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This book fulfils the need of doctors, medical students, and all healthcare personnel for information that addresses fundamental patient safety concepts that are not usually covered in conventional medical curricula.There are three valuable features. Firstly, the content encompasses the main areas of human factors and patient safety in short and easily accessible language supplemented by anecdotes from safety-critical industries such as aviation and nuclear power. Secondly, each chapter highlights the problems of human error and provides solutions that help to reduce the risks to patients. Finally, the coverage highlights the important role the public should play in protecting their own safety when in contact with healthcare systems.

The second edition of this well-received book, the first to provide detailed guidance on how to conduct incident investigations in primary care, has been thoroughly revised and updated throughout to reflect the current nomenclature for different aspects of the investigatory process in the UK and the latest format for incident reporting.Key features: Explains how to recognise a serious clinical incident, how to conduct a root cause analysis (RCA) investigation, and how and when duty of candour applies Covers the technical aspects of serious incident recognition and report writing Includes a wealth of practical advice and'top tips', including how to manage the common pitfalls in writing reports Offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow Explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. At a time of increasing regulatory scrutiny and medico-legal risk, in which failure to manage appropriately can have serious consequences both for service organisations and for individuals involved, this concise and convenient book continues to provide a master class for anyone performing RCA and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices,'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical incidents are investigated and managed.

An essential guide for all healthcare students to develop and hone their skills in safe and effective communication. Request a digital sample - for educators Critical Conversations for Patient Safety, 3rd edition, provides comprehensive, practical advice for healthcare students to develop excellent communication skills that improve patient safety and wellbeing. It addresses communication between healthcare professionals and their patients and families, as well as interprofessional communication and collaboration. Diverse disciplinary perspectives and authentic patient stories provide different lenses for students to understand effective patient-safe communication in the evolving and complex nature of contemporary healthcare. Critical Conversations is suitable for Nursing, Midwifery, and Healthcare students, supporting their foundational professional practice knowledge and skills for clinical placement and beyond. Samples Download the detailed table of contents > Preview sample pages from Critical Conversations for Patient Safety >

This book aims to serve as a playbook and a guide for the creation of a safer healthcare system in the contemporary healthcare ecosystem. It meets this goal through examinations of clinical case studies that illustrate core principles of patient safety, coverage of a broad range of medical errors including medication errors, and solutions to reducing medical errors that are widely applicable in many settings. Throughout the book, the chapters offer viewpoints from healthcare leaders, accomplished practitioners, and experts in patient safety. In addition to highlighting important concepts in patient safety, the book also provides a vision of patient safety in the subsequent decade. Furthermore, it will describe what changes need to “fall into place” between now and the next 10-15 years to have that future realized. The book presents and analyzes a number of cases to illustrate the most common types of medical errors and to help readers learn thekey clinical, organizational, and systems issues in patient safety. Patient Safety, 2nd edition, is an invaluable text for all physicians, healthcare workers, policymakers, and residents who are working towards a more equitable and effective healthcare system.

The best clinicians take into account the life challenges of their patients when planning their care, a process Drs. Weiner and Schwartz refer to as'contextualizing care.'Failures to contextualize care, when they results in care plans that seem appropriate from a narrowly clinical perspective but are nevertheless unlikely to achieve their intended aims represent'contextual errors.'Prescribing a medication a patient cannot afford when a less costly alternative is available would constitute such an error. Drawing on two decades of research including analysis of nearly 10,000 audio recorded medical encounters, the authors document an unmeasured dimension of quality: the extent to which clinicians attend to patient context, and its substantial implications for health care outcomes and costs. Listening for What Matters provides a comprehensive overview of research and quality improvement efforts to address the problem of contextual error. This second edition has been revamped and updated to include studies testing clinical decision support tools in the electronic medical record, medical student and resident trainee educational interventions, and an audio-recording based quality improvement program within the Department of Veterans Affairs. This book is a must-read for physicians, other health care professionals, policymakers and administrators, medical students, and medical educators.

