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Implementing Patient Safety: addressing culture, conditions and values to help people work safely Over the last two decades across the globe we have seen a multitude of programs, projects and books to help improve the safety of patient care in healthcare. However, the full potential of these has not yet been reached. Most of the current approaches are top down, programmatic and target driven. These look at problems in isolation one harm at a time with simplistic solutions that fail to support a holistic, systematic approach. They are focused on collecting incident data and learning from failure using tools that are not fit for purpose in a complex nonlinear system. Very rarely do the solutions help build the conditions, cultures and behaviours that support a safer system and help the people involved work safely. Healthcare is stuck in a relentlessly negative approach to safety. Those working in patient safety and healthcare are struggling, and books on patient safety to date instruct the reader to continue doing the same things we have been doing for the last 20 years. This book uniquely combines the latest thinking in safety, including creating a balanced approach to learning from what works as a way to understand why it fails, together with the evidence on building a just culture, positive workplaces and working relationships that we now know are so important for safety. It helps people understand how to address issues despite their complexities and improve safety with practical ways to truly understand what day to day healthcare work is actually like, rather than what people imagine it is like. This book builds on the author's first book Rethinking Patient Safety which exposed what we need to do differently to truly transform our approach to patient safety. It updates the reader further on the concepts explored in the first book but also vitally helps readers understand the 'how'. Implementing Patient Safety goes beyond the rhetoric and provides the reader with ideas and examples for how the latest thinking can actually be achieved. It is based on the author's personal experience of leading a national culture change campaign in the National Health Service for five years. The lessons arise from helping hundreds of organisations and people rethink and implement a whole new way of thinking about improving patient safety in healthcare.
Five Disciplines for Zero Patient Harm Safe care for every patient, in every setting, every time. Is this really an achievable goal for all healthcare organizations? Yes, it is. The vast majority of occurrences of harm to patients during their care are preventable. But simply aiming for improvement won't do; healthcare organizations must reset their patient safety goal to zero patient harm . Five Disciplines for Zero Patient Harm: How High Reliability Happens offers real-world, how-to guidance for driving fundamental change that consistently achieves safe patient care. Drawing on best practices from high-hazard industries such as aviation, nuclear power, and air traffic control, this book details the safety habits and disciplines that are ingrained in such organizations' cultures and behaviors. Specifically, five disciplines of performance excellence, when consistently applied to healthcare organizations, can save lives and protect patients from harm: Prepare for excellent performance through simulation, deliberate practice, and training.Apply proven offensive strategies that exhibit consistent, excellent individual and team performance.Minimize both individual and team errors through immediate feedback and coach interventions.Employ strong defensive strategies that effectively block the potential negative effects of errors, latent hazards, and emerging threats.Coach individuals and teams to achieve consistent, excellent performance in the first four disciplines.Zero preventable patient harm can be the norm, not the stretch goal, when the practices and action steps in this comprehensive resource are implemented. Five Disciplines for Zero Patient Harm provides an evidence-based guide for hospitals and healthcare systems to transform unsafe behaviors into safe behaviors and safe behaviors into safe habits. That's how high reliability happens.
Improving Patient Safety: tools and strategies for quality improvement Based on the IOM's estimate of 44,000 deaths annually, medical errors rank as the eighth leading cause of death in the U.S. Clearly medical errors are an epidemic that needs to be contained. Despite these numbers, patient safety and medical errors remain an issue for physicians and other clinicians. This book bridges the issues related to patient safety by providing clinically relevant, vignette-based description of the areas where most problems occur. Each vignette highlights a particular issue such as communication, human facturs, E.H.R., etc. and provides tools and strategies for improving quality in these areas and creating a safer environment for patients.
