Practical patient safety:
Saved in:
| Main Authors: | , , |
|---|---|
| Format: | Book |
| Language: | English |
| Published: |
Oxford
Oxford Univ. Press
2009
|
| Edition: | 1. publ. |
| Subjects: | |
| Online Access: | Inhaltsverzeichnis |
| Physical Description: | XVIII, 304 S. Ill., graph. Darst. |
| ISBN: | 9780199239931 0199239932 |
Staff View
MARC
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| 100 | 1 | |a Reynard, John |e Verfasser |4 aut | |
| 245 | 1 | 0 | |a Practical patient safety |c by John Reynard ; John Reynolds ; Peter Stevenson |
| 250 | |a 1. publ. | ||
| 264 | 1 | |a Oxford |b Oxford Univ. Press |c 2009 | |
| 300 | |a XVIII, 304 S. |b Ill., graph. Darst. | ||
| 336 | |b txt |2 rdacontent | ||
| 337 | |b n |2 rdamedia | ||
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| 650 | 4 | |a Medical Errors |x prevention & control | |
| 650 | 4 | |a Medical errors |x Prevention | |
| 650 | 4 | |a Organizational Culture | |
| 650 | 4 | |a Patient Care |x methods | |
| 650 | 4 | |a Patients |x Safety measures | |
| 650 | 4 | |a Safety Management | |
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| 700 | 1 | |a Reynolds, John |e Verfasser |4 aut | |
| 700 | 1 | |a Stevenson, Peter |e Verfasser |4 aut | |
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Record in the Search Index
| _version_ | 1804140767034212352 |
|---|---|
| adam_text | Contents
Preface
vii
Acknowledgements
xiii
1
Clinical error: the scale of the problem
1
The Harvard Medical Practice Study
1984 2
The Quality in Australian Healthcare Study
1992 3
The University College London Study
2001 4
Danish, New Zealand, Canadian, and French studies
4
The frequency and costs of adverse drug events
4
Accuracy of retrospective studies
6
Error rates revealed in retrospective studies are of the same order of
magnitude as those found in observational studies
7
Error rates according to type of clinical activity
7
Deaths from adverse events
9
Extra bed days as a consequence of error
10
Criminal prosecutions for medical errors
12
Reliability: other industries
12
Reliability: healthcare
12
References
13
2
Clinical errors: What are they?
15
Sources of error in primary care and office practice
15
Sources of error along the patient pathway in hospital care and
potential methods of error prevention
16
Errors in dealing with referral letters
16
Errors of identification
17
Errors in note keeping
26
Errors with medical records in general
26
Other slips in letters that you have dictated
27
Errors as a consequence of patients failing to attend appointments for
investigations
от
for outpatient consultations
28
Washing your hands between patients and attention to
infection control
28
Admission to hospital
32
Diagnostic errors in general
32
xvi
CONTENTS
Errors in drug prescribing and administration
36
Reducing errors in blood transfusion
45
Intravenous drug administration
46
Errors in the operating theatre
47
The use of diathermy
48
Harm related to patient positioning
49
Leg supports that give way
52
Generic safety checks prior to any surgical procedure
52
Failure to give DVT prophylaxis
53
Failure to give antibiotic prophylaxis
53
Errors in the postoperative period
54
Shared care
55
Medical devices
55
References
62
3
Safety culture in high reliability organizations
65
High reliability organizations: background
65
High reliability organizations: common features
68
The consequences of failure
69
Convergent evolution and its implication for
healthcare
71
Learning from accidents: overview of basic high reliability
organizational culture
72
Elements of the safety culture
72
Counter-intuitive aspects of high reliability organization
safety culture
78
References
S3
4
Casestudies
85
Casestudy
1:
wrong patient
87
Case study
2:
wrong blood
88
Case study
3:
wrong side nephrectomy
89
Case study
4:
another wrong side nephrectomy
90
Case study
5:
yet another wrong side nephrectomy case
93
Case study
6:
medication error
—
wrong route
(intrathecal vincristine)
94
Case study
7:
another medication error
—
wrong route
(intrathecal vincristine)
97
Case study
8:
medication error
—
wrong route
(intrathecal vincristine)
98
Case study
9:
medication error—miscalculation of dose
100
CONTENTS XVÜ
Case study
10:
medication error
—
frequency of administration
mis-prescribed as daily instead of weekly
101
Case study
11:
medication error
—
wrong drug
202
Case study
12:
miscomrmmication of path lab result
103
Case study
13:
biopsy results for two patients mixed up
105
Case study
14:
penicillin allergy death
107
Case study
15:
missing X-ray report
107
Case study
16:
medication not given
108
Case study
17:
oesophageal intubation
109
Case study
18:
tiredness error
109
Case study
19:
inadequate training
110
Case study
20:
patient fatality
—
anaesthetist fell asleep
112
References
113
5
Error management
115
How accidents happen: the person approach versus the
systems approach
115
Error chains
117
System failures
119
Catalyst events
121
Human error
123
Error classification
124
How experts and novices solve problems
126
Three error management opportunities
130
Detecting and reversing incipient adverse events in real time:
Red flags
134
Red flags: the symptoms and signs of evolving error chains
135
Speaking up protocols
141
Error management using accident and incident data
144
References
148
6
Communication failure
149
The prevalence of communication failures in adverse events in
healthcare
150
Communication failure categories
153
Whose fault: message sender or receiver?
