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More About This Title Error Reduction in Health Care: A Systems Approach to Improving Patient Safety, 2nd Edition
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Error Reduction in Health Care
Completely revised and updated, this second edition of Error Reduction in Health Care offers a step-by-step guide for implementing the recommendations of the Institute of Medicine to reduce the frequency of errors in health care services and to mitigate the impact of errors when they do occur.
With contributions from noted leaders in health safety, Error Reduction in Health Care provides information on analyzing accidents and shows how systematic methods can be used to understand hazards before accidents occur. In the chapters, authors explore how to prioritize risks to accurately focus efforts in a systems redesign, including performance measures and human factors.
This expanded edition covers contemporary material on innovative patient safety topics such as applying Lean principles to reduce mistakes, opportunity analysis, deductive adverse event investigation, improving safety through collaboration with patients and families, using technology for patient safety improvements, medication safety, and high reliability organizations.
The Editor
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Patrice L. Spath, MA, RHIT, is president of Brown-Spath & Associates and assistant professor in the Department of Health Services Administration at the University of Alabama in Birmingham. She serves on the advisory board for WebM&M, an online case-based journal and forum on patient safety and health care quality sponsored by the Agency for Healthcare Research and Quality. Spath has authored numerous books and journal articles on health care performance improvement and patient safety.
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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
