Understanding Patient Safety, Third Edition

SECTION I: AN INTRODUCTION TO PATIENT

SAFETY AND MEDICAL ERRORS

Chapter 1

-          New ways of detecting errors, including Trigger Tools and electronic methods of monitoring

-          New measures of patient safety

-          Safety rating systems

The Nature and Frequency of Medical Errors and Adverse Events

Adverse Events, Preventable Adverse Events, and Errors

The Challenges of Measuring Errors and Safety

The Frequency and Impact of Errors

Key Points

References and Additional Readings

Chapter 2

Basic Principles of Patient Safety

The Modern Approach to Patient Safety: Systems Thinking and the Swiss Cheese Model

Errors at the Sharp End: Slips versus Mistakes

Complexity Theory and Complex Adaptive Systems

General Principles of Patient Safety Improvement Strategies

Key Points

References and Additional Readings

Chapter 3

-          Challenges in prioritizing patient safety given the increased pressure to decrease waste, and improve value, patient experience and access

Safety, Quality, and Value

What is Quality?

The Epidemiology of Quality Problems

Catalysts for Quality Improvement

The Changing Quality Landscape

Quality Improvement Strategies

Commonalities and Differences Between Quality and Patient Safety

Value: Connecting Quality (and Safety) to the Cost of Care

Key Points

References and Additional Readings

SECTION II: TYPES OF MEDICAL ERRORS

Chapter 4

Medication Errors

Some Basic Concepts, Terms, and Epidemiology

Strategies to Decrease Medication Errors

Key Points

References and Additional Readings

Chapter 5

-          Procedural safety, including role of video review and simulators

Surgical Errors

Some Basic Concepts and Terms

Volume–Outcome Relationships

Patient Safety in Anesthesia

Wrong-Site/Wrong-Patient Surgery

Retained Sponges and Instruments

Surgical Fires

 Safety in Nonsurgical Bedside Procedures

Key Points

References and Additional Readings

Chapter 6

-          Update on diagnostic errors (in light of a 2015 IOM report)

Diagnostic Errors

Some Basic Concepts and Terms

Missed Myocardial Infarction: A Classic Diagnostic Error

Cognitive Errors: Iterative Hypothesis Testing, Bayesian Reasoning, and Heuristics

Improving Diagnostic Reasoning

Communication and Information Flow Issues in Diagnostic Errors

Overdiagnosis

The Policy Context for Diagnostic Errors

Key Points

References and Additional Readings

Chapter 7

Human Factors and Errors at the Person–Machine Interface

Introduction

Human Factors Engineering

Usability Testing and Heuristic Analysis

Applying Human Factors Engineering Principles

Key Points

References and Additional Readings

Chapter 8

-          Better understanding of the challenges of handoffs and signouts, new best practices

Transition and Handoff Errors

Some Basic Concepts and Terms

Best Practices for Person-to-Person Handoffs

Site-to-Site Handoffs: The Role of the System

Best Practices for Site-to-Site Handoffs Other Than Hospital Discharge

Preventing Readmissions: Best Practices for Hospital Discharge

Key Points

References and Additional Readings

Chapter 9

Teamwork and Communication Errors

Some Basic Concepts and Terms

The Role of Teamwork in Healthcare

Fixed Versus Fluid Teams

Teamwork and Communication Strategies

Key Points

References and Additional Readings

Chapter 10

Healthcare-Associated Infections

General Concepts and Epidemiology

Surgical Site Infections

Ventilator-Associated Pneumonia

Central Line–Associated Bloodstream Infections

Catheter-Associated Urinary Tract Infections

Methicillin-Resistant S. Aureus Infection

C. Difficile Infection

What Can Patient Safety Learn from the Approach to Hospital-Associated Infections

Key Points

References and Additional Readings

Chapter 11

-          Post-hospital syndrome

Other Complications of Healthcare

General Concepts

Venous Thromboembolism Prophylaxis

Preventing Pressure Ulcers

Preventing Falls

Preventing Delirium

Key Points

References and Additional Readings

Chapter 12

-          Increased emphasis on safety in ambulatory and non-hospital settings

Patient Safety in the Ambulatory Setting

General Concepts and Epidemiology

Hospital Versus Ambulatory Environments

Improving Ambulatory Safety

Key Points

References and Additional Readings

SECTION III: SOLUTIONS

Chapter 13

-          CPOE and EHRs: more on unanticipated  consequences (new kinds of errors, alert fatigue), lack of interoperability

