Error Reduction in Health Care A Systems Approach to Improving Patient Safety

by Spath, Patrice L.

• ISBN13: 9780470502402
• ISBN10: 0470502401
• Edition: 2nd
• Format: Paperback
• Copyright: 2011-04-12
• Publisher: Jossey-Bass

Summary

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.

Author Biography

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 WebMM, 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.

Table of Contents

Figures, Tables, and Exhibits	p. v
Foreword	p. ix
Preface	p. xi
The Editor	p. xvii
The Authors	p. xix
The Basics of Patient Safety
A Formula for Errors: Good People + Bad Systems	p. 3
The Human Side of Medical Mistakes	p. 21
High Reliability and Patient Safety	p. 35
Measure and Evaluate Patient Safety
Measuring Patient Safety Performance	p. 59
Analyzing Patient Safety Performance	p. 103
Using Performance Data to Prioritize Safety Improvement Projects	p. 119
Reactive and Proactive Safety Investigations
Accident Investigation and Anticipatory Failure Analysis	p. 143
MTO and DEB Analysis Can Find System Breakdowns	p. 157
Using Deductive Analysis to Examine Adverse Events	p. 171
How to Make Health Care Processes Safer
Proactively Error-Proofing Health Care Processes	p. 197
Reducing Errors Through Work System Improvements	p. 217
Improve Patient Safety with Lean Techniques	p. 245
Focused Patient Safety Initiatives
How Information Technology Can Improve Patient Safety	p. 269
A Structured Teamwork System to Reduce Clinical Errors	p. 297
Medication Safety Improvement	p. 335
Glossary	p. 369
Index	p. 383
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