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

Error Reduction in Health Care: A Systems Approach to Improving Patient Safety, 2nd Edition 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.

Table of Contents:
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

About the Author :
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.