Over the past decade or so, we have seen a multitude of improvement programmes and projects to improve the safety of patient care in healthcare. However, the full potential of these efforts and especially those that seek to address an entire system has not yet been reached. The current pandemic has made this more evident than ever.We have tended to focus on problems in isolation, one harm at a time, and our efforts have been simplistic and myopic. If we are to save more lives and significantly reduce patient harm, we need to adopt a holistic, systematic approach that extends across cultural, technological, and procedural boundaries. Patient Safety Now is about the fact that it is time to care for everyone impacted by patient safety, how we need to take the time to care for everyone in a meaningful way and how hospitals need to enable staff time to care safely.This book builds on the author's two previous books on patient safety. Rethinking Patient Safety talked about ways in which we need to rethink patient safety in healthcare and describes what we've learned over the last two decades. Implementing Patient Safety talked about what we can do differently and how we can use those lessons learned to improve the way we implement patient safety initiatives and encourage a culture of safety across a healthcare system. Patient Safety Now unites the concepts, theories and ideas of the previous two books with updated material and examples, including what has been learned by patient safety specialists during a pandemic.Patient Safety Now provides the reader with a unique view of patient safety that looks beyond the traditional negative and retrospective approach to one that is proactive and recognizes the impact of conditions, behaviours and cultures that exist in healthcare on everyone. It is written not only for healthcare professionals and patient safety personnel, but for patients and their families who all want the same thing. Too often when things go wrong, relationships quickly become adversarial when in fact this can be avoided by recognizing that, rather than being in separate camps, there are shared needs and goals in relations to patient safety.

When you experience a medical emergency, you expect to be treated by a licensed physician with expertise in your condition. What happens when you look up from your hospital gurney to find that the doctor has been replaced by a non-physician practitioner w

The book follows a proven training outline, including real-life examples and exercises, to teach healthcare professionals and students how to lead effective and successful Root Cause Analysis (RCA) to eliminate patient harm.This book discusses the need for RCA in the healthcare sector, providing practical advice for its facilitation. It addresses when to use RCA, how to create effective RCA action plans, and how to prevent common RCA failures. An RCA training curriculum is also included.This book is intended for those leading RCAs of patient harm events, leaders, students, and patient safety advocates who are interested in gaining more knowledge about RCA in healthcare.

Conversational and easy to read, Avoiding Common Errors in Pediatric Emergency Medicine discusses 198 errors commonly made in the practice of pediatric emergency medicine and gives practical, easy-to-remember tips for avoiding these pitfalls. This unique manual offers brief, approachable, evidence-based chapters suitable for reading immediately before the start of a rotation, for quick reference on call, or daily for personal assessment and review.

Patient safety and quality of care are critical concerns of healthcare consumers, payers, providers, organizations, health systems, and governments. Although a strong body of knowledge shows that high reliability methods enable the most efficient, safe, and effective care, these methods have yet to be completely implemented across healthcare. According to authors Cynthia Oster and Jane Braaten, nurses—who are on the frontline of providing safe and effective care—are ideally situated to drive high reliability. High Reliability Organizations: A Healthcare Handbook for Patient Safety & Quality, Second Edition, equips nurses and healthcare professionals with the tools necessary to establish an error detection and prevention system. This new edition builds on the foundation of the first book with best practices, relevant exemplars, and important discussions about cultural aspects essential to sustainability. New material focuses on: High reliability performance during a pandemic Organizational learning and tiered safety huddles High reliability in infection prevention and ambulatory care The emerging field of human factors engineering within healthcare Creating a virtual resource toolkit for frontline staff

De verpleegkundige als communicator helpt de student bij de ontwikkeling van communicatieve vaardigheden in alle zorgdomeinen. Het boek heeft een evidence-based benadering, biedt veel praktijkvoorbeelden en behandelt nieuwe gespreksvaardigheden zoals gezamenlijke besluitvorming en motiverende gespreksvoering. Ook wordt aandacht besteed aan communicatieve vaardigheden specifiek voor bepaalde domeinen zoals de kinderverpleegkunde, ggz (geestelijke gezondheidszorg) en vgz (de zorg aan verstandelijk beperkten) en aan interculturele communicatie. Alle aangeboden theorie is ingepast in diverse casuïstiek en uitgeschreven dialogen, allen afkomstig uit de dagelijkse praktijk van de zorg. Waar mogelijk is gekozen voor een generieke benadering in de casuïstiek, dat wil zeggen dat de casussen uit de agz ook herkenbaar zijn voor verpleegkundigen uit de ggz en/of de vgz; Bij dit leerboek zijn digitaal beschikbaar gesteld: de volledige tekst en per hoofdstuk een samenvatting. Ook zijn er meer deeplinks opgenomen met verwijzing naar videovignets als oefenmateriaal voor zowel studenten als docenten.

