To Err Is Human

To Err Is Human PDF Author: Institute of Medicine
Publisher: National Academies Press
ISBN: 0309068371
Category : Medical
Languages : en
Pages : 312

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Book Description
Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

To Err Is Human

To Err Is Human PDF Author: Institute of Medicine
Publisher: National Academies Press
ISBN: 0309068371
Category : Medical
Languages : en
Pages : 312

Get Book Here

Book Description
Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

Safe Patients, Smart Hospitals

Safe Patients, Smart Hospitals PDF Author: Peter Pronovost
Publisher: Penguin
ISBN: 1101185279
Category : Health & Fitness
Languages : en
Pages : 237

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Book Description
The inspiring story of how a leading innovator in patient safety found a simple way to save countless lives. First, do no harm-doctors, nurses and clinicians swear by this code of conduct. Yet in hospitals and doctors' offices across the country, errors are made every single day - avoidable, simple mistakes that often cost lives. Inspired by two medical mistakes that not only ended in unnecessary deaths but hit close to home, Dr. Peter Pronovost made it his personal mission to improve patient safety and make preventable deaths a thing of the past, one hospital at a time. Dr. Pronovost began with simple improvements to a common procedure in the ER and ICU units at Johns Hopkins Hospital. Creating an easy five-step checklist based on the most up-to-date research for his fellow doctors and nurses to follow, he hoped that streamlining the procedure itself could slow the rate of infections patients often died from. But what Dr. Pronovost discovered was that doctors and nurses needed more than a checklist: the day-to-day environment needed to be more patient-driven and staff needed to see scientific results in order to know their efforts were a success. After those changes took effect, the units Dr. Pronovost worked with decreased their rate of infection by 70%. Today, all fifty states are implementing Dr. Pronovost's programs, which have the potential to save more lives than any other medical innovation in the past twenty-five years. But his ideas are just the beginning of the changes being made by doctors and nurses across the country making huge leaps to improve patient care. In Safe Patients, Smart Hospitals, Dr. Pronovost shares his own experience, anecdotal stories from his colleagues at Johns Hopkins and other hospitals that have made his approach their own, alongside comprehensive research-showing readers how small changes make a huge difference in patient care. Inspiring and thought provoking, this compelling book shows how one person with a cause really can make a huge difference in our lives.

Keeping Patients Safe

Keeping Patients Safe PDF Author: Institute of Medicine
Publisher: National Academies Press
ISBN: 0309187362
Category : Medical
Languages : en
Pages : 485

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Book Description
Building on the revolutionary Institute of Medicine reports To Err is Human and Crossing the Quality Chasm, Keeping Patients Safe lays out guidelines for improving patient safety by changing nurses' working conditions and demands. Licensed nurses and unlicensed nursing assistants are critical participants in our national effort to protect patients from health care errors. The nature of the activities nurses typically perform â€" monitoring patients, educating home caretakers, performing treatments, and rescuing patients who are in crisis â€" provides an indispensable resource in detecting and remedying error-producing defects in the U.S. health care system. During the past two decades, substantial changes have been made in the organization and delivery of health care â€" and consequently in the job description and work environment of nurses. As patients are increasingly cared for as outpatients, nurses in hospitals and nursing homes deal with greater severity of illness. Problems in management practices, employee deployment, work and workspace design, and the basic safety culture of health care organizations place patients at further risk. This newest edition in the groundbreaking Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety.

A Safer Place for Patients

A Safer Place for Patients PDF Author: Great Britain: Parliament: House of Commons: Committee of Public Accounts
Publisher: The Stationery Office
ISBN: 9780215029621
Category : Medical
Languages : en
Pages : 52

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Book Description
Everyday the NHS successfully treats over 1 million people. However there are risks and treatments can go wrong. A report by the Chief Medical Officer in 2000, ('An organisation with a memory', ISBN 0113224419) estimated that one in ten patients admitted to hospital were unintentionally harmed and that a blame culture and lack of a national system for sharing experience were key barriers to reducing the number of patient safety incidents. In Government's response included plans, timetables and targets to promote patient safety and the establishment of the National Patient Safety Agency. This report finds that insufficient progress has been made. In particular there is a question mark over the National Patient Safety Agency because of cost over-runs and delays in its National Reporting and Learning System and the limited feedback it has so far provided to trusts.

