Title Details

Joanne E. Turnbull, RN, MS, is a well-known writer and speaker on the subject of patient safety. Until 2001 she was the executive director of the National Patient Safety Foundation.

Preface xv

Acknowledgments xxiii

The Authors xxvii

Introduction 1

1 Declare Patient Safety Urgent and a Priority 12

2 Error and Harm in Health Care 23

3 Understanding the Basics of Patient Safety 44

4 Assume Executive Responsibility 71

5 Import New Knowledge and Skills 96

6 Install a Blameless Reporting System 120

7 Assign Accountability 148

8 Align External Controls and Reform Education 181

9 Accelerate Change For Improvement 204

10 The End of the Beginning 234

References 245

Glossary 255

Appendixes

1 Checklist for Assessing Institutional Resilience 279

2 Creating De-Identified Case Studies for Dissemination 283

3 Medical Accidents Policy: Reporting and Disclosure,

Including Sentinel Events 285

4 Medication Safety Team Feedback Form 295

5 Patient Safety Workplan 297

6 Safety Learning Report 300

7 Stop-the-Line Policy: Authority to Intervene to Restore Patient Safety 303

8 Complexity Lens Reflection 308

9 A Brief Look at Gaps in the Continuity of Care 311

10 A Brief Look at the New Look in Complex System Failure, Error, and Safety 313

11 A Reminder on Every Chart 315

12 List of Serious Reportable Events in Health Care 316

13 Statement of Principle: Talking to Patients About Health Care Injury 321

14 VHA Patient Safety Organizational Assessment 322

Additional Readings 331

Resources 335

Index 345