Over the last two decades across the globe we have seen a multitude of programs, projects and books to help improve the safety of patient care in healthcare. However, the full potential of these has not yet been reached.Most of the current approaches are top down, programmatic and target driven. These look at problems in isolation one harm at a time with simplistic solutions that fail to support a holistic, systematic approach. They are focused on collecting incident data and learning from failure using tools that are not fit for purpose in a complex nonlinear system. Very rarely do the solutions help build the conditions, cultures and behaviours that support a safer system and help the people involved work safely.Healthcare is stuck in a relentlessly negative approach to safety. Those working in patient safety and healthcare are struggling, and books on patient safety to date instruct the reader to continue doing the same things we have been doing for the last 20 years.This book uniquely combines the latest thinking in safety, including creating a balanced approach to learning from what works as a way to understand why it fails, together with the evidence on building a just culture, positive workplaces and working relationships that we now know are so important for safety. It helps people understand how to address issues despite their complexities and improve safety with practical ways to truly understand what day to day healthcare work is actually like, rather than what people imagine it is like.This book builds on the author's first book Rethinking Patient Safety which exposed what we need to do differently to truly transform our approach to patient safety. It updates the reader further on the concepts explored in the first book but also vitally helps readers understand the ‘how'. Implementing Patient Safety goes beyond the rhetoric and provides the reader with ideas and examples for how the latest thinking can actually be achieved. It is based on the author's personal experience of leading a national culture change campaign in the National Health Service for five years. The lessons arise from helping hundreds of organisations and people rethink and implement a whole new way of thinking about improving patient safety in healthcare.

Investigating Patient Safety opens with a summary on the main theories representative of human error, such as: “Bad Apples Theory”, “Normal Accident Theories” and “High Reliability Organizations Theory.” Following this, the authors define mistakes in the diagnostic process, identifying their major causes and suggesting several principles for optimal, bias-free diagnoses. Evidence is presented which supports the idea that the Common Assessment Framework is a total quality management tool that public organizations can use for free for their self-assessment, aiming to improving their administrative capacity and services without having to ask for support from external sources. An analytical exploration of patient advocacy related to patient safety and the concept of a “Theory-Practice-Ethics gap” is presented, reinforcing the importance of their synonymous relationship for trustworthy healthcare practices. The concluding chapter proposes that inline fluid warming devices must employ the safest technology to ensure patients are not exposed to additional risks during the active warming of infused fluids.

This book, written by a lawyer and a doctor explains to everyday readers ways in which they can avoid death and injury caused by medical mistakes. It may be shocking to learn that preventable errors by doctor and hospital personnel are a leading cause of death and injury in the United States—perhaps even exceeding the annual deaths caused by heart disease and cancer. But avoiding these mistakes is possible, and the rules found in this book will arm readers against the careless errors that lead to such deaths and injuries. From hospitals to doctors'offices, medical professionals are overwhelmed, overtired, even overworked and mistakes are sometimes unavoidable even with the best safety measures in place. A resident at the end of a 36-hour on-call stint may forget to wash her hands before performing a surgical procedure. A chart may be mismarked. Medications may be inaccurately listed. Test results may be inaccurately interpreted. But patients are in a position to help themselves and their medical caregivers to avoid these mistakes by taking more active and attentive part in their own healthcare. By being aware of the most common errors, patients can look for ways to ask questions, review information, even examine test results with a critical eye toward their own health and specific situations. Robert Fox and Chris Landon show them how.

Design for Health: Applications of Human Factors delves into critical and emergent issues in healthcare and patient safety and how the field of human factors and ergonomics play a role in this domain. The book uses the Design for X (DfX) methodology to discuss a wide range of contexts, technologies, and population dependent criteria (X's) that must be considered in the design of a safe and usable healthcare ecosystem. Each chapter discusses a specific topic (e.g., mHealth, medical devices, emergency response, global health, etc.), reviews the concept, and presents a case study that demonstrates how human factors techniques and principles are utilized for the design, evaluation or improvements to specific tools, devices, and technologies (Section 1), healthcare systems and environments (Section 2), and applications to special populations (Section 3). The book represents an essential resource for researchers in academia as well as practitioners in medical device industries, consumer IT, and hospital settings. It covers a range of topics from medication reconciliation to self-care to the artificial heart. - Uses the Design for X (DfX) methodology - A case study approach provides practical examples for operationalization of key human factors principles and guidelines - Provides specific design guidelines for a wide range of topics including resilience, stress and fatigue management, and emerging technologies - Examines special populations, such as the elderly and the underserved - Brings a multidisciplinary, multi-industry approach to a wide range of healthcare human factors issues

Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare exposes a vast conspiracy of political maneuvering and corporate greed that has led to the replacement of qualified medical professionals by lesser trained p

