New Search Search History

Holdings Information

Action Navigation

Action Box More Info Navigation

    Action Box

    Understanding patient safety / Robert M. Wachter, Kiran Gupta.

    Bibliographic Record Display

    • Title:Understanding patient safety / Robert M. Wachter, Kiran Gupta.
    •    
    • Author/Creator:Wachter, Robert M., author.
    • Other Contributors/Collections:Gupta, Kiran, author.
    • Published/Created:New York : McGraw-Hill Education, [2018]

    • Holdings

      Holdings Record Display

       
    • Library of Congress Subjects:Medical errors--Prevention.
      Patients--Safety measures.
      Medicine--Practice--Safety measures.
    • Medical Subjects: Medical Errors--prevention & control.
      Patient Safety.
      Safety Management--methods.
    • Edition:Third edition.
    • Description:xviii, 510 pages ; 24 cm
    • Summary:"This book begins with an introduction to patient safety and medical errors. Its second section surveys specific types of medical errors, including those related to surgery, medications, diagnosis, transition and handoff, and infections. The third edition reflects pivotal new developments in the field, including major updates in diagnostic errors, information technology and patient safety, ambulatory safety, and clinician burnout."--Publisher.
    • Notes:Includes bibliographical references and index.
    • ISBN:9781259860249 paperback ; alkaline paper
      1259860248 paperback ; alkaline paper
      9781259860256 Ebook
      1259860256 Ebook
    • Contents:Machine generated contents note: ch. 1 Nature and Frequency of Medical Errors and Adverse Events
      Adverse Events, Preventable Adverse Events, and Errors
      Challenges of Measuring Errors and Safety
      Frequency and Impact of Errors
      References and Additional Readings
      ch. 2 Basic Principles of Patient Safety
      Modern Approach to Patient Safety: Systems Thinking and the Swiss Cheese Model
      Errors at the Sharp End: Slips Versus Mistakes
      Complexity Theory and Complex Adaptive Systems
      General Principles of Patient Safety Improvement Strategies
      References and Additional Readings
      ch. 3 Safety, Quality, and Value
      What is Quality?
      Epidemiology of Quality Problems
      Catalysts for Quality Improvement
      Changing Quality Landscape
      Quality Improvement Strategies
      Commonalities and Differences Between Quality and Patient Safety
      Value: Connecting Quality (and Safety) to the Cost of Care
      References and Additional Readings
      ch. 4 Medication Errors
      Some Basic Concepts, Terms, and Epidemiology
      Strategies to Decrease Medication Errors
      References and Additional Readings
      ch. 5 Surgical Errors
      Some Basic Concepts and Terms
      Volume-Outcome Relationships
      Patient Safety in Anesthesia
      Wrong-Site/Wrong-Patient Surgery
      Retained Sponges and Instruments
      Surgical Fires
      Safety in Nonsurgical Bedside Procedures
      References and Additional Readings
      ch. 6 Diagnostic Errors
      Some Basic Concepts and Terms
      Missed Myocardial Infarction:A Classic Diagnostic Error
      Cognitive Errors: Iterative Hypothesis Testing, Bayesian Reasoning, and Heuristics
      Improving Diagnostic Reasoning
      System, Communication, and Information Flow Issues in Diagnostic Errors
      Overdiagnosis
      Policy Context for Diagnostic Errors
      References and Additional Readings
      ch. 7 Human Factors and Errors at the Person-Machine Interface
      Introduction
      Human Factors Engineering
      Usability Testing and Heuristic Analysis
      Applying Human Factors Engineering Principles
      References and Additional Readings
      ch. 8 Transition and Handoff Errors
      Some Basic Concepts and Terms
      Best Practices for Person-to-Person Handoffs
      Site-to-Site Handoffs: The Role of the System
      Best Practices for Site-to-Site Handoffs other than Hospital Discharge
      Preventing Readmissions: Best Practices for Hospital Discharge
      References and Additional Readings
      ch. 9 Teamwork and Communication Errors
      Some Basic Concepts and Terms
      Role of Teamwork in Healthcare
      Fixed Versus Fluid Teams
      Teamwork and Communication Strategies
      References and Additional Readings
      ch. 10 Healthcare-Associated Infections
      General Concepts and Epidemiology
      Surgical Site Infections
      Ventilator-Associated Pneumonia
      Central Line-Associated Bloodstream Infections
      Catheter-Associated Urinary Tract Infections
      Methicillin-Resistant S. Aureus Infection
      C. Difficile Infection
      What Can Patient Safety Learn from the Approach to Hospital-Associated Infections?
      References and Additional Readings
      ch. 11 Other Complications of Healthcare
      General Concepts
