Error reduction in health care: a systems approach to improving patient safety
Gespeichert in:
| Format: | Buch |
|---|---|
| Sprache: | English |
| Veröffentlicht: |
San Francisco
Jossey-Bass
2000
|
| Schlagworte: | |
| Online-Zugang: | Inhaltsverzeichnis |
| Beschreibung: | XXXI, 284 S. graph. Darst. |
| ISBN: | 0787955965 |
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| 650 | 4 | |a Health Facilities | |
| 650 | 4 | |a Health facilities |x Risk management | |
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| 650 | 4 | |a Medical errors |x Prevention | |
| 650 | 4 | |a Risk Management | |
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Datensatz im Suchindex
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|---|---|
| adam_text | Contents
List of Figures and Tables vii
About the Editor xi
About the Contributors xiii
Foreword xxi
Preface xxv
Acknowledgments xxxi
CHAPTER 1 A Formula for Errors: Good People +
Bad Systems 1
Susan McClanahan, RN, BSN,
Susan T. Goodwin, RN, MSN, and Frank Houser, MD
CHAPTER 2 Measuring Performance of High Risk Processes 17
Karen Ferraco and Patrice L. Spath, BA, ART
CHAPTER 3 __
The Human Side of Medical Mistakes 97
Sven Ternov, MD
CHAPTER 4 Accident Investigation and Anticipatory Failure
Analysis in Hospitals 139
Sanford E. Feldman, MD, FACS,
and Douglas W. Roblin, PhD
CHAPTER 5 Automating Root Cause Analysis 155
Robert J. Latino
v
Vi CONTENTS
CHAPTER 6 One Hospital s View of Software Facilitation
of Root Cause Analysis 165
Kenneth A. Hirsch, MD, PhD,
and Dennis T. Wallace, DABRM
CHAPTER 7 Proactively Error Proofing Health Care Processes 179
Richard J. Croteau, MD, and Paul M. Schyve, MD
CHAPTER 8 Reducing Errors through Work System Improvements 199
Patrice L. Spath, BA, ART
CHAPTER 9 A Structured Teamwork System to Reduce
Clinical Errors 235
Daniel T. Risser, PhD, Robert Simon, MEd, EdD,
Matthew M. Rice, MD, JD, FACEP,
and Mary L. Salisbury, RN, MSN
Index 279
List of Figures and Tables
Figures
2 1 Activities That Must Be Regularly Evaluated in Health Care
Organizations Accredited by the Joint Commission 22
2 2 General Risk Related Performance Measures 27
2 3 Examples of Performance Measures for Safety Critical Tasks
in Major Patient Care Functions 33
2A Sample Hospital Incident Report 39
2 5 Definitions for Common Reportable Incidents 42
2 6 Sample Aggregate Incident Report for a Hospital 45
2 7 Occurrence Report 46
2 8 Taxonomy of Medication Errors Recommended
by the National Coordinating Council for Medication Error
Reporting and Prevention, United States Pharmacopeia 51
2 9 Patient Encounter Worksheet 70
2 10 Percentage of Children Overdue for Routine Immunizations
at Quarterly Intervals (July 1993 to April 1994) 71
2 11 Percentage of Patient Incidents That Did Not Result
in Discomfort, Infection, Pain, or Harm to the Patient 77
2 12 Control Chart Prototype 78
2 13 Clinical Profile 81
3 1 Typical Questions Asked during a Medical Accident
Investigation 112
3 2 Typical Medical Accident Trajectory 113
vil
Viii LIST OF FIGURES AND TABLES
3 3 Steps of the MTO Analysis 120
3 4 Training and Support of the Team in MTO Analysis 121
4 1 Root Cause Analysis Results of the Death of a Patient
Following Blood Transfusion (Case #1) 147
4 2 Retrospective Root Cause Analysis of Serious Disability
Following Elective Arthroscopic Knee Surgery (Case #2) 148
7 1 Levels of Analysis 183
7 2 A Checklist for Proactive Risk Reduction Activities 196
8 1 Work System Improvement Principles 204
8 2 Physicians Order Sheet 206
8 3 Patients Role in Medication Usage 213
8 4 Sample Family Education Guide for Infant Security 214
8 5 Strategies to Help Reduce the Risk
of Restraint Related Deaths 217
8 6 Tips for Reducing Medication Errors
in the Physician s Office 221
9 1 Most Frequent Teamwork Errors 240
9 2 Care Resources Managed by the ED Core Team 243
9 3 The Interrelationships of the Five Team Dimensions 246
9 4 The Teamwork Check Cycle 251
9 5 Teamwork Failure Checklist 254
9 6 Individual Claim Assessment Process 257
9 7 Example of Completed Teamwork Failure Checklist 261
9 8 Senior Leader Actions Necessary to Support
Teamwork Implementation 269
9 9 Teamwork System Implementation 271
LIST OF FIGURES AND TABLES JX
Tables
2 1 Task Criticality Scoring System for the Process
of Warfarin Administration 32
2 2 ICD 9 CM Codes for Fetal Complications/Birth Injuries 67
2 3 Error Management Report for the High Risk Activity
of Medication Usage 75
3 1 Example of a Blank MTO Diagram 124
3 2 Taxonomy of Contributing Causes 127
3 3 Example of a Schematic Diagram from an MTO Analysis.... 129
6 1 Matrix to Use in Setting Priorities
for RCA Software Features 176
7 1 Probability of Success in a Process 185
9 1 Team Characteristics 245
9 2 Teamwork Behavior Matrix 248
9 3 Potential Uses of Teamwork Failure Checklist Findings 266
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| isbn | 0787955965 |
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| spelling | Error reduction in health care a systems approach to improving patient safety Patrice L. Spath San Francisco Jossey-Bass 2000 XXXI, 284 S. graph. Darst. txt rdacontent n rdamedia nc rdacarrier Health Facilities Health facilities Risk management Medical Errors Medical errors Prevention Risk Management Spath, Patrice L. Sonstige oth HBZ Datenaustausch application/pdf http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=009768600&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA Inhaltsverzeichnis |
| spellingShingle | Error reduction in health care a systems approach to improving patient safety Health Facilities Health facilities Risk management Medical Errors Medical errors Prevention Risk Management |
| title | Error reduction in health care a systems approach to improving patient safety |
| title_auth | Error reduction in health care a systems approach to improving patient safety |
| title_exact_search | Error reduction in health care a systems approach to improving patient safety |
| title_full | Error reduction in health care a systems approach to improving patient safety Patrice L. Spath |
| title_fullStr | Error reduction in health care a systems approach to improving patient safety Patrice L. Spath |
| title_full_unstemmed | Error reduction in health care a systems approach to improving patient safety Patrice L. Spath |
| title_short | Error reduction in health care |
| title_sort | error reduction in health care a systems approach to improving patient safety |
| title_sub | a systems approach to improving patient safety |
| topic | Health Facilities Health facilities Risk management Medical Errors Medical errors Prevention Risk Management |
| topic_facet | Health Facilities Health facilities Risk management Medical Errors Medical errors Prevention Risk Management |
| url | http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=009768600&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA |
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