The term'patient safety'rose to popularity in the late nineties, as the medical community -- in particular, physicians working in nonmedical and administrative capacities -- sought to raise awareness of the tens of thousands of deaths in the US attributed to medical errors each year. But what was causing these medical errors? And what made these accidents to rise to epidemic levels, seemingly overnight? Still Not Safe is the story of the rise of the patient-safety movement -- and how an'epidemic'of medical errors was derived from a reality that didn't support such a characterization. Physician Robert Wears and organizational theorist Kathleen Sutcliffe trace the origins of patient safety to the emergence of market trends that challenged the place of doctors in the larger medical ecosystem: the rise in medical litigation and physicians'aversion to risk; institutional changes in the organization and control of healthcare; and a bureaucratic movement to'rationalize'medical practice -- to make a hospital run like a factory. If these social factors challenged the place of practitioners, then the patient-safety movement provided a means for readjustment. In spite of relatively constant rates of medical errors in the preceding decades, the'epidemic'was announced in 1999 with the publication of the Institute of Medicine report To Err Is Human; the reforms that followed came to be dominated by the very professions it set out to reform. Weaving together narratives from medicine, psychology, philosophy, and human performance, Still Not Safe offers a counterpoint to the presiding, doctor-centric narrative of contemporary American medicine. It is certain to raise difficult, important questions around the state of our healthcare system -- and provide an opening note for other challenging conversations.

This case-based book illustrates and explores common cognitive biases and their consequences in the practice of medicine. The book begins with an introduction that explains the concept of cognitive errors and their importance in clinical medicine and current controversies within healthcare. The core of the book features chapters dedicated to particular cognitive biases; cases are presented and followed by a discussion of the clinician's rationale and an overview of the particular cognitive bias. Engaging and easy to read, this text provides strategies on minimizing cognitive errors in various medical and professional settings.

This volume explores the ways in which structural changes in health care environments impact patient safety. It delves into the potential that design thinking can have when applied to organizational systems and structures, as well as the physical environment, to mitigate risks, reduce medical errors and ultimately improve the quality of care, provider well-being, and the overall patient experience. Much of health management empirical research has focused on the process and outcomes and then attempted to reverse engineer the structure that may reasonably explain that. This volume presents studies from the United States and Europe to demonstrate the benefits of a structure led approach. The chapters employ a variety of methods including needs assessment, consensus building, systems modelling, survey research, secondary analysis of EMR data, and qualitative methodologies. Together they provide meaningful conclusions to the question of how structural approaches in learning health care environments can be improved to create a positive impact on patient safety.

Based on the IOM's estimate of 44,000 deaths annually, medical errors rank as the eighth leading cause of death in the U.S. Clearly medical errors are an epidemic that needs to be contained. Despite these numbers, patient safety and medical errors remain an issue for physicians and other clinicians. This book bridges the issues related to patient safety by providing clinically relevant, vignette-based description of the areas where most problems occur. Each vignette highlights a particular issue such as communication, human facturs, E.H.R., etc. and provides tools and strategies for improving quality in these areas and creating a safer environment for patients.

This book utilizes big data to undertake a cluster analysis of medical accidents. Highlighting shared worldwide accident patterns, it represents a first step toward reducing the incidence of accidents through kaizen innovation driven by information and communications technology. This initiative comes against a background where medical accidents are currently the third largest cause of death after heart attack and cancer, making accident prevention an urgent concern. With the objective of preventing these accidents, which negatively impact numerous different stakeholders, and based on interdisciplinary research, the book examines (1) the application of data mining to identify shared accident patterns; (2) proposals for system improvement and organizational innovation aimed at risk and resilience in crisis management; and (3) the use of a global platform to achieve sustainability in the Internet of Medicine (IoM).

Safe care for every patient, in every setting, every time. Is this really an achievable goal for all healthcare organizations? Yes, it is. The vast majority of occurrences of harm to patients during their care are preventable. But simply aiming for improvement won't do; healthcare organizations must reset their patient safety goal to zero patient harm.Five Disciplines for Zero Patient Harm: How High Reliability Happens offers real-world, how-to guidance for driving fundamental change that consistently achieves safe patient care. Drawing on best practices from high-hazard industries such as aviation, nuclear power, and air traffic control, this book details the safety habits and disciplines that are ingrained in such organizations'cultures and behaviors. Specifically, five disciplines of performance excellence, when consistently applied to healthcare organizations, can save lives and protect patients from harm:Prepare for excellent performance through simulation, deliberate practice, and training.Apply proven offensive strategies that exhibit consistent, excellent individual and team performance.Minimize both individual and team errors through immediate feedback and coach interventions.Employ strong defensive strategies that effectively block the potential negative effects of errors, latent hazards, and emerging threats.Coach individuals and teams to achieve consistent, excellent performance in the first four disciplines.Zero preventable patient harm can be the norm, not the stretch goal, when the practices and action steps in this comprehensive resource are implemented. Five Disciplines for Zero Patient Harm provides an evidence-based guide for hospitals and healthcare systems to transform unsafe behaviors into safe behaviors and safe behaviors into safe habits. That's how high reliability happens.

Each year, more than 200,000 patients die as a result of medical errors—the third leading cause of death in the United States.Although the numbers are staggering and the challenges great, this national healthcare crisis is solvable—and fixing it has become a personal mission for John Byrnes, MD, and Susan Teman, RN.Byrnes and Teman have a proven track record in helping hospitals and health systems transform into high-reliability organizations that aim to deliver error-free care at an affordable cost. In The Safety Playbook: A Healthcare Leader's Guide to Building a High-Reliability Organization, they lay out their process for building a safety program that can eradicate preventable medical errors.Written in a clear, conversational style, the book applies to all types of healthcare organizations and speaks to leaders across the spectrum—from board members and C-suite executives to clinical leaders; managers; and staff of quality, safety, and risk management departments. Readers of The Safety Playbook will:• Review the current rate of medical errors and explore proven solutions, including high reliability• Discover how transparency about errors and their causes makes a successful safety program possible• Learn how developing internal safety experts saves time and money• Examine safety tools and practices used effectively in high-reliability industries• Understand why communication is the top cause of medical errors and how to improve it• Explore guidelines used in other healthcare organizations that create a culture of safety• Study a sample project plan and timeline for implementing a safety programFilled with compelling case studies and practical tools and strategies, this groundbreaking book can be a catalyst for transforming an organization's culture, delivering safer care to patients, and ultimately saving lives. The American College of Healthcare Executives and the Institute for Healthcare Improvement/National Patient Safety Foundation's Lucian Leape Institute (IHI/NPSF LLI) have partnered to collaborate with some of the most progressive healthcare organizations and globally renowned experts in leadership, safety, and culture to develop Leading a Culture of Safety: A Blueprint for Success. This document is an evidence-based, practical resource with tools and proven strategies to help senior leaders in healthcare create a culture of safety—an essential foundation for achieving zero harm. The guide, freely downloadable from the IHI/NPSF website, is an excellent complement to The Safety Playbook. With both high-level strategies and practical tactics, the guide can be used to help determine the current state of an organization's journey, inform dialogue with its board and leadership team, and help its leaders set priorities. Whether an organization is just beginning the journey to a culture of safety or is working to sustain its safety culture, Leading a Culture of Safety can serve as a useful guide for directing efforts and evaluating an organizati

Knapp 20 Jahre nach Erscheinen von „To Err Is Human“ legt das Aktionsbündnis Patientensicherheit e.V. (APS) mit dem „Weißbuch“ eine grundlegende Analyse der Situation und konkrete Forderungen zur Verbesserung der Patientensicherheit vor. Der Autor, Prof. Dr. Matthias Schrappe, war selbst Gründungsvorsitzender des APS und hat nicht nur die theoretischen Grundlagen, die Erhebungsmethodik, die Daten zur Häufigkeit und die ökonomischen Implikationen aufgearbeitet, sondern daraus auch ein innovatives Konzept entwickelt, das als Basis für die weitere praktische Entwicklung und die gesundheitspolitische Bewertung des Themas dienen kann. Die zentrale Botschaft lautet: Mehr Patientensicherheit ist machbar, wenn man die richtigen Methoden zur Verbesserung in Anwendung bringt. Das APS befürwortet eine aktualisierte Agenda für die Patientensicherheit in Deutschland ausdrücklich. Eine konzertierte Aktion, mit der theoretisches Wissen und moralischer Anspruch in konkrete Verbesserungen umgesetzt wird, erscheint unabdingbar.

From the nation's leading experts in healthcare safety—the first comprehensive guide to delivering care that ensures the safety of patients and staff alike.One of the primary tenets among healthcare professionals is, “First, do no harm.” Achieving this goal means ensuring the safety of both patient and caregiver. Every year in the United States alone, an estimated 4.8 million hospital patients suffer serious harm that is preventable. To address this industry-wide problem—and provide evidence-based solutions—a team of award-winning safety specialists from Press Ganey/Healthcare Performance Improvement have applied their decades of experience and research to the subject of patient and workforce safety. Their mission is to achieve zero harm in the healthcare industry, a lofty goal that some hospitals have already accomplished—which you can, too.Combining the latest advances in safety science, data technology, and high reliability solutions, this step-by-step guide shows you how to implement 6 simple principles in your workplace. 1. Commit to the goal of zero harm.2. Become more patient-centric.3. Recognize the interdependency of safety, quality, and patient-centricity.4. Adopt good data and analytics.5. Transform culture and leadership.6. Focus on accountability and execution.In Zero Harm, the world's leading safety experts share practical, day-to-day solutions that combine the latest tools and technologies in healthcare today with the best safety practices from high-risk, yet high-reliability industries, such as aviation, nuclear power, and the United States military. Using these field-tested methods, you can develop new leadership initiatives, educate workers on the universal skills that can save lives, organize and train safety action teams, implement reliability management systems, and create long-term, transformational change. You'll read case studies and success stories from your industry colleagues—and discover the most effective ways to utilize patient data, information sharing, and other up-to-the-minute technologies. It's a complete workplace-ready program that's proven to reduce preventable errors and produce measurable results—by putting the patient, and safety, first.

Leading Reliable Healthcare describes ‘state of the art'healthcare management systems. The key focus of the publication is ‘reliable'; describing how leadership can ensure never less than reliable standards of care for patients and how excellence can be achieved. The focus throughout is on ensuring that patients and their families can depend on a reliable healthcare system for their needs, fulfilling their expectations that hospitals are trustworthy, stable and capable of dealing with their health, from the simplest to the most complex illnesses.Each of the chapters focuses on a different aspect of building a reliable healthcare system, concentrating on the leadership necessary to deliver and manage the different component elements of the healthcare system. The nominated contributors for this book are recognized leaders from various healthcare systems around the globe, including the UK, USA, Canada and South Korea/Singapore. The contributors have been selected to ensure a wide perspective of healthcare management, building on diverse approaches, practices and experiences, and are currently practicing healthcare management in their respective systems. The book aims to focus on the pragmatic rather than theoretical and will provide a series of practical methodologies and case studies to help improve decision making in healthcare management.With contributions by: Sallie J. Weaver, PhD, MHS, Associate Professor, Armstrong Institute for Patient Safety and Quality and Dept. of Anesthesiology & Critical Care Medicine, John Hopkins University School of Medicine Susan Mascitelli, Senior Vice President, Patient Services & Liaison to the Board of Trustees, New York-Presbyterian Hospital Dr. Sandra Fenwick, Chief Executive Officer, Boston Children's Hospital Martin A. Makary, MD, MPH, Professor of Surgery, Johns Hopkins University School of Medicine; Professor of Health Policy and Management, John Hopkins Bloomberg School of Public Health Frank Federico, RPh, Vice President, Institute for Healthcare Improvement Dr. Hanan Edrees, Manager, Quality Management, KAMC-Riyadh Dr. Hee Hwang, CIO and Associate Professor; Seoul National University Bundang Hospital, Department of Pediatrics, Division of pediatric Neurology, Center of Medical Informatics Dr. M. Andrew Padmos, Chief Executive Officer, The Royal College of Physicians and Surgeons of Canada Professor Richard Hobbs, Professor of Primary Care Health Sciences, Director, NIHR English School for Primary Care Research, Nuffield Department of Primary Care Health Sciences, University of Oxford Ms. Jules Martin, Managing Director, Central London Clinical Commissioning Group Dr. Bruno Holthof, Chief Executive Officer, Oxford University Hospitals Tara Donnelly, Chief Executive, Health Innovation Network, South London Göran Henriks, Chief Executive of Learning and Innovation, Qulturum, County Council of Jönköping, Sweden

This book examines the organizational consequences of the recent international preoccupation with managing patient safety in the clinic. Built on presuppositions about failsafe system-design, risk elimination, and human fallibility, the patient safety programme introduces new problems and safety threats in clinical practice by devaluing practical forms of reasoning and the trained safety dispositions of clinicians. Developing a pragmatic and more situated stance on patient safety, Pedersen offers an alternative vocabulary that refocuses attention towards the importance of conduct, habits and experience-based learning in delivering safe care. This innovative book will be of great interest to scholars and practitioners of organization and risk studies, health, science and technology studies and the wider social and medical sciences.

The harm associated with health care is a questionable issue and several systemic global strategies to reduce it with a safer system are being developed. Despite these efforts, errors continue to happen and one of the most important challenges is to become aware of its real dimension and process-occurrence. This book provides new research on patient safety and management. It discusses different perspectives, principles and reviews emerging issues in the medical field.

Adverse events occur in healthcare with worrying and surprising frequency and, of these, a substantial portion are preventable. This highly-readable book, translated and update from the original Dutch edition, presents 15 model case studies which have been carefully designed to explore common themes in medical errors and offer learnings from those events that will guide practice to prevent similar tragedies unfolding in future. Using 15 years of experience working in patient safety, the author makes concrete recommendations around assessment, attitude and performance, and provides a concise and accessible methodology for working safely.

The vast majority of healthcare is provided safely and effectively. However, just like any high-risk industry, things can and do go wrong. There is a world of advice about how to keep people safe but this delivers little in terms of changed practice. Written by a leading expert in the field with over two decades of experience, Rethinking Patient Safety provides readers with a critical reflection upon what it might take to narrow the implementation gap between the evidence base about patient safety and actual practice. This book provides important examples for the many professionals who work in patient safety but are struggling to narrow the gap and make a difference in their current situation.It provides insights on practical actions that can be immediately implemented to improve the safety of patient care in healthcare and provides readers with a different way of thinking in terms of changing behavior and practices as well as processes and systems. Suzette Woodward shares lessons from the science of implementation, campaigning and social movement methods and offers the reader the story of a discovery. Her team has explored an approach which could profoundly affect the safety culture in healthcare; a methodology to help people talk to each other and their patients and to listen through facilitated safety conversations. This is their story.

At a time of increasing regulatory scrutiny and medico-legal risk, managing serious clinical incidents within primary care has never been more important. Failure to manage appropriately can have serious consequences both for service organisations and for individuals involved.This is the first book to provide detailed guidance on how to conduct incident investigations in primary care. The concise guide: explains how to recognise a serious clinical incident, how to conduct a root cause analysis investigation, and how and when duty of candour applies covers the technical aspects of serious incident recognition and report writing includes a wealth of practical advice and'top tips', including how to manage the common pitfalls in writing reports offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. This book offers a master class for anyone performing RCA and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices,'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical are investigated and managed.

Concise, portable, and user-friendly, The Washington Manual® of Patient Safety and Quality Improvement covers essential information in every area of this complex field. With a focus on improving systems and processes, preventing errors, and promoting transparency, this practical reference provides an overview of PS/QI fundamentals, as well as insight into how these principles apply to a variety of clinical settings. Part of the popular Washington Manual® series, this unique volume provides the knowledge and skills necessary for an effective, proactive approach to patient safety and quality improvement.

Dit boek helpt de student bij de ontwikkeling van communicatieve vaardigheden in alle zorgdomeinen. Het boek heeft een evidence based benadering, biedt veel praktijkvoorbeelden en behandelt nieuwe gespreksvaardigheden zoals gezamenlijke besluitvorming en motiverende gespreksvoering. Ook wordt aandacht besteed aan communicatieve vaardigheden specifiek voor bepaalde domeinen zoals de MGZ, GGZ en VGZ en aan interculturele communicatie.

Explore Important Tools for High-Quality Work in Pharmaceutical SafetyStatistical Methods for Drug Safety presents a wide variety of statistical approaches for analyzing pharmacoepidemiologic data. It covers both commonly used techniques, such as proportional reporting ratios for the analysis of spontaneous adverse event reports, and newer approach

Too many Americans die each year as a result of preventable medical error—mistakes, complications, and misdiagnoses. And many more of us are not receiving the best care possible, even though it's readily available and we're entitled to it. The key is knowing how to access it. The Patient's Playbook is a call to action. It will change the way you manage your health and the health of your family, and it will show you how to choose the right doctor, coordinate the best care, and get to the No-Mistake Zone in medical decision making. Leslie D. Michelson has devoted his life's work to helping people achieve superior medical outcomes at every stage of their lives. Michelson presents real-life stories that impart lessons and illuminate his easy-to-follow strategies for navigating complex situations and cases. The Patient's Playbook is an essential guide to the most effective techniques for getting the best from a broken system: sourcing excellent physicians, selecting the right treatment protocols, researching with precision, and structuring the ideal support team. Along the way you will learn: Why having the right primary care physician will change your lifeThree things you can do right now to be better prepared when illness strikesThe ten must-ask questions at the end of a hospital stayHow to protect yourself from unnecessary and dangerous treatmentsWays to avoid the four most common mistakes in the first twenty-four hours of a medical emergency This book will enable you to become a smarter health care consumer—and to replace anxiety with confidence.

Quality and Safety in Anesthesia and Perioperative Care offers practical suggestions for improving quality of care and patient safety in the perioperative setting. Chapters are organized into sections on clinical foundations and practical applications, and emphasize strategies that support reform at all levels, from operating room practices to institutional procedures. Written by leading experts in their fields, chapters are based on accepted safety, human performance, and quality management science and they illustrate the benefits of collaboration between medical professionals and human factors experts. The book highlights concepts such as situation awareness, staff resource management, threat and error management, checklists, explicit practices for monitoring, and safety culture. Quality and Safety in Anesthesia and Perioperative Care is a must-have resource for those preparing for the quality and safety questions on the American Board of Anesthesiology certification examinations, as well as clinicians and trainees in all practice settings.

