Cover Image

Textbook of Patient Safety and Clinical Risk Management.

Bibliographic Details
Main Author: Donaldson, Liam.
Other Authors: Ricciardi, Walter., Sheridan, Susan., Tartaglia, Riccardo.
Format: eBook
Language:English
Published: Cham : Springer International Publishing AG, 2020.
Edition:1st ed.
Subjects:
Electronic books.
Online Access:Click to View
Table of Contents:
  • Intro
  • Foreword
  • Preface
  • Acknowledgements
  • Contents
  • Part I: Introduction
  • 1: Guidelines and Safety Practices for Improving Patient Safety
  • 1.1 Introduction
  • 1.2 The Need to Understand Guidelines Before Improving Safety
  • 1.3 The Current Patient Safety Picture and the Demand for Guidelines
  • 1.4 Implementing the Research on Patient Safety to Improve Clinical Practice
  • 1.5 Working Towards Producing Guidelines That Improve Safety Practices
  • 1.6 The Challenges of Improving Safety and the Current Limits of Guidelines
  • 1.7 Recommendations
  • References
  • 2: Brief Story of a Clinical Risk Manager
  • 2.1 Introduction
  • 2.2 The Start
  • 2.3 The Evolution of the Patient Safety System
  • 2.4 The Network of Clinical Risk Manager
  • 2.5 Training and Instruction
  • 2.6 Adverse Events
  • 2.7 The First Results
  • 2.8 The Relationship with Politics and Managers
  • 2.9 The Italian Law on the Safety of Care
  • References
  • 3: Human Error and Patient Safety
  • 3.1 Introduction
  • 3.2 What Is an Error?
  • 3.3 Understanding Error
  • 3.3.1 Slips and Lapses
  • 3.3.2 Mistakes
  • 3.3.3 Violations
  • 3.4 Understanding the Influence of the Wider System
  • 3.5 Contributory Factors: Seven Levels of Safety
  • 3.6 Putting It All Together: Illustration of Two Cases from an Acute Care Setting
  • 3.6.1 Case 1: An Avoidable Patient Fall
  • 3.6.2 Case 2: An Avoidable Emergency Laparotomy in a Case of Ectopic Pregnancy
  • 3.7 Conducting Your Own Incident Investigation
  • 3.8 Systems Analysis of Clinical Incidents
  • 3.8.1 From Analysis to Meaningful Action
  • 3.9 Supporting Patients, Families, and Staff
  • 3.10 Conclusions and Recommendations
  • References
  • 4: Looking to the Future
  • 4.1 Introduction
  • 4.2 The Vision for the Future
  • 4.3 The Challenges to Overcome to Facilitate Safety.
  • 4.4 Develop the Language and Culture of Safety
  • 4.5 Promote Psychological Safety
  • 4.6 Design for Health and for Safety
  • 4.7 Social Determinants of Patient Safety
  • 4.8 Harnessing Technology for the Future (Reference Chap. 33)
  • 4.9 Conclusion
  • References
  • Overview
  • Develop the Language and Culture of Safety
  • Psychological Safety and Well-Being
  • Design for Safety
  • Social Determinants for Patient Safety
  • Digital Health and Patient Safety
  • 5: Safer Care: Shaping the Future
  • 5.1 Introduction
  • 5.2 Thinking About Safer Healthcare
  • 5.2.1 Accidents and Incidents: The Importance of Systems
  • 5.2.2 Culture, Blame, and Accountability
  • 5.2.3 Leadership at the Frontline
  • 5.3 Global Action to Improve Safety
  • 5.3.1 Patient Safety on the Global Health Agenda
  • 5.3.2 World Alliance for Patient Safety: Becoming Global
  • 5.3.3 The Global Patient Safety Challenges
  • 5.3.4 Patients and Families: Championing Change
  • 5.3.5 African Partnerships for Patient Safety
  • 5.3.6 Third Global Patient Safety Challenge: Medication Without Harm
  • 5.3.7 The 2019 WHA Resolution and World Patient Safety Day
  • 5.4 Conclusions
  • References
  • 6: Patients for Patient Safety
  • 6.1 Introduction
  • 6.2 What is Co-production in Healthcare?
