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

by Patrice L. Spath

• ISBN13: 9781556482717
• ISBN10: 155648271X
• Edition: 1st
• Format: Hardcover
• Copyright: 2000-03-01
• Publisher: AMERICAN HOSPITAL PUBLISHING

Summary

An AHA Press/Jossey-Bass PublicationForeword by Lucian LeapeError Reduction in Health Care explores the complex causes of medical mistakes and offers sound advice for leaders who want to reduce the frequency of errors in health care services and mitigate the impact of those errors that do occur. The book is packed pull of examples of thorough incident investigations and process improvement recommAndations from leaders in the field of health care quality and risk management.

Author Biography

Patrice L. Spath, BA, ART, is a health care quality and information management specialist based in Forest Grove, Oregon Richard J. Croteau, MD, is executive director for strategic initiatives at the Joint Commission on Accreditation of Healthcare Organizations Sanford E. Feldman, MD, FACS, is a retired general surgeon Karen Ferraco is a risk management consultant at ProNational Insurance Company in Okemos, Michigan Susan T. Goodwin, RN, MSN, is director of quality management in the quality standards department for Columbia/HCA Healthcare Corporation in Nashville, Tennessee Kenneth A. Hirsch, MD, PhD, is a director of Medical Risk Management Associates, LLC, in San Diego, California Frank Houser, MD, is the chief medical director and senior vice president of quality at Columbia/HCA Physician Services in Nashville Robert J. Latino is vice-president of strategic development for Reliability Center, Inc. in Hopewell, Virginia Susan McClanahan, RN, BSN, is a director in the quality standards department of Columbia/HCA Healthcare Corporation in Nashville Matthew M. Rice, MD, JD, FACEP, is a board-certified emergency physician; a fellow of the American College of Emergency Physicians, and an attorney. He is chief of the department of emergency medicine at Madigan Army Medical Center and program director for emergency medicine residency; assistant clinical professor at the Uniformed Services University of Health Sciences in Bethesda, Maryland; clinical assistant professor in medicine at the University of Washington in Seattle Daniel T. Risser, PhD, is an experimental social psychologist. He is a senior scientist in the Crew Performance Group at Dynamics Research Corporation in Andover, Massachusetts Douglas W. Roblin, PhD, is senior research scientist with Kaiser Permanente's Georgia region Mary L. Salisbury, RN, MSN, is the director of the Institute for Quality Healthcare of Dynamics Research Corporation in Andover, Massachusetts Paul M. Schyve, MD, is the senior vice president of the Joint Commission on Accreditation of Healthcare Organizations Robert Simon, MEd, EdD, is the chief scientist and manager of the Crew Performance Group at Dynamics Research Corporation in Andover, Massachusetts Sven Ternov, MD, a physician specializing in general medicine, is an inspector for the Swedish Board of Health and Welfare at the regional unit in Malmoe Dennis T. Wallace, DABRM, is a director of Medical Risk Management Associates, LLC in San Diego

Table of Contents

List of Figures and Tables	vii
About the Editor	xi
About the Contributors	xiii
Foreword	xxi
Preface	xxv
Acknowledgments	xxxi
A Formula for Errors: Good People + Bad Systems	1	(16)
Susan McClanahan
Susan T. Goodwin
Frank Houser
Measuring Performance of High-Risk Processes	17	(80)
Karen Ferraco
Patrice L. Spath
The Human Side of Medical Mistakes	97	(42)
Sven Ternov
Accident Investigation and Anticipatory Failure Analysis in Hospitals	139	(16)
Sanford E. Feldman
Douglas
W. Roblin
Automating Root Cause Analysis	155	(10)
Robert J. Latino
One Hospital's View of Software Facilitation of Root Cause Analysis	165	(14)
Kenneth A. Hirsch
Dennis T. Wallace
Proactively Error-Proofing Health Care Processes	179	(20)
Richard J. Croteau
Paul M. Schyve
Reducing Errors through Work System Improvements	199	(36)
Patrice L. Spath
A Structured Teamwork System to Reduce Clinical Errors	235	(44)
Daniel T. Risser
Robert Simon
Matthew M. Rice
Mary L. Salisbury
Index	279