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Practical Patient Safety 1st Edition by John Reynard, John Reynolds, Peter Stevenson ISBN 0199239932 9780199239931

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Practical Patient Safety 1st Edition John Reynard Digital Instant Download

Author(s): John Reynard, John Reynolds, Peter Stevenson
ISBN(s): 9780199239931, 0199239932
Edition: 1
File Details: PDF, 1.71 MB
Year: 2009
Language: english
SKU: EB-5223330 Category: Tags: , ,

Practical Patient Safety 1st Edition by John Reynard, John Reynolds, Peter Stevenson – Ebook PDF Instant Download/Delivery: 0199239932, 9780199239931
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Product details:

ISBN 10: 0199239932 
ISBN 13: 9780199239931
Author: John Reynard, John Reynolds, Peter Stevenson

Following recent high profile cases of surgical error in the UK and USA, patient safety has become a key issue in healthcare, now placed at heart of junior doctor’s training. Errors made by doctors are very similar to those made in other high risk organisations, such as aviation, nuclear and petrochemical industries. Practical Patient Safety aims to demonstrate how core principles of safety from these industries can be applied in surgical and medical practice, in particular through training for health care professionals and healthcare managers. Whilst theoretical aspects of risk management form the backdrop, the book focuses on key techniques and principles of patient safety in a practical way, giving the reader practical advice on how to avoid personal errors, and more importantly how to start patient safety training within his or her department or hospital.

Practical Patient Safety 1st Table of contents:

1. Clinical Error: The Scale of the Problem

  • The Harvard Medical Practice Study 1984

  • The Quality in Australian Healthcare Study 1992

  • The University College London Study 2001

  • Danish, New Zealand, Canadian, and French studies

  • The frequency and costs of adverse drug events

  • Accuracy of retrospective studies

  • Error rates revealed in retrospective studies

  • