The Value Of Close Calls In Improving Patient Safety

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

"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/

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.

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

Drawing on the findings of a series of empirical studies undertaken with boards of directors and CEOs in the United States, this groundbreaking book develops a new paradigm to provide a structured analysis of ethical healthcare governance. Governance Ethics in Healthcare Organizations begins by presenting a clear framework for ethical analysis, designed around basic features of ethics – who we are, how we function, and what we do – before discussing the paradigm in relation to clinical, organizational and professional ethics. It goes on to apply this framework in areas that are pivotal for effective governance in healthcare: oversight structures for trustees and executives, community benefit, community health, patient care, patient safety and conflicted collaborative arrangements. This book is an important read for all those interested in healthcare management, corporate governance and healthcare ethics, including academics, students and practitioners.

After heart disease and cancer, the third leading cause of death in the United States is iatrogenic injury (avoidable injury or infection caused by a healer). Research suggests that avoidable errors claim several hundred thousand lives every year. The principal economic counterforce to such errors, malpractice litigation, has never been a particularly effective deterrent for a host of reasons, with fewer than 3% of negligently injured patients (or their families) receiving any compensation from a doctor or hospital's insurer. Closing Death's Door brings the psychology of decision making together with the law to explore ways to improve patient safety and reduce iatrogenic injury, when neither the healthcare industry itself nor the legal system has made a substantial dent in the problem. Beginning with an unflinching introduction to the problem of patient safety, the authors go on to define iatrogenic injury and its scope, shedding light on the culture and structure of a healthcare industry that has failed to effectively address the problem-and indeed that has influenced legislation to weaken existing legal protections and impede the adoption of potentially promising reforms. Examining the weak points in existing systems with an eye to using law to more effectively bring about improvement, the authors conclude by offering a set of ideas intended to start a conversation that will lead to new legal policies that lower the risk of harm to patients. Closing Death's Door is brought to vivid life by the stories of individuals and groups that have played leading roles in the nation's struggle with iatrogenic injury, and is essential reading for medical and legal professionals, as well as lawmakers and laypeople with an interest in healthcare policy.

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.

This case studies book is an indispensable resource for educators, students, and practitioners of nursing. It is innovative in its application of lessons from the communication sciences to common challenges in the delivery of safe patient care. The authors apply basic tenets of human communication to the context of nursing to provide a foundation for practices that can advance the safety and quality of care. The cases, which describe "close calls" and adverse events, are organized along the continuum of healthcare delivery, providing quick access to solutions in commonly encountered care situations. Each case is accompanied by a discussion of how skillful communication can be key to preventing and recovering from errors and adverse events. Thought-provoking discussion questions and references for further reading make this book a valuable reference for nursing educators, students, and practitioners across the world.