Information Technology

Healthcares Information Problem

Electronic Health Records

Computerized Provider Order Entry

Other IT-Related Safety Solutions

Computerized Clinical Decision Support Systems

IT Solutions for Improving Diagnostic Accuracy

The Policy Environment for HIT

Key Points

References and Additional Readings

Chapter 14

-          Rethinking root cause analysis

Reporting Systems, Root Cause Analysis, and Other Methods of Understanding Safety Issues

Overview

General Characteristics of Reporting Systems

Hospital Incident Reporting Systems

The Aviation Safety Reporting System

Reports to Entities Outside the Healthcare Organization

Patient Safety Organizations

Root Cause Analysis and Other Incident Investigation Methods

Morbidity and Mortality Conferences

Other Methods of Capturing Safety Problems

Key Points

References and Additional Readings

Chapter 15

-          Update on checklists

Creating a Culture of Safety

Overview

An Illustrative Case

Measuring Safety Culture

Hierarchies, Speaking Up, and the Culture of Low Expectations

Production Pressures

Teamwork Training

Checklists and Culture

Rules, Rule Violations, and Workarounds

Some Final Thoughts on Safety Culture

Key Points

References and Additional Readings

Chapter 16

-          Workforce issues and clinician burnout

Workforce Issues

Overview

Nursing Workforce Issues

Rapid Response Teams

House Staff Duty Hours

The “July Effect”

Nights and Weekends

“Second Victims”: Supporting Caregivers After Major Errors

Key Points

References and Additional Readings

Chapter 17         

-          Safety and medical education (including impact of 2011 duty hours reform and new ACGME patient safety assessment)

Education and Training Issues

Overview

Autonomy Versus Oversight

Simulation Training

Teaching Patient Safety

Key Points

References and Additional Readings

Chapter 18

The Malpractice System

Overview

Tort Law and the Malpractice System

Error Disclosure, Apologies, and Malpractice

No-Fault Systems and “Health Courts”: An Alternative to Tort-Based Medical Malpractice

Cases as a Source of Safety Lessons

Key Points

References and Additional Readings

Chapter 19

Accountability

Overview

Accountability

Disruptive Providers

The “Just Culture”

Reconciling “No Blame” and Accountability

The Role of the Media

Key Points

References and Additional Readings

Chapter 20

-          Impact of major policy initiatives, including the Affordable Care Act and the Partnership for Patients

Accreditation and Regulations

Overview

Accreditation

Regulations

Other Levers to Promote Safety

Problems with Regulatory, Accreditation, and Other Prescriptive Solutions

Key Points

References and Additional Readings

Chapter 21

The Role of Patients

Overview

Patients with Limited English Proficiency

Patients with Low Health Literacy

Errors Caused by Patients Themselves

Patient Engagement as a Safety Strategy

Key Points

References and Additional Readings

Chapter 22

-          Learning healthcare systems

Organizing a Safety Program

Overview

Structure and Function

Managing the Incident Reporting System

Dealing with Data

Strategies to Connect Senior Leadership with Frontline Personnel

Strategies to Generate Frontline Activity to Improve Safety

Dealing with Major Errors and Sentinel Events

Failure Mode and Effects Analyses

Qualifications and Training of the Patient Safety Officer

The Role of the Patient Safety Committee

Engaging Physicians in Patient Safety

Board Engagement in Patient Safety

Research in Patient Safety

Patient Safety Meets Evidence-Based Medicine

Key Points

References and Additional Readings

Conclusion

SECTION IV: APPENDICES

Appendix I. Key Books, Reports, Series, and Web Sites on Patient Safety

Appendix II. The AHRQ Patient Safety Network (AHRQ PSNet) Glossary of Selected Terms in Patient Safety

Appendix III. Selected Milestones in the Field of Patient Safety

Appendix IV. The Joint Commissions National Patient Safety Goals (Hospital Version, 2011)

Appendix V. Agency for Healthcare Research and Qualitys (AHRQ) Patient Safety Indicators (PSIs)

Appendix VI. The National Quality Forums List of Serious Reportable Events,

Appendix VII. The National Quality Forums List of “Safe Practices for Better Healthcare—2010 Update”

Appendix VIII. Medicares “No Pay for Errors” List

Appendix IX. Things Patients and Families Can Do, and Questions They Can Ask, to Improve Their Chances of Remaining Safe in the Hospital

Index