Closing Death's Door by
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 sucherrors, 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 unflinchingintroduction 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 legalprotections 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 legalpolicies 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 lawmakersand laypeople with an interest in healthcare policy.
High Reliability Organizations by
Nurses represent the majority of healthcare workers and are on the front lines of delivery and provision of safe and effective care. As a result, nurses are ideally situated to drive the mission to achieve high reliability in healthcare. We expect the primary audience of this text to be frontline nursing staff, nurses in administration, quality and patient safety professionals, advanced practice nurses, and nurse educators. The healthcare professional who purchases this book will do so with the desire to learn more about the application of HRO principles to patient safety and quality problems. This book is unique in that it uses HRO principles as an organizing framework for practical application. The intent of the editors is to provide a quality and patient safety book that is useful to professionals doing the work of healthcare. Healthcare professionals are constantly seeking practical tools and descriptions of practices that will improve and enhance patient safety and quality outcomes. High reliability is a current goal for hospitals, and the principles are sound. However, there is little in the literature that discusses how to apply the principles at the front lines of care to improve outcomes. This text addresses this gap by placing the need for high reliability concepts into our current climate in healthcare through illustrative discussion (theory and research) of each of the five concepts of HRO, along with a description of a current best practice and/or tool that applies to the model. The goal of this book is to stimulate organizations to embrace high reliability concepts while striving to improve the quality and safety of care delivered to patients and families. We all benefit from a safer healthcare environment. The book is divided into eight parts: Part 1: This part provides background for the current safety and quality climate. Parts 2-6: These parts offer HRO concepts as a framework for the new model with examples. The first of these HRO concepts is that HROs have a preoccupation with failure. The second of these HRO concepts is that HROs restrain the impulse to view events through a single lens and are reluctant to simplify. The third HRO concept is that HROs demonstrate sensitivity to operations by making strong responses to weak signs. The fourth HRO concept is that HROs shift decision making away from formal authority and apply deference to expertise. The final HRO concept is that HROs have a commitment to resilience. Part 7: This part puts it all together and provides the reader with examples of how HRO concepts are assimilated into practice across the care continuum.Part 8: This part provides the reader with real-world examples of HRO principles employed in a variety of patient care areas. Comprehensive Instructor's Guide and Student Workbook are available for this book.
Human Factors in Healthcare by
Have you ever experienced the burden of an adverse event or a near-miss in healthcare and wished there was a way to mitigate it? This book walks you through a classic adverse event as a case study and shows you how. It is a practical guide to continuously improving your healthcare environment, processes, tools, and ultimate outcomes, through the discipline of human factors. Using this book, you as a healthcare professional can improve patient safety and quality of care. Adverse events are a major concern in healthcare today. As the complexity of healthcare increases-with technological advances and information overload-the field of human factors offers practical approaches to understand the situation, mitigate risk, and improve outcomes. The first part of this book presents a human factors conceptual framework, and the second part offers a systematic, pragmatic approach. Both the framework and the approach are employed to analyze and understand healthcare situations, both proactively-for constant improvement-and reactively-learning from adverse events. This book guides healthcare professionals through the process of mapping the environmental and human factors; assessing them in relation to the tasks each person performs; recognizing how gaps in the fit between human capabilities and the demands of the task in the environment have a ripple effect that increases risk; and drawing conclusions about what types of changes facilitate improvement and mitigate risk, thereby contributing to improved healthcare outcomes.
Making Healthcare Safe: The Story of the Patient Safety Movement by
This unique and engaging open access title provides a compelling and ground-breaking account of the patient safety movement in the United States, told from the perspective of one of its most prominent leaders, and arguably the movement's founder, Lucian L. Leape, MD. Covering the growth of the field from the late 1980s to 2015, Dr. Leape details the developments, actors, organizations, research, and policy-making activities that marked the evolution and major advances of patient safety in this time span. In addition, and perhaps most importantly, this book not only comprehensively details how and why human and systems errors too often occur in the process of providing health care, it also promotes an in-depth understanding of the principles and practices of patient safety, including how they were influenced by today's modern safety sciences and systems theory and design. Indeed, the book emphasizes how the growing awareness of systems-design thinking and the self-education and commitment to improving patient safety, by not only Dr. Leape but a wide range of other clinicians and health executives from both the private and public sectors, all converged to drive forward the patient safety movement in the US. Making Healthcare Safe is divided into four parts: I. In the Beginning describes the research and theory that defined patient safety and the early initiatives to enhance it. II. Institutional Responses tells the stories of the efforts of the major organizations that began to apply the new concepts and make patient safety a reality. Most of these stories have not been previously told, so this account becomes their histories as well. III. Getting to Work provides in-depth analyses of four key issues that cut across disciplinary lines impacting patient safety which required special attention. IV. Creating a Culture of Safety looks to the future, marshalling the best thinking about what it will take to achieve the safe care we all deserve. Captivatingly written with an "insider's" tone and a major contribution to the clinical literature, this title will be of immense value to health care professionals, to students in a range of academic disciplines, to medical trainees, to health administrators, to policymakers and even to lay readers with an interest in patient safety and in the critical quest to create safe care.
