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.
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.
Figures, Tables, and Exhibits. Foreword (Lucien L. Leape). Preface. The Editor. The Authors. PART ONE The Basics of Patient Safety. 1: A Formula for Errors Good People + Bad Systems (Susan McClanahan, Susan T. Goodwin, and Jonathan B. Perlin). 2: The Human Side of Medical Mistakes (Sven Ternov). 3: High Reliability and Patient Safety (Yosef D. Dlugacz and Patrice L. Spath). PART TWO Measure and Evaluate Patient Safety. 4: Measuring Performance of High-Risk Processes (Karen Ferraco and Patrice L. Spath). 5: Analyzing Patient Safety Performance (Karen Ferraco and Patrice L. Spath). 6: Using Performance Data to Prioritize Safety Improvement Projects (Robert Latino). PART THREE Reactive and Proactive Safety Investigations. 7: Accident Investigation and Anticipatory Failure Analysis Sanford E. Feldman and Douglas W. Roblin 8: MTO and DEB Analysis Can Find System Breakdowns (Sven Ternov). 9: Using Deductive Analysis to Examine Adverse Events (Robert Latino). PART FOUR How to Make Health Care Processes Safer. 10: Proactively Error-Proofing Health Care Processes (Richard J. Croteau and Paul M. Schyve). 11: Reducing Errors Through Work Systems Improvements (Patrice L. Spath). 12: Improve Patient Safety with Lean Techniques (Danielle Lavallee). PART FIVE Focused Patient Safety Initiatives. 13: How Information Technology Can Improve Patient Safety (Donna J. Slovensky and Nir Menachemi). 14: A Structured Teamwork System to Reduce Clinical Errors (Daniel T. Risser, Robert Simon, Matthew M. Rice, Mary L. Salisbury, and John C. Morey). 15: Medication Safety Improvement (Yosef D. Dlugacz). Glossary. Index.