A Safer Place for Patients

A Safer Place for Patients PDF Author: Great Britain: National Audit Office
Publisher: The Stationery Office
ISBN: 0102933448
Category : Medical
Languages : en
Pages : 100

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Book Description
The Department of Health estimates that one in ten patients admitted to NHS hospitals will be unintentionally harmed (a rate similar to other developed countries), due to incidents such as an injury from a fall, medication errors, equipment related incidents, record documentation errors and hospital acquired infections. About half of such incidents could have been avoided, if lessons from previous incidents had been learned. This NAO report examines the progress being made in the NHS to improve the patient safety culture, to encourage incident reporting and to learn lessons for the future. The report finds that most trusts have developed a predominantly open and fair reporting culture at the local level, driven largely by the Department of Health's clinical governance initiative and more effective risk management systems. However, a 'blame culture' still exists in some trusts, and there have been delays in establishing an effective national reporting system. There is scope for improving strategies for sharing good practice and for monitoring that lessons are learned.

Still Not Safe

Still Not Safe PDF Author: Robert L. Wears
Publisher:
ISBN: 0190271264
Category : Medical
Languages : en
Pages : 305

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Book Description
Still Not Safe is the story of the rise of the patient-safety movement- and how an "epidemic" of medical errors was derived from a reality that didn't support such a characterization. Physician Robert Wears and organizational theorist Kathleen Sutcliffe trace the origins of patient safety to the emergence of market trends that challenged the place of doctors in the larger medical ecosystem: the rise in medical litigation and physicians' aversion to risk; institutional changes in the organization and control of healthcare; and a bureaucratic movement to "rationalize" medical practice- to make a hospital run like a factory. Weaving together narratives from medicine, psychology, philosophy, and human performance, Still Not Safe offers a counterpoint to the presiding, doctor-centric narrative of contemporary American medicine.--book jacket

Access to Health Care in America

Access to Health Care in America PDF Author: Institute of Medicine
Publisher: National Academies Press
ISBN: 0309047420
Category : Medical
Languages : en
Pages : 240

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Book Description
Americans are accustomed to anecdotal evidence of the health care crisis. Yet, personal or local stories do not provide a comprehensive nationwide picture of our access to health care. Now, this book offers the long-awaited health equivalent of national economic indicators. This useful volume defines a set of national objectives and identifies indicatorsâ€"measures of utilization and outcomeâ€"that can "sense" when and where problems occur in accessing specific health care services. Using the indicators, the committee presents significant conclusions about the situation today, examining the relationships between access to care and factors such as income, race, ethnic origin, and location. The committee offers recommendations to federal, state, and local agencies for improving data collection and monitoring. This highly readable and well-organized volume will be essential for policymakers, public health officials, insurance companies, hospitals, physicians and nurses, and interested individuals.

Crossing the Quality Chasm

Crossing the Quality Chasm PDF Author: Institute of Medicine
Publisher: National Academies Press
ISBN: 0309132967
Category : Medical
Languages : en
Pages : 359

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Book Description
Second in a series of publications from the Institute of Medicine's Quality of Health Care in America project Today's health care providers have more research findings and more technology available to them than ever before. Yet recent reports have raised serious doubts about the quality of health care in America. Crossing the Quality Chasm makes an urgent call for fundamental change to close the quality gap. This book recommends a sweeping redesign of the American health care system and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others. In this comprehensive volume the committee offers: A set of performance expectations for the 21st century health care system. A set of 10 new rules to guide patient-clinician relationships. A suggested organizing framework to better align the incentives inherent in payment and accountability with improvements in quality. Key steps to promote evidence-based practice and strengthen clinical information systems. Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change.

Patient Safety and Quality

Patient Safety and Quality PDF Author: Ronda Hughes
Publisher: Department of Health and Human Services
ISBN:
Category : Medical
Languages : en
Pages : 592

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Book Description
"Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043)." - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/

Making Health Care Safer

Making Health Care Safer PDF Author:
Publisher: Department of Health and Human Services
ISBN:
Category : Medical
Languages : en
Pages : 744

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Book Description
"This project aimed to collect and critically review the existing evidence on practices relevant to improving patient safety"--P. v.