Medical Device Use Error: Root Cause Analysis offers practical guidance on how to methodically discover and explain the root cause of a use error-a mistake-that occurs when someone uses a medical device. Covering medical devices used in the home and those used in clinical environments, the book presents informative case studies about the use errors

Effective health care requires physicians tailor care to patients'individual life contexts, including their financial situation, social support, competing responsibilities, and cognitive abilities. Physicians, however, are poorly prepared to consider patients'lives when planning their care. The result is measurably harmful to individuals and costly to society. Listening for What Matters: Avoiding Contextual Errors in Health Care covers ten years of empirical research based on hundreds of recorded doctor visits by patients and undercover actors alike, which revealed a widespread disregard of patients'individual circumstances and needs resulting in inappropriate care. These medical errors have been largely undocumented and unaddressed by the American healthcare system. This book tells the stories of patients whose care was compromised by inattention to individual context, and introduces novel methods for assessing the magnitude of the problem. It describes how these errors, termed'contextual errors,'can be minimized through changes in how doctors are trained, how medicine is practiced and quality measured, and in the ways patients assert their needs during visits. The aim of this book is to open a dialog between patients, physicians, policy makers, and medical educators, about a serious quality problem that has been overlooked and understudied.

Clinical Oncology and Error Reduction fills a gap - the lack of a single volume on medical error in the vast field of cancer care - that has existed since a 1999 Institute of Medicine's report introduced the term ‘medical error'as a topic for doctors and patients alike. The volume, edited by Antonella Surbone, M.D., a clinical oncologist and Michael Rowe, Ph.D., a medical sociologist, includes chapters written by experts on the topic including physicians, nurses, patients, and advocates, and covers a wide range of topics essential to an understanding of the unique character, challenges, and needed responses to the risk, incidence, and aftermath of medical error in the diagnosis, treatment, and aftermath of treatment for cancer. Clinical Oncology and Error Reduction will serve as the standard for framing the discussion of error in the field for oncologists, epidemiologists, nurses, healthcare administrators, researchers, and scholars. An indispensable handbook for all clinical oncologists, their staff, nurses, and oncology residents and fellows, this book: Contains practical information for immediate clinical application Covers topics such as patient safety, error prevention, quality improvement, errors disclosure and apology, and the impact of errors on patients and doctors Each chapter contains special'take home'points that highlight issues of particular clinical relevance and application Prepared by an expert, multidisciplinary, international team of physicians, nurses, researchers, hospital administrators, bioethicists, patients and patient advocates Dr. Surbone shared with ASCO Connection her insights about patient safety and medical errors and offered a glimpse into the history that led to this new book:https://connection.asco.org/magazine/features/opening-dialogue-about-medical-errors

Patientinnen und Patienten im stationären und ambulanten Gesundheitswesen erwarten eine interprofessionell organisierte Versorgung in Diagnostik, Therapie und Pflege, die sich am aktuellen Stand von Wissenschaft und Forschung orientiert. Diese Versorgung muss frei von vermeidbaren Risiken und Gefahren erfolgen. Sie erwarten Sicherheit! Das bewährte Buch in seiner 2., vollständig aktualisierten　und erweiterten　Auflage gibt einen umfassenden Überblick über Forschungsergebnisse, Handlungsfelder und Präventionsmaßnahmen für Klinik und Praxis aus interprofessionell klinischer, psychologischer, betriebswirtschaftlicher, IT-technischer sowie juristischer Perspektive. Es orientiert sich dabei am Curriculum der WHO und empfiehlt sich damit als Lehrbuch　zu den Themen Patientensicherheitsmanagement und klinisches Risikomanagement. Der Leser erhält anhand von interdisziplinären Theorie- und Denkansätzen, Anwendungsbeispielen, Checklisten und anderen Instrumenten　Anregungen und Hilfestellung bei der Implementierung von Patientensicherheitsstrategien in den Versorgungsalltag. Ein Autorenteam von über 100 ausgewiesenen Experten hat an diesem Buch mitgewirkt. Die　2. Auflage　bietet einen　umfassenden Überblick über Forschungsergebnisse, Handlungsfelder und anwendbare Präventionsmaßnahmen für Klinik und Praxis und wendet sich an Ärzte, Pflegende, Qualitäts- und Risikomanager sowie Vorstände und Geschäftsführer und nicht zuletzt an die Versicherungswirtschaft.