SECTION I: AN INTRODUCTION TO PATIENT
SAFETY AND MEDICAL ERRORS
Chapter 1
- New ways of detecting errors, including Trigger Tools and electronic methods of monitoring
- New measures of patient safety
- Safety rating systems
The Nature and Frequency of Medical Errors and Adverse Events
Adverse Events, Preventable Adverse Events, and Errors
The Challenges of Measuring Errors and Safety
The Frequency and Impact of Errors
Key Points
References and Additional Readings
Chapter 2
Basic Principles of Patient Safety
The 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
Key Points
References and Additional Readings
Chapter 3
- Challenges in prioritizing patient safety given the increased pressure to decrease waste, and improve value, patient experience and access
Safety, Quality, and Value
What is Quality?
The Epidemiology of Quality Problems
Catalysts for Quality Improvement
The Changing Quality Landscape
Quality Improvement Strategies
Commonalities and Differences Between Quality and Patient Safety
Value: Connecting Quality (and Safety) to the Cost of Care
Key Points
References and Additional Readings
SECTION II: TYPES OF MEDICAL ERRORS
Chapter 4
Medication Errors
Some Basic Concepts, Terms, and Epidemiology
Strategies to Decrease Medication Errors
Key Points
References and Additional Readings
Chapter 5
- Procedural safety, including role of video review and simulators
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
Key Points
References and Additional Readings
Chapter 6
- Update on diagnostic errors (in light of a 2015 IOM report)
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
Communication and Information Flow Issues in Diagnostic Errors
Overdiagnosis
The Policy Context for Diagnostic Errors
Key Points
References and Additional Readings
Chapter 7
Human Factors and Errors at the Person-Machine Interface
Introduction
Human Factors Engineering
Usability Testing and Heuristic Analysis
Applying Human Factors Engineering Principles
Key Points
References and Additional Readings
Chapter 8
- Better understanding of the challenges of handoffs and signouts, new best practices
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
Key Points
References and Additional Readings
Chapter 9
Teamwork and Communication Errors
Some Basic Concepts and Terms
The Role of Teamwork in Healthcare
Fixed Versus Fluid Teams
Teamwork and Communication Strategies
Key Points
References and Additional Readings
Chapter 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
Key Points
References and Additional Readings
Chapter 11
- Post-hospital syndrome
Other Complications of Healthcare
General Concepts
Venous Thromboembolism Prophylaxis
Preventing Pressure Ulcers
Preventing Falls
Preventing Delirium
Key Points
References and Additional Readings
Chapter 12
- Increased emphasis on safety in ambulatory and non-hospital settings
Patient Safety in the Ambulatory Setting
General Concepts and Epidemiology
Hospital Versus Ambulatory Environments
Improving Ambulatory Safety
Key Points
References and Additional Readings
SECTION III: SOLUTIONS
Chapter 13
- CPOE and EHRs: more on unanticipated consequences (new kinds of errors, alert fatigue), lack of interoperability
Information Technology
Healthcare's Information Problem
Electronic Health Records
Computerized Provider Order Entry
Other IT-Related Safety Solutions
Computerized Clinical Decision Support Systems
IT Solutions for Improving Diagnostic Accuracy
The Policy Environment for HIT
Key Points
References and Additional Readings
Chapter 14
- Rethinking root cause analysis
Reporting Systems, Root Cause Analysis, and Other Methods of Understanding Safety Issues
Overview
General Characteristics of Reporting Systems
Hospital Incident Reporting Systems
The 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
Key Points
References and Additional Readings
Chapter 15
- Update on checklists
Creating a Culture of Safety
Overview
An 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
Key Points
References and Additional Readings
Chapter 16
- Workforce issues and clinician burnout
Workforce Issues
Overview
Nursing Workforce Issues
Rapid Response Teams
House Staff Duty Hours
The July Effect
Nights and Weekends
Second Victims: Supporting Caregivers After Major Errors
Key Points
References and Additional Readings
Chapter 17
- Safety and medical education (including impact of 2011 duty hours reform and new ACGME patient safety assessment)
Education and Training Issues
Overview
Autonomy Versus Oversight
Simulation Training
Teaching Patient Safety
Key Points
References and Additional Readings
Chapter 18
The 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 Medical Malpractice
Cases as a Source of Safety Lessons
Key Points
References and Additional Readings
Chapter 19
Accountability
Overview
Accountability
Disruptive Providers
The Just Culture
Reconciling No Blame and Accountability
The Role of the Media
Key Points
References and Additional Readings
Chapter 20
- Impact of major policy initiatives, including the Affordable Care Act and the Partnership for Patients
Accreditation and Regulations
Overview
Accreditation
Regulations
Other Levers to Promote Safety
P roblems with Regulatory, Accreditation, and Other Prescriptive Solutions
Key Points
References and Additional Readings
Chapter 21
The 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
Key Points
References and Additional Readings
Chapter 22
- Learning healthcare systems
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
The 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
Key Points
References and Additional Readings
Conclusion
SECTION IV: APPENDICES
Appendix I. Key Books, Reports, Series, and Web Sites on Patient Safety
Appendix II. The 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. The Joint Commission's National Patient Safety Goals (Hospital Version, 2011)
Appendix V. Agency for Healthcare Research and Quality's (AHRQ) Patient Safety Indicators (PSIs)
Appendix VI. The National Quality Forum's List of Serious Reportable Events,
Appendix VII. The 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
Index