  • 6.3 Background: The Genesis of a Global Movement for Co-production for Safer Care
  • 6.4 Co-Production in Research
  • 6.4.1 Example: United States
  • 6.4.1.1 Mothers Donating Data: Going from Research to Policy to Practice
  • 6.4.1.2 Civil Society: Driving Patient-Centered Research to Prevent Diagnostic Errors
  • 6.5 Co-production in Medical Professions Education Courses
  • 6.5.1 Example: Mexico
  • 6.5.1.1 Leveraging a Regional Network of PFPS Champions to Enhance Medical Education
  • 6.5.2 Example: Denmark
  • 6.5.2.1 Patients as Educators.
  • 6.6 Co-production in Healthcare Organization Quality Improvement
  • 6.6.1 Example: Egypt
  • 6.6.1.1 Improving Disparities in Care for New Mothers: The Power of Partnership Between a Civil Society Leader and a Public Teaching Hospital
  • 6.6.2 Italy
  • 6.6.2.1 Democratizing Healthcare: A Government-Driven/Citizen Partnership to Improve Patient Centeredness
  • 6.7 Co-Production in Policy
  • 6.7.1 Example: Canada
  • 6.7.1.1 Working from Within: Co-producing National Policy as an Insider
  • 6.8 Conclusion
  • References
  • 7: Human Factors and Ergonomics in Health Care and Patient Safety from the Perspective of Medical Residents
  • 7.1 Introduction
  • 7.2 Application of SEIPS Model to Medical Residents
  • 7.3 Linkage of Work System to Patient Safety and Medical Resident Well-Being
  • 7.4 Challenges and Trade-Offs in Improving Residents' Work System
  • 7.5 Role of Residents in Improving Their Work System
  • 7.6 Conclusion
  • References
  • Part II: Background
  • 8: Patient Safety in the World
  • 8.1 Introduction
  • 8.2 Epidemiology of Adverse Events
  • 8.3 Most Frequent Adverse Events
  • 8.3.1 Medication Errors
  • 8.3.2 Healthcare-Associated Infections
  • 8.3.3 Unsafe Surgical Procedures
  • 8.3.4 Unsafe Injections
  • 8.3.5 Diagnostic Errors
  • 8.3.6 Venous Thromboembolism
  • 8.3.7 Radiation Errors
  • 8.3.8 Unsafe Transfusion
  • 8.4 Implementation Strategy
  • 8.5 Recommendations and Future Challenges
  • Bibliography
  • 9: Infection Prevention and Control
  • 9.1 Introduction
  • 9.2 Main Healthcare-Associated Infection
  • 9.2.1 Urinary Tract Infections (UTIs)
  • 9.2.2 Bloodstream Infections (BSIs)
  • 9.2.3 Surgical Site Infections
  • 9.2.4 Healthcare-Associated Pneumonia
  • 9.3 Antimicrobial Resistance
  • 9.4 Healthcare-Associated Infection Prevention.