Mclaughlin and Kaluzny's Continuous Quality Improvement in Health Care by Patient Safety and Quality Improvement in Healthcare by
This text uses a case-based approach to share knowledge and techniques on how to operationalize much of the theoretical underpinnings of hospital quality and safety. Written and edited by leaders in healthcare, education, and engineering, these 22 chapters provide insights as to where the field of improvement and safety science is with regards to the views and aspirations of healthcare advocates and patients. Each chapter also includes vignettes to further solidify the theoretical underpinnings and drive home learning. End of chapter commentary by the editors highlight important concepts and connections between various chapters in the text. Patient Safety and Quality Improvement in Healthcare: A Case-Based Approach presents a novel approach towards hospital safety and quality with the goal to help healthcare providers reach zero harm within their organizations.
The Quality Improvement Challenge by
Efforts to improve the quality of healthcare have failed to achieve a meaningful and sustainable improvement. Patients continue to experience fragmented, inconvenient, and unsafe care while providers are increasingly becoming overburdened with administrative tasks. The need for change is clear. Healthcare professionals need to take on new leadership roles in quality improvement (QI) projects to effect real change. The Quality Improvement Challenge in Healthcare equips readers with the skills and knowledge required to develop and implement successful operational improvement initiatives. Designed for healthcare providers seeking to apply QI in practice, this valuable resource delivers step-by-step guidance on improvement methodology, team dynamics, and organizational change management in the context of real-world healthcare environments. The text integrates the principles and practices of Lean Six Sigma, human-centered design, and neurosciences to present a field-tested framework. Detailed yet accessible chapters cover topics including identifying and prioritizing the problem, developing improvement ideas, defining the scope of the project, organizing the QI team, implementing and sustaining the improvement, and much more. Clearly explaining each step of the improvement process, this practical guide: Presents the material in a logical sequence, gradually introducing each step of the process with clearly defined workflow templates Features a wealth of examples demonstrating QI application, and case studies emphasizing key concepts to highlight successful and unsuccessful improvement initiatives Includes end-of-chapter exercises and review questions for assessing and reinforcing comprehension Offers practical tips and advice on communicating effectively, leading a team meeting, conducting a tollgate review, and motivating people to change Leading QI projects requires a specific set of skills not taught in medical school. The Quality Improvement Challenge in Healthcare bridges this gap for experienced and trainee healthcare providers, and serves as an important reference for residency program directors, physician educators, healthcare leaders, and health-related professional organizations.
Rethinking Patient Safety by
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 Safetyprovides 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.
Understanding Patient Safety, 3rd edition by
Understanding Patient Safety is must read for those seeking to master the clinical, organizational, and systems issues of patient safety. In this bestselling primer, patient safety pioneer Robert Wachter and Kiran Gupta put all the essential tools and principles at your fingertips. Engaging and accessible, the book is filled with high-yield cases, analyses, tables, graphics, along with key points and referencesall designed to help you optimize quality and safety.
Writing to Improve Healthcare: An Author's Guide to Publication by
This new book is a 'what and how to' guide to writing for successful scholarly publication in the emerging fields of healthcare improvement and patient safety. While there are many useful authors¿ aids for scholarly biomedical publication, none focuses explicitly on these relatively new fields. It offers practical advice that includes preparation and organization of a scholarly healthcare improvement manuscript, where to submit it to find the most likely interested editor and journal, how to take full advantage of coauthors¿ working together effectively, and strategies for authors to reach a broader health professions readership.