Error Reduction in Health Care: A Systems Approach to Improving Patient Safety / Edition 2

by Patrice L. Spath

Overview

Error Reduction in Health Care

Completely revised and updated, this second edition of Error Reduction in Health Care offers a step-by-step guide for implementing the recommendations of the Institute of Medicine to reduce the frequency of errors in health care services and to mitigate the impact of errors when they do occur.

With contributions from noted leaders in health safety, Error Reduction in Health Care provides information on analyzing accidents and shows how systematic methods can be used to understand hazards before accidents occur. In the chapters, authors explore how to prioritize risks to accurately focus efforts in a systems redesign, including performance measures and human factors.

This expanded edition covers contemporary material on innovative patient safety topics such as applying Lean principles to reduce mistakes, opportunity analysis, deductive adverse event investigation, improving safety through collaboration with patients and families, using technology for patient safety improvements, medication safety, and high reliability organizations.

The Editor

Product Details

ISBN-13:	9780470502402
Publisher:	Wiley
Publication date:	04/12/2011
Edition description:	2nd Secondtion ed.
Pages:	416
Product dimensions:	7.00(w) x 9.20(h) x 1.00(d)

About the Author

Patrice L. Spath, MA, RHIT, is president of Brown-Spath & Associates and assistant professor in the Department of Health Services Administration at the University of Alabama in Birmingham. She serves on the advisory board for WebM&M, an online case-based journal and forum on patient safety and health care quality sponsored by the Agency for Healthcare Research and Quality. Spath has authored numerous books and journal articles on health care performance improvement and patient safety.

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Table of Contents

Figures, Tables, and Exhibits v

Foreword ix
Lucian L. Leape

Preface xi

The Editor xvii

The Authors xix

PART ONE: The Basics of Patient Safety

Chapter 1 A Formula for Errors: Good People + Bad Systems 3
Susan McClanahan, Susan T. Goodwin, and Jonathan B. Perlin

Chapter 2 The Human Side of Medical Mistakes 21
Sven Ternov

Chapter 3 High Reliability and Patient Safety 35
Yosef D. Dlugacz and Patrice L. Spath

PART TWO: Measure and Evaluate Patient Safety

Chapter 4 Measuring Patient Safety Performance 59
Karen Ferraco and Patrice L. Spath

Chapter 5 Analyzing Patient Safety Performance 103
Karen Ferraco and Patrice L. Spath

Chapter 6 Using Performance Data to Prioritize Safety Improvement Projects 119
Robert Latino

PART THREE: Reactive and Proactive Safety Investigations

Chapter 7 Accident Investigation and Anticipatory Failure Analysis 143
Sanford E. Feldman and Douglas W. Roblin

Chapter 8 MTO and DEB Analysis Can Find System Breakdowns 157
Sven Ternov

Chapter 9 Using Deductive Analysis to Examine Adverse Events 171
Robert Latino

PART FOUR: How to Make Health Care Processes Safer

Chapter 10 Proactively Error-Proofing Health Care Processes 197
Richard J. Croteau and Paul M. Schyve

Chapter 11 Reducing Errors Through Work System Improvements 217
Patrice L. Spath

Chapter 12 Improve Patient Safety with Lean Techniques 245
Danielle Lavallee

PART FIVE: Focused Patient Safety Initiatives

Chapter 13 How Information Technology Can Improve Patient Safety 269
Donna J. Slovensky and Nir Menachemi

Chapter 14 A Structured Teamwork System to Reduce Clinical Errors 297
Daniel T. Risser, Robert Simon, Matthew M. Rice, Mary L. Salisbury, and John C. Morey

Chapter 15 Medication Safety Improvement 335
Yosef D. Dlugacz

Glossary 369

Index 383

What People are Saying About This

Donald M. Berwick

Error Reduction in Health Care explores the complex causes of medical mistakes and offers sound advice for leaders who want to reduce the frequency of errors in health care services and mitigate the impact of those errors that do occur. The book is packed pull of examples of thorough incident investigations and process improvement recommendations from leaders in the field of health care quality and risk management. Reducing errors is rightly becoming a higher and higher priority in the health care world, and this book will help committed clinicians and administrators make progress toward the goal. (Donald M. Berwick, president and CEO, Institute for Healthcare Improvement)

Paula S. Swain

Error Reduction in Health Care provides a clear focus on issues that make a difference to patients and health care providers. Every improvement program needs to consider this book as essential in continuous improvement training. (Paula S. Swain, Swain and Associates, Healthcare Accreditation and Compliance Specialists)