Understanding Patient Safety, 3rd ed. Now revised and updated--the landmark patient safety primer written by the world's leading authorities Medical errors are the unfortunate byproduct of an increasingly complex healthcare system. Now more than ever, keeping patients safe takes well-trained caregivers, relevant insights from a range of industries, additional investment--and a groundbreaking text like Understanding Patient Safety. 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 references--all designed to help you optimize quality and safety. Understanding Patient Safety 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 section covers proven solutions, from establishing reporting systems, to creating a culture of safety. 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. Features: *Coverage of human factors and errors at the person-machine interface *Review of workplace issues, including supporting caregivers after major errors *How to organize an effective safety program *Coordination of patient education and training *Overview of the malpractice system *Discussion of the patient's role
Patient Safety Strategies: evidence-based practices for fall prevention This book takes you step-by-step through setting up a successful and sustainable evidence-based multidisciplinary fall prevention program to protect patients.
Quality and Safety in Nursing: a competency approach to improving outcomes Drawing on the universal values in health care, the second edition of Quality and Safety in Nursing continues to devote itself to the nursing community and explores their role in improving quality of care and patient safety. Edited by key members of the Quality and Safety Education for Nursing (QSEN) steering team, Quality and Safety in Nursing is divided into three sections. Itfirst looks at the national initiative for quality and safety and links it to its origins in the IOM report. The second section defines each of the six QSEN competencies as well as providing teaching and clinical application strategies, resources and current references. The final section now features redesigned chapters on implementing quality and safety across settings. New to this edition includes: Instructional and practice approaches including narrative pedagogy and integrating the competencies in simulation A new chapter exploring the application of clinical learning and the critical nature of inter-professional teamwork A revised chapter on the mirror of education and practice to better understand teaching approaches This ground-breaking unique text addresses the challenges of preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the health care system in which they practice.
High-Reliability Healthcare: improving patient safety and outcomes with Six Sigma High-Reliability Organizations prioritize safety over other performance measures and equip staff with operational tactics so that they can anticipate potential problems early on and respond to safety threats. Driven by the desire to improve, healthcare providers have recognized that the principles and approaches of High-Reliability Organizations have much to offer healthcare organizations in meeting important goals related to patient safety and improved outcomes.
Patient Safety: investigating and reporting serious clinical incidents At a time of increasing regulatory scrutiny and medico-legal risk, managing serious clinical incidents within primary care has never been more important. Failure to manage appropriately can have serious consequences both for service organisations and for individuals involved. This is the first book to provide detailed guidance on how to conduct incident investigations in primary care. The concise guide explains how to recognise a serious clinical incident, how to conduct a root cause analysis investigation, and how and when duty of candour applies covers the technical aspects of serious incident recognition and report writing includes a wealth of practical advice and 'top tips', including how to manage the common pitfalls in writing reports offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. This book offers a master class for anyone performing RCA and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices, 'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical are investigated and managed. e all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. This book offers a master class for anyone performing RCA and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices, 'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical are investigated and managed.
High Reliability Organizations: a healthcare handbook for patient safety & quality Patient safety and quality are an ever-increasing concern to consumers, payers, providers, organizations, and governments. However, high reliability methods and science that can provide efficient and effective care have still not been totally implemented into our healthcare culture. Nurses, representing the majority of healthcare workers, are on the front line of the delivery and provision of safe and effective care and are ideally situated to drive the mission to achieve high reliability in healthcare.
Patient Safety Handbook In the current climate of managed care, tight cost controls, limited resources, and the growing demand for health care services, conditions for medical errors are ripe. Nearly 100,000 people die each year from medical errors and tens of thousands more are injured. This comprehensive handbook on patient safety reflects the goals of many in the health care industry to advance the reliability of healthcare systems worldwide. With contributions from prominent thought leaders in the field, this thoroughly revised, Second Edition of The Patient Safety Handbook looks at all the recent changes in the industry and offers practical guidance on implementing systems and processes to improve outcomes and advance patient safety. The book covers the full spectrum of patient safety and risk reduction-- from the fundamentals of the science of safety, through a thorough discussion of operational issues, and the application of the principles of research. Real-life case studies from renowned health care organizations and their leadership help the reader understand the practical application of the strategies presented. Key Features: * Offers contributions from prominent thought leaders in both academia and the profession. * Examines the newest scientific advances in the science of safety. * Includes real-life case studies from renowned health care organizations.
