基本説明
Experts from the aviation industry, world-class organizations such as Toyota and General Electric, and innovative hospitals such as Johns Hopkins offer their insight.
Full Description
From newborns switched in the nursery to medication mix-ups and hospital-acquired infections, we are all familiar with the horror stories about hospital safety, and unfortunately, the statistics say we aren't exaggerating. The safety issue in U.S. hospitals has become so profound and embedded, that we cannot hope to fix it without a paradigm shift in our approach. After defining and demonstrating the true depth of this dangerous concern, Safer Hospital Care: Strategies for Continuous Innovation elaborates on the steps required to make that paradigm shift a reality.A respected and sought out expert on hospital safety, author Dev Raheja draws on his 25 years of experience as a risk management and quality assurance consultant to provide hospital stakeholders with a systematic way to learn the science of safe care. Supported by case studies as well as input from such paradigm pioneers as Johns Hopkins and Seattle Children's, he explains how to:Adapt evidence-based safety theories and tools taken from the aerospace, nuclear, and chemical industriesIdentify the combination of root causes that result in an adverse eventApply analytical tools that can effectively measure hospital efficiencyEstablish evidence between Lean strategies and patient satisfactionMake use of various types of innovation including accidental, incremental, strategic, and radical, and establish a culture conducive to innovationThis practical guide shows how to find solutions that are simple and comprehensive, and can produce a high ROI. To reform hospitals, we must recognize that they are highly dynamic systems that must be fixed systemically. Instead of thinking in terms of continuous improvement, we need to think in terms of continuous innovation. Safe hospital care is not just about doing things right; it is also about breaking old habits, finding new tools and doing the right things.
Contents
The Etiologies of Unsafe HealthcareFailure Is Not an OptionAn Unconventional Way to Manage RisksDefining Unsafe WorkHow Unsafe Work Propagates UnknowinglyHow Does Unsafe Work Originate?So, Why Do We Unknowingly Sustain Unsafe Work?Using Best Practices Is InsufficientThere Is HopeThe Lessons LearnedSufficient Understanding Is a Prerequisite to Safe CareInsufficient Understanding of System VulnerabilityInsufficient Understanding of What Is PreventableInsufficient Understanding from MyopiaInsufficient Understanding of Oversights and OmissionsInsufficient Understanding of VariationSome RemediesPreventing "Indifferencity" to Enhance Patient SafetyPerformance without PassionNot Learning from MistakesInattention to the Voice of the PatientMaking Premature Judgments without Critical ThinkingLack of TeamworkLack of Feedback and Follow-UpPerformance without Due ConcernLack of AccountabilityEncouraging Substandard WorkReacting to Unsafe Incidences Instead of Proactively Seeking ThemInattention to Clinical SystemsDifference in Mindset between Management and EmployeesPoor Risk ManagementPerformance Diligently Done in a Substandard MannerContinuing to Do Substandard Work, Knowing It IsSubstandardIgnoring Bad BehaviorInattention to QualityContinuous Innovation Is Better Than Continuous ImprovementWhy Continuous Innovation?Types of InnovationsMarginal InnovationIncremental InnovationRadical InnovationDisruptive InnovationAccidental InnovationStrategic InnovationDiffusion InnovationTranslocation InnovationThe Foundation for the Innovation CultureChoice of InnovationEncouraging CreativityStructure for Sustaining InnovationInnovations Should Start with Incidence ReportsThe Purpose and Scope of Incidence ReportsWhat to Do with Incidence Reports?A Sample Incidence Reporting ProcedureA Sample Incidence Report FormIdeas for Innovative SolutionsDoing More with Less Is InnovationBe Lean, Don't Be MeanEliminate Waste, Don't Eliminate ValueDo It Right the First Time-Excellence Does MatterAdd More Right Work to Save Time and MoneyAttack ComplacencyCreate a Sense of UrgencyEstablish Evidence between Lean Strategies and Patient SatisfactionIdeas for Lean InnovationReinvent Quality ManagementA Recipe for SuccessRedefine QualityConduct Negative Requirements AnalysisDevelop Strategic Plan Based on SWOT AnalysisConsciously Manage Quality at All the Levels of an Organization Quality at Conformance Level Quality at Process Level Quality of Kind at Organization Level Architect a Patient-Centric Quality System Validate Interactions and Dependencies Frequently Incorporate Feedback Loops Reinvent Risk ManagementIdentify RisksFailure Mode and Effects Analysis (FMEA)Fault Tree Analysis (FTA)Operations and Support Hazard AnalysisMore Safety Analysis TechniquesMitigate RisksOrchestrate RisksCreate a Sound StructureIntegrate the Support StaffConduct Risk Management RehearsalsAim at High Return on Investment without Compromising SafetyHuman Errors May Be Unpreventable; Preventing Harm Is an InnovationPrinciples of Human Factors EngineeringPrinciples of Human Factors Engineering (HFE)Harm Prevention MethodologiesCrew Resource Management (CRM)Management Oversight and Risk Tree (MORT)Change Analysis Swiss Cheese Model for Error Trapping Mistake Proofing Managing Safety: Lessons from AerospaceWhere Does US Healthcare Stand on System Safety?System Safety Theory of AccidentsSystem Safety in Emergency MedicineAerospace Hazard Analysis TechniquesThe Paradigm Pioneers Johns Hopkins HospitalAllegheny General Hospital Geisinger Health System VA Hospitals Seattle Children's Hospital Ideas for Future Paradigm Pioneers Protect Patients from Dangers in Medical Devices The Nature of DangersHazard Mitigation for Existing DevicesPotential Dangers in New Devices and TechnologiesHazard Mitigation for New Devices and TechnologiesCan We Use This Knowledge in Bedside Intelligence?Heuristics for Continuous InnovationHeuristics for Medicine Other Heuristics for Medicine Heuristics for Frontline Processes Stop Working on Wrong Things, and You Will AutomaticallyWork on Right Things Learn to Say "No" to Yes Men "No Action" Is an ActionNo Control Is the Best ControlHeuristics for ManagementIf You Don't Know Where You Are Going, Any Road Will Get You ThereConvert Bad News into Good NewsAs Quality Goes up, the Costs Go DownThat Which Gets Measured, Is What Gets Done% of Causes Are Responsible For % of EffectsAequanimitas-The Best-Known Strategy for Safe CareAequanimitas ExplainedWhy Aequanimitas Is the Best-Known Strategy for Safe Care?The Practice of AequanimitasModern Variations of AequanimitasEmotional Intelligence (EI)The Beginner's MindRay Brown's Senses Appendix A: Swiss Cheese Model for Error Trapping IndexEach chapter includes an Introduction, Summary, & References