Michael L. Millenson

This book, with its step-by-step guide to operationalizing error reduction, is a must-read for hospital administrators, senior medical staff, and conscientious board members. (Michael L. Millenson, principal, William M. Mercer, Inc.. and author of Demanding Medical Excellence: Doctors and Accountability in the Information Age)

Susan Anderson

A timely gathering of distinguished authors to guide health care professionals through the mazes of error investigation and reduction strategies. A must read for those of us responsible for adverse event review processes. (Susan Anderson, Risk Management Consultant, University of Michigan Health System)

Editorial Reviews

5 Stars! from Doody

This is one of the first comprehensive references available since the release of the Institute of Medicine Report. The full spectrum of patient safety management is covered, from the prospective identification and evaluation of hazardous situations through error reporting and analysis. This text contains easily applied strategies for error reduction across the continuum of healthcare. The editor aims to detail essential information on the subject matter as well as offer both reactive and proactive methods of patient safety improvement. The content exceeds the reader's expectations and the text is a worthy reference in a climate of growing national attention. Its scope constitutes mandatory reading for executive and middle managers, as well as quality assurance and risk management professionals and physician leaders. The distinguished contributors bring unsurpassed expertise from a variety of sources, both inside and outside of healthcare. This valuable effort, according to the editor, is written for healthcare professionals. The information presented can be easily and practically applied to almost any healthcare setting and provides a step-by-step guide to operationalize a variety of patient safety initiatives. The concepts of latent errors, situational factors, and defective system barriers are clearly addressed. The chapter on automating root cause analysis will catch the attention of any quality assessment professional and provides practical options for error analysis. The review of proven error reduction techniques in the areas of medication administration, patient assessment, and use of restraints provide immediately useful approaches. As the healthcare industry struggleswith a less than favorable public perception, the editor of this publication provides not only a theoretical framework to gain an understanding of the nature of error, but also outlines useful, practical, proven strategies for beginning a patient safety initiative in any healthcare organization. This is one of the first comprehensive references available since the subject has gained national attention.

Catherine J. Buck

On November 30, 1999, the Institute of Medicine reported that as many as 98,000 patients die each year because of medical errors, igniting growing concern about patient safety in hospitals. This book is a timely and well thought-out response....The current public demand for change comes at the risk of increased medical-legal liability and potentially onerous bureaucracy. But it also offers an enormous opportunity to improve our ability as physicians to provide excellent, error-free care to our patients. This book offers a constructive and proactive means to that end.

Journal of the American Medical Association

Doctors, nurses, and professionals in risk management and quality control, examine the causes of medical mistakes and offer advice for reducing the frequency of errors in health care services based on systems theory and a non-punitive reporting structure. Articles cover topics such as the human side of medical mistakes, automating root cause analysis, error-proofing health care processes, and using a structured teamwork system to reduce clinical errors. Annotation c. Book News, Inc., Portland, OR (booknews.com)

Booknews

Reviewer: Catherine J. Buck, RN, MSN (Froedtert Hospital)
Description: This is one of the first comprehensive references available since the release of the Institute of Medicine Report. The full spectrum of patient safety management is covered, from the prospective identification and evaluation of hazardous situations through error reporting and analysis. This text contains easily applied strategies for error reduction across the continuum of healthcare.
Purpose: The editor aims to detail essential information on the subject matter as well as offer both reactive and proactive methods of patient safety improvement. The content exceeds the reader's expectations and the text is a worthy reference in a climate of growing national attention. Its scope constitutes mandatory reading for executive and middle managers, as well as quality assurance and risk management professionals and physician leaders. The distinguished contributors bring unsurpassed expertise from a variety of sources, both inside and outside of healthcare.
Audience: This valuable effort, according to the editor, is written for healthcare professionals.
Features: The information presented can be easily and practically applied to almost any healthcare setting and provides a step-by-step guide to operationalize a variety of patient safety initiatives. The concepts of latent errors, situational factors, and defective system barriers are clearly addressed. The chapter on automating root cause analysis will catch the attention of any quality assessment professional and provides practical options for error analysis. The review of proven error reduction techniques in the areas of medication administration, patient assessment, and use of restraints provide immediately useful approaches.
Assessment: As the healthcare industry struggles with a less than favorable public perception, the editor of this publication provides not only a theoretical framework to gain an understanding of the nature of error, but also outlines useful, practical, proven strategies for beginning a patient safety initiative in any healthcare organization. This is one of the first comprehensive references available since the subject has gained national attention.

Doody's Review Service