165
Safety-critical communications (SCC) protocols
166
How to prevent communication errors in specific healthcare
situations
180
Composing an abnormal (non-routine)
safety-critical message
191
xviii CONTENTS
Written communication/documentation
communication failures
197
References
198
7
Situation awareness
201
Situation awareness: definitions
202
Three levels of situation awareness
202
Catastrophic loss of situation awareness and the associated syndrome:
mind lock
203
Understanding loss of situation awareness
207
Cognitive failures: the role of mental models/the psychology of
mistakes
207
Mental models: the problems
208
Ensuring high situation awareness
213
Two special cases involving loss of situation awareness
220
References
244
8
Professional culture
247
Similarities between two professions
247
Negative aspects of professional cultures
248
Steep hierarchy
248
Changing the pilots professional culture
250
Team resource management/non-technical skills
256
References
262
9
When carers deliberately cause harm
263
References
265
10
Patient safety toolbox
267
Practical ways to enhance the safety of your patients
267
11
Conclusions
271
Glossary
275
Appendices
285
Appendix
1:
Initiating a safety-critical (verbal) communication
(STAR)
285
Appendix
2:
1-SBAR
—
to describe a (deteriorating) patient s
condition
286
Appendix
3:
General patient safety tools
287
Appendix
4:
Red iags (the symptoms and signs of an
impending error)
289
Index
291
|
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| discipline | Medizin |
| edition | 1. publ. |
| format | Book |
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| illustrated | Illustrated |
| indexdate | 2024-07-09T22:05:12Z |
| institution | BVB |
| isbn | 9780199239931 0199239932 |
| language | English |
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| physical | XVIII, 304 S. Ill., graph. Darst. |
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| spelling | Reynard, John Verfasser aut Practical patient safety by John Reynard ; John Reynolds ; Peter Stevenson 1. publ. Oxford Oxford Univ. Press 2009 XVIII, 304 S. Ill., graph. Darst. txt rdacontent n rdamedia nc rdacarrier Medical Errors prevention & control Medical errors Prevention Organizational Culture Patient Care methods Patients Safety measures Safety Management Ärztlicher Kunstfehler (DE-588)4000617-7 gnd rswk-swf Ärztlicher Kunstfehler (DE-588)4000617-7 s DE-604 Reynolds, John Verfasser aut Stevenson, Peter Verfasser aut Digitalisierung UB Regensburg application/pdf http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=018673020&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA Inhaltsverzeichnis |
| spellingShingle | Reynard, John Reynolds, John Stevenson, Peter Practical patient safety Medical Errors prevention & control Medical errors Prevention Organizational Culture Patient Care methods Patients Safety measures Safety Management Ärztlicher Kunstfehler (DE-588)4000617-7 gnd |
| subject_GND | (DE-588)4000617-7 |
| title | Practical patient safety |
| title_auth | Practical patient safety |
| title_exact_search | Practical patient safety |
| title_full | Practical patient safety by John Reynard ; John Reynolds ; Peter Stevenson |
| title_fullStr | Practical patient safety by John Reynard ; John Reynolds ; Peter Stevenson |
| title_full_unstemmed | Practical patient safety by John Reynard ; John Reynolds ; Peter Stevenson |
| title_short | Practical patient safety |
| title_sort | practical patient safety |
| topic | Medical Errors prevention & control Medical errors Prevention Organizational Culture Patient Care methods Patients Safety measures Safety Management Ärztlicher Kunstfehler (DE-588)4000617-7 gnd |
| topic_facet | Medical Errors prevention & control Medical errors Prevention Organizational Culture Patient Care methods Patients Safety measures Safety Management Ärztlicher Kunstfehler |
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