基本説明
Explains how to implement Institute of Medicine guidelines to reduce the frequency of errors in health care services and mitigate the impact of those errors that do occur.
Full Description
Error Reduction in Health Care: A Systems Approach to Improving Patient Safety, 2nd Edition
Completely revised and updated this book offers a step-by-step guide for implementing the Institute of Medicine guidelines to reduce the frequency of errors in health care services and mitigate the impact of those errors that do occur. It explores the fundamental concepts and tools of error reduction, and shows how to design an effective error reduction initiative. The book pinpoints how to reduce and eliminate medical mistakes that threaten the health and safety of patients and teaches how to identify the root cause of medical errors, implement strategies for improvement, and monitor the effectiveness of these new approaches.
Contents
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