      Preventing Venous Thromboembolism
      Preventing Pressure Ulcers
      Preventing Falls
      Preventing Delirium
      References and Additional Readings
      ch. 12 Patient Safety in the Ambulatory Setting
      General Concepts and Epidemiology
      Hospital Versus Ambulatory Environments
      Improving Ambulatory Safety
      References and Additional Readings
      ch. 13 Information Technology
      Healthcare's Information Problem
      Electronic Health Records
      Computerized Provider Order Entry
      IT Safety Solutions to Improve Medication Safety
      IT Solutions for Improving Communication and Access
      Computerized Clinical Decision Support Systems
      IT Solutions for Improving Diagnostic Accuracy
      Policy Environment for HIT
      References and Additional Readings
      ch. 14 Reporting Systems, Root Cause Analysis, and other Methods of Understanding Safety Issues
      Overview
      General Characteristics of Reporting Systems
      Hospital Incident Reporting Systems
      Aviation Safety Reporting System
      Reports to Entities Outside the Healthcare Organization
      Patient Safety Organizations
      Root Cause Analysis and Other Incident Investigation Methods
      Morbidity and Mortality Conferences
      Other Methods of Capturing Safety Problems
      References and Additional Readings
      ch. 15 Creating a Culture of Safety
      Overview
      Illustrative Case
      Measuring Safety Culture
      Hierarchies, Speaking Up, and the Culture of Low Expectations
      Production Pressures
      Teamwork Training
      Checklists and Culture
      Rules, Rule Violations, and Workarounds
      Some Final Thoughts on Safety Culture
      References and Additional Readings
      ch. 16 Workforce Issues
      Overview
      Nursing Workforce Issues
      Rapid Response Teams
      House Staff Duty Hours
      "July Effect"
      Nights and Weekends
      "Second Victims": Supporting Caregivers After Major Errors
      References and Additional Readings
      ch. 17 Education and Training Issues
      Overview
      Autonomy Versus Oversight
      Simulation Training
      Teaching Patient Safety
      References and Additional Readings
      ch. 18 Malpractice System
      Overview
      Tort Law and the Malpractice System
      Error Disclosure, Apologies, and Malpractice
      No-Fault Systems and "Health Courts": An Alternative to Tort-Based Malpractice
      Medical Malpractice Cases as a Source of Safety Lessons
      References and Additional Readings
      ch. 19 Accountability
      Overview
      Accountability
      Disruptive Providers
      "Just Culture"
      Reconciling "No Blame" and Accountability
      Role of the Media
      References and Additional Readings
      ch. 20 Accreditation and Regulations
      Overview
      Accreditation
      Regulations
      Other Levers to Promote Safety
      Problems with Regulatory, Accreditation, and Other Prescriptive Solutions
      References and Additional Readings
      ch. 21 Role of Patients
      Overview
      Patients with Limited English Proficiency
      Patients with Low Health Literacy
      Errors Caused by Patients Themselves
      Patient Engagement as a Safety Strategy
      References and Additional Readings
      ch. 22 Organizing a Safety Program
      Overview
      Structure and Function
      Managing the Incident Reporting System
      Dealing with Data
      Strategies to Connect Senior Leadership with Frontline Personnel
      Strategies to Generate Frontline Activity to Improve Safety
      Dealing with Major Errors and Sentinel Events
      Failure Mode and Effects Analyses
      Qualifications and Training of the Patient Safety Officer
      Role of the Patient Safety Committee
      Engaging Physicians in Patient Safety
      Board Engagement in Patient Safety
      Research in Patient Safety
      Patient Safety Meets Evidence-Based Medicine
      References and Additional Readings
      Conclusion
      Appendix I Key Books, Reports, Series, and Websites on Patient Safety
      Appendix II AHRQ Patient Safety Network (AHRQ PSNET) Glossary of Selected Terms in Patient Safety
      Appendix III Selected Milestones in the Field of Patient Safety
      Appendix IV Joint Commission's National Patient Safety Goals (Hospital Version, 2017)
      Appendix V Agency for Healthcare Research and Quality's (AHRQ) Patient Safety Indicators (PSIS)
      Appendix VI National Quality Forum's List of Serious Reportable Events, 2011
      Appendix VII National Quality Forum's List of "Safe Practices for Better Healthcare-2010 Update"
      Appendix VIII Medicare's "No Pay For Errors" List*
      Appendix IX Things Patients and Families Can Do, and Questions They Can Ask, to Improve Their Chances of Remaining Safe in the Hospital.
    Session Timeout
    New Session