  • 9.4.1 The Prevention and Control of Healthcare-Associated Infection: A Challenge for Clinical Risk Management
  • 9.4.2 Risk Management Tools
  • 9.4.2.1 Root Cause Analysis
  • 9.4.2.2 Significant Event Audit
  • 9.4.2.3 Process Analysis
  • 9.4.2.4 Failure Modes and Effects Analysis
  • 9.4.3 The Best Practices Approach
  • 9.4.3.1 Hand Hygiene
  • 9.4.3.2 Antimicrobial Stewardship
  • 9.4.3.3 Care Bundles
  • CAUTI Maintenance Bundle
  • Ventilator Bundle
  • 9.5 Engaging Patients and Families in Infection Prevention
  • 9.6 Identification and Rapid Management of Sepsis: A Test Bed for the Integration of Risk Management and IPC
  • 9.6.1 Sepsis and Septic Shock Today
  • 9.6.2 Sepsis as an Adverse Event: Failures in Identification and Management
  • 9.7 Conclusions
  • References
  • 10: The Patient Journey
  • 10.1 Introduction
  • 10.2 The Patient Journey
  • 10.3 Contextualizing Patient Safety in the Patient Journey
  • 10.4 From PartecipaSalute to the Accademia del Cittadino: The Importance of Training Courses to Empower Patients
  • 10.5 Recommendations
  • References
  • 11: Adverse Event Investigation and Risk Assessment
  • 11.1 Risk Management in Complex Human Systems and Organizations
  • 11.1.1 Living with Uncertainty
  • 11.1.2 Two Levels of Risk Management in Healthcare Systems
  • 11.2 Patient Safety Management
  • 11.3 Clinical Risk Management
  • 11.4 Systemic Analysis of Adverse Events
  • 11.4.1 The Dynamics of an Incident
  • 11.4.2 A Practical Approach: The London Protocol Revisited
  • 11.5 Analysis of Systems and Processes Reliability
  • 11.6 An Integrated Vision of Patient Safety
  • References
  • 12: From Theory to Real-World Integration: Implementation Science and Beyond
  • 12.1 Introduction
  • 12.1.1 Characteristics of Healthcare and Its Complexity
  • 12.1.2 Epidemiology of Adverse Events and Medical Errors.
  • 12.1.2.1 Barriers to Safe Practice in Healthcare Settings
  • 12.1.3 Error and Barriers to Safety: The Human or the System?
  • 12.2 Approaches to Ensuring Quality and Safety
  • 12.2.1 The Role of Implementation Science and Ethnography in the Implementation of Patient Safety Initiatives
  • 12.2.1.1 WHO Twinning Partnership for Improvement (TPI) Model
  • 12.2.1.2 Institute for Healthcare Improvement Breakthrough Collaborative
  • 12.2.1.3 Case Study: Kenya
  • 12.2.2 Challenges and Lessons Learned from the Field Experience and the Need for More Extensive Collaboration and Integration of Different Approaches
  • 12.2.3 Human Factors and Ergonomics
  • 12.3 Way Forward
  • 12.3.1 International Ergonomics Association General Framework Model
  • References
  • Part III: Patient Safety in the Main Clinical Specialties
  • 13: Intensive Care and Anesthesiology
  • 13.1 Introduction
  • 13.2 Epidemiology of Adverse Events
  • 13.3 Most Frequent Errors
  • 13.4 Safety Practices and Implementation Strategies
  • 13.4.1 Medication Errors
  • 13.4.2 Monitoring
  • 13.4.3 Equipment
  • 13.4.4 Cognitive Aids
  • 13.4.5 Communication and Teamwork
  • 13.4.6 Building a Safety Culture
  • 13.4.7 Psychological Status of Staff and Staffing Policies
  • 13.4.8 The Building Factor
  • 13.5 Recommendations
  • References
  • 14: Safe Surgery Saves Lives
  • 14.1 Safety Best Practices in Surgery
  • 14.2 Factors Which Influence Patient Safety in Surgery
  • 14.3 Techniques and Procedures
  • 14.4 Surgical Equipment and Instruments
  • 14.5 Pathways and Practice Management Guidelines
  • 14.6 Gender
  • 14.7 Training
  • 14.8 Costs and Risks
  • 14.9 Infection Control
  • 14.10 Surgical Safety Checklist
  • 14.11 Overlap Between Surgical and Other Safety Initiatives
  • 14.12 Technical and Non-technical Skills
  • 14.13 Simulation.
  • 14.14 Training Future Leaders in Patient Safety.

Similar Items