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Author:
Publisher: World Health Organization
ISBN: 9240010335
Category : Medical
Languages : en
Pages : 72
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Book Description
Patient safety incident reporting and learning systems aim to capture patient safety incidents and provide structured learning, since this can be key to improving patient safety and preventing the occurrence of harm. This document presents the purpose and strengths of patient safety incident reporting and provides some practical guidance on establishing patient safety incident reporting and learning systems.
Author:
Publisher: World Health Organization
ISBN: 9240010335
Category : Medical
Languages : en
Pages : 72
Get Book
Book Description
Patient safety incident reporting and learning systems aim to capture patient safety incidents and provide structured learning, since this can be key to improving patient safety and preventing the occurrence of harm. This document presents the purpose and strengths of patient safety incident reporting and provides some practical guidance on establishing patient safety incident reporting and learning systems.
Author: Kerm Henriksen
Publisher:
ISBN:
Category : Medical
Languages : en
Pages : 526
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Book Description
v. 1. Research findings -- v. 2. Concepts and methodology -- v. 3. Implementation issues -- v. 4. Programs, tools and products.
Author: Cornelia Spitzer
Publisher: Springer
ISBN: 0857294105
Category : Technology & Engineering
Languages : en
Pages : 3803
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Book Description
A collection of papers presented at the PSAM 7 – ESREL ’04 conference in June 2004, reflecting a wide variety of disciplines, such as principles and theory of reliability and risk analysis, systems modelling and simulation, consequence assessment, human and organisational factors, structural reliability methods, software reliability and safety, insights and lessons from risk studies and management/decision making. This volume covers both well-established practices and open issues in these fields, identifying areas where maturity has been reached and those where more development is needed.
Author: Institute of Medicine
Publisher: National Academies Press
ISBN: 0309131529
Category : Medical
Languages : en
Pages : 427
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Book Description
Medical residents in hospitals are often required to be on duty for long hours. In 2003 the organization overseeing graduate medical education adopted common program requirements to restrict resident workweeks, including limits to an average of 80 hours over 4 weeks and the longest consecutive period of work to 30 hours in order to protect patients and residents from unsafe conditions resulting from excessive fatigue. Resident Duty Hours provides a timely examination of how those requirements were implemented and their impact on safety, education, and the training institutions. An in-depth review of the evidence on sleep and human performance indicated a need to increase opportunities for sleep during residency training to prevent acute and chronic sleep deprivation and minimize the risk of fatigue-related errors. In addition to recommending opportunities for on-duty sleep during long duty periods and breaks for sleep of appropriate lengths between work periods, the committee also recommends enhancements of supervision, appropriate workload, and changes in the work environment to improve conditions for safety and learning. All residents, medical educators, those involved with academic training institutions, specialty societies, professional groups, and consumer/patient safety organizations will find this book useful to advocate for an improved culture of safety.
Author: Health Quality Ontario
Publisher:
ISBN: 9781460693322
Category :
Languages : en
Pages : 23
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Book Description
"A patient safety learning system (sometimes called a critical incident reporting system) refers to structured reporting, collation, and analysis of critical incidents. To inform a provincial working group's recommendations for an Ontario Patient Safety Event Learning System, a systematic review was undertaken to determine design features that would optimize its adoption into the health care system and would inform implementation strategies."--Abstract.
Author: OECD
Publisher: OECD Publishing
ISBN: 9264805907
Category :
Languages : en
Pages :
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Book Description
This volume, developed by the Observatory together with OECD, provides an overall conceptual framework for understanding and applying strategies aimed at improving quality of care. Crucially, it summarizes available evidence on different quality strategies and provides recommendations for their implementation. This book is intended to help policy-makers to understand concepts of quality and to support them to evaluate single strategies and combinations of strategies.
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/
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
Author: Lucian L. Leape
Publisher: Springer Nature
ISBN: 3030711234
Category : Medical
Languages : en
Pages : 450
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Book Description
This unique and engaging open access title provides a compelling and ground-breaking account of the patient safety movement in the United States, told from the perspective of one of its most prominent leaders, and arguably the movement’s founder, Lucian L. Leape, MD. Covering the growth of the field from the late 1980s to 2015, Dr. Leape details the developments, actors, organizations, research, and policy-making activities that marked the evolution and major advances of patient safety in this time span. In addition, and perhaps most importantly, this book not only comprehensively details how and why human and systems errors too often occur in the process of providing health care, it also promotes an in-depth understanding of the principles and practices of patient safety, including how they were influenced by today’s modern safety sciences and systems theory and design. Indeed, the book emphasizes how the growing awareness of systems-design thinking and the self-education and commitment to improving patient safety, by not only Dr. Leape but a wide range of other clinicians and health executives from both the private and public sectors, all converged to drive forward the patient safety movement in the US. Making Healthcare Safe is divided into four parts: I. In the Beginning describes the research and theory that defined patient safety and the early initiatives to enhance it. II. Institutional Responses tells the stories of the efforts of the major organizations that began to apply the new concepts and make patient safety a reality. Most of these stories have not been previously told, so this account becomes their histories as well. III. Getting to Work provides in-depth analyses of four key issues that cut across disciplinary lines impacting patient safety which required special attention. IV. Creating a Culture of Safety looks to the future, marshalling the best thinking about what it will take to achieve the safe care we all deserve. Captivatingly written with an “insider’s” tone and a major contribution to the clinical literature, this title will be of immense value to health care professionals, to students in a range of academic disciplines, to medical trainees, to health administrators, to policymakers and even to lay readers with an interest in patient safety and in the critical quest to create safe care.
