Error reduction in health care : a systems approach to improving patient safety

著者

    • Spath, Patrice L.

書誌事項

Error reduction in health care : a systems approach to improving patient safety

Patrice L. Spath, editor

Jossey-Bass, c2011

2nd ed

  • : pbk

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注記

Includes bibliographical references and index

内容説明・目次

内容説明

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

目次

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

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