Safety Culture: building and sustaining a cultural change in aviation and health care In this work, the four authors draw upon their extensive teaching, research and field experience from multiple industries to describe the dynamic nature of a culture-change process, particularly in safety-critical domains.
Patient Safety Pocket Guide by Gives you background that you need to identify and prevent critical patient safety issues, including patient falls, alarm fatigue, catheter-associated urinary tract infections (CAUTI), suicide prevention, medication reconciliation and more. This guide is divided into the five sections: Infections, Medications, Falls, Pressure Ulcers, and Suicide.
Patient Safety and Hospital Accreditation: a model for ensuring success Improving the culture of safety in our health care institutions is an essential component of preventing or reducing errors as well as improving overall health care quality. This book presents the clinically tested Myer's Patient Safety Model for health care system leaders, middle managers, and administrators to build their patient safety program and to help sustain, renew, or obtain accreditation. The author provides detailed explanations of why medical errors still occur in accredited hospitals, and provides the much needed organization-wide steps to prevent these errors and enhance patient safety for improved outcomes. Current patient safety challenges are discussed with an emphasis on the concept of reliability. The Myers Model is examined in detail, along with current evidence for its three interrelated levels of organizational structure-the leadership (system) level, the unit (microsystem) level, and the individual level. The text includes interviews about key aspects of patient safety with three leaders of major health care accreditation programs in the U.S., Canada, and Australia. Additionally, it provides an overview of reporting systems within the U.S. and covers two essential tools for patient safety-root cause analysis and failure mode and effect analysis. The book links all aspects of patient safety with accreditation standards at the national level, and also discusses efforts to globalize accreditation criteria and procedures. Key Features: Presents a clinically tested model for building a patient safety program and helping to sustain, renew, or obtain accreditation Provides tools for use in ensuring patient safety and accreditation, including root cause analysis and failure mode and effect analysis Discusses how aggregate data inform patient safety documentation and accreditation through integrated perspectives Offers a global view of accreditation and patient safety Includes techniques to improve communication among members of health care teams
Just Culture: balancing safety and accountability Building on the success of the 2007 original, Dekker revises, enhances and expands his view of just culture for this second edition, additionally tackling the key issue of how justice is created inside organizations. The goal remains the same: to create an environment where learning and accountability are fairly and constructively balanced. The First Edition of Sidney Dekker¿s Just Culture brought accident accountability and criminalization to a broader audience. It made people question, perhaps for the first time, the nature of personal culpability when organizational accidents occur. Having raised this awareness the author then discovered that while many organizations saw the fairness and value of creating a just culture they really struggled when it came to developing it: What should they do? How should they and their managers respond to incidents, errors, failures that happen on their watch? In this Second Edition, Dekker expands his view of just culture, additionally tackling the key issue of how justice is created inside organizations. The new book is structured quite differently. Chapter One asks, ¿what is the right thing to do?¿ - the basic moral question underpinning the issue. Ensuing chapters demonstrate how determining the ¿right thing¿ really depends on one¿s viewpoint, and that there is not one ¿true story¿ but several. This naturally leads into the key issue of how justice is established inside organizations and the practical efforts needed to sustain it. The following chapters place just culture and criminalization in a societal context. Finally, the author reflects upon why we tend to blame individual people for systemic failures when in fact we bear collective responsibility. The changes to the text allow the author to explain the core elements of a just culture which he delineated so successfully in the First Edition and to explain how his original ideas have evolved. Dekker also introduces new material on ethics and on caringMayo Clinic Libraries Librarians are available to assist in retrieving information on specific topics for you.
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