Author: Tanya Hewitt
Publisher:
ISBN:
Category : Hospital patients
Languages : en
Pages :
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Book Description
Patient safety has been on the research agenda since 2000, when unnecessary harm to patients in providers' care came to light. In 2005, the improvements in patient safety fell short of expectations, and the patient safety research community recognized that the issues are more difficult to resolve than first thought. One of the tools to address this vexing problem has been voluntary incident reporting systems, although the literature has given incident reporting systems mixed reviews. This qualitative comparative case study comprises 85 semi-structured interviews in two separate divisions of a tertiary care hospital, General Internal Medicine (GIM) and Obstetrics and Neonatology (OBS/NEO). The main line of questioning concerned incident reporting; general views of patient safety were also sought. This is a thesis by publication. The thesis consists of a general introduction to patient safety, a literature review, a description of the methods and cases, followed by the manuscripts. The thesis concludes with a summarization of the findings, and implications of the study. Manuscript one focuses on the reporter end of incident reporting systems. It asks what frames underlie GIM nurse and physician self reporting and peer reporting practices. The findings showed that frames that inhibit reporting are shared by physicians and nurses, such as the fear of blame frame regarding self reporting, and the tattletale frame regarding peer reporting. These frames are underpinned by a focus on the individual, despite the organisational message of reporting for learning. A learning frame is an enabler to incident reporting. Viewing the objective of voluntary incident reporting as learning allows practitioners to depersonalize incident reporting. The focus becomes preventing recurrence and not the individual reporting or reported on. Manuscript two again focuses on the reporter end, and on one type of reportable incident --a problem that healthcare practitioners can fix themselves. The study asks: when faced with such a problem, do practitioners fix it in the moment and forget about it, or do they fix it in the moment and report it? We found that zfixing and forgettingy was the main choice that most GIM practitioners made in situations where they faced problems that they themselves could resolve. These situations included a) handling near misses, which were seen as unworthy of reporting since they did not result in actual harm to the patient, b) prioritizing solving individual patients' safety problems, which were viewed as unique or one-time events, and c) encountering re-occurring safety problems, which were framed as inevitable, routine events. The paper argues that fixing and forgetting patient safety problems encountered may not serve patient safety as well as fixing and reporting. The latter approach aligns with a preventive view of patient safety. Manuscript three focuses on the practice of double checking, drawing from interviews conducted in both GIM and OBS/NEO. It asks what weaknesses are in the double checking process and what alternative views can help the double checking process enhance patient safety. The findings showed weaknesses in the double checking process, such as: a) double checking trusted as an independent process, b) double (or more) checking as a costly and time consuming procedure, and c) double checking as preventing reporting of near misses. It is proposed that there are alternative ways of viewing and practising double checking in order to enhance patient safety. These include: a) recognizing that double checking requires training, b) introducing automated double checking, and c) expanding double checking beyond error detection. The paper argues that practitioners need to be more aware of the caveats of double checking, and to view the double checking process through alternate lenses to help enhance its effectiveness. Manuscript four focuses on the reporting system more comprehensively, and attends to the reporting process in GIM and OBS/NEO. This is a comparative case study of the two divisions, and considers the different stages in the process and the factors that help shape the process. The findings showed that there were major differences between the two divisions in terms of: a) what comprised a typical report (outcome based vs communication and near-miss based); b) how the reports were investigated (individual manager vs interdisciplinary team); c) learning from reporting (interventions having ambiguous linkages to the reporting system vs interventions having clear linkages to reported incidents); and d) feedback (limited feedback vs multiple feedback). The differences between the two divisions can be explained in terms of: a) the influence of litigation on practice, b) the availability or lack of interprofessional training, and c) the introduction of the reporting system (top-down vs bottom-up approach). A model based on the findings portraying the influences on incident reporting and learning is provided. This thesis contributes to an in-depth understanding of front line perspectives on incident reporting systems and safety, and aims to provide insights into improving patient safety. Implications for practice and research will be addressed.
