinical disciplines and specialties to show how health care organizations use close calls to identify and solve patient safety problems

Patient Safety

Patient Safety
Author: Institute of Medicine
Publisher: National Academies Press
Total Pages: 551
Release: 2003-12-20
Genre: Medical
ISBN: 0309090776

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Americans should be able to count on receiving health care that is safe. To achieve this, a new health care delivery system is needed â€" a system that both prevents errors from occurring, and learns from them when they do occur. The development of such a system requires a commitment by all stakeholders to a culture of safety and to the development of improved information systems for the delivery of health care. This national health information infrastructure is needed to provide immediate access to complete patient information and decision-support tools for clinicians and their patients. In addition, this infrastructure must capture patient safety information as a by-product of care and use this information to design even safer delivery systems. Health data standards are both a critical and time-sensitive building block of the national health information infrastructure. Building on the Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm, Patient Safety puts forward a road map for the development and adoption of key health care data standards to support both information exchange and the reporting and analysis of patient safety data.

Patient Safety and Quality

Patient Safety and Quality
Author: Ronda Hughes
Publisher: Department of Health and Human Services
Total Pages: 592
Release: 2008
Genre: Medical
ISBN:

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"Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043)." - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/

Advances in Patient Safety

Advances in Patient Safety
Author: Kerm Henriksen
Publisher:
Total Pages: 526
Release: 2005
Genre: Medical
ISBN:

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v. 1. Research findings -- v. 2. Concepts and methodology -- v. 3. Implementation issues -- v. 4. Programs, tools and products.

Principles of Perioperative Safety and Efficiency

Principles of Perioperative Safety and Efficiency
Author: Jamal J. Hoballah
Publisher: Springer Nature
Total Pages: 421
Release: 2024
Genre: Operating room nursing
ISBN: 3031410890

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Perioperative safety continues to be a global challenge. It is estimated that approximately 200 million surgical procedures are performed annually worldwide, and despite various national and global safety initiatives, perioperative adverse event rates remain alarmingly high. Although hospitals and governmental agencies impose safety standards and certification by organizations such as the Joint Commission, which can address issues of perioperative safety, many hospitals in developed, developing or underdeveloped countries lack the resources or knowhow to decrease perioperative adverse events. There is a great opportunity for improving perioperative safety worldwide especially in underdeveloped or developing countries. Filling a gap in the literature, this book teaches healthcare providers the basic principles of perioperative safety and efficiency, including checklists and processes to reduce adverse events. Presented here are the basics of intraoperative monitoring and safety measures to reduce patient adverse events, including wrong site surgery, electric burn injury, deep venous thrombosis, surgical site infection and foreign body retention. Emphasis is given toward developing awareness into measures preventing occupational injuries, such as sharp injury, radiation exposure, laser exposure and smoke hazard. It also addresses dealing and reporting adverse events and disruptive behaviors in the operating rooms as well as new measures for enhanced recovery following surgery and anesthesia. Principles of Perioperative Safety and Efficiency is a valuable resource and reference for all operating room personnel including surgeons, surgical residents, medical students and nurses.

Resident Duty Hours

Resident Duty Hours
Author: Institute of Medicine
Publisher: National Academies Press
Total Pages: 427
Release: 2009-04-27
Genre: Medical
ISBN: 0309131529

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Medical residents in hospitals are often required to be on duty for long hours. In 2003 the organization overseeing graduate medical education adopted common program requirements to restrict resident workweeks, including limits to an average of 80 hours over 4 weeks and the longest consecutive period of work to 30 hours in order to protect patients and residents from unsafe conditions resulting from excessive fatigue. Resident Duty Hours provides a timely examination of how those requirements were implemented and their impact on safety, education, and the training institutions. An in-depth review of the evidence on sleep and human performance indicated a need to increase opportunities for sleep during residency training to prevent acute and chronic sleep deprivation and minimize the risk of fatigue-related errors. In addition to recommending opportunities for on-duty sleep during long duty periods and breaks for sleep of appropriate lengths between work periods, the committee also recommends enhancements of supervision, appropriate workload, and changes in the work environment to improve conditions for safety and learning. All residents, medical educators, those involved with academic training institutions, specialty societies, professional groups, and consumer/patient safety organizations will find this book useful to advocate for an improved culture of safety.

Patient Safety Handbook

Patient Safety Handbook
Author: Barbara J. Youngberg
Publisher: Jones & Bartlett Publishers
Total Pages: 677
Release: 2013
Genre: Medical
ISBN: 0763774049

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Examines the newest scientific advances in the science of safety.

Handbook of Human Factors and Ergonomics in Health Care and Patient Safety

Handbook of Human Factors and Ergonomics in Health Care and Patient Safety
Author: Pascale Carayon
Publisher: CRC Press
Total Pages: 855
Release: 2016-04-19
Genre: Technology & Engineering
ISBN: 1439830347

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The first edition of Handbook of Human Factors and Ergonomics in Health Care and Patient Safety took the medical and ergonomics communities by storm with in-depth coverage of human factors and ergonomics research, concepts, theories, models, methods, and interventions and how they can be applied in health care. Other books focus on particular human

Crossing the Quality Chasm

Crossing the Quality Chasm
Author: Institute of Medicine
Publisher: National Academies Press
Total Pages: 360
Release: 2001-08-19
Genre: Medical
ISBN: 0309072808

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Second in a series of publications from the Institute of Medicine's Quality of Health Care in America project Today's health care providers have more research findings and more technology available to them than ever before. Yet recent reports have raised serious doubts about the quality of health care in America. Crossing the Quality Chasm makes an urgent call for fundamental change to close the quality gap. This book recommends a sweeping redesign of the American health care system and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others. In this comprehensive volume the committee offers: A set of performance expectations for the 21st century health care system. A set of 10 new rules to guide patient-clinician relationships. A suggested organizing framework to better align the incentives inherent in payment and accountability with improvements in quality. Key steps to promote evidence-based practice and strengthen clinical information systems. Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change.

To Err Is Human

To Err Is Human
Author: Institute of Medicine
Publisher: National Academies Press
Total Pages: 312
Release: 2000-03-01
Genre: Medical
ISBN: 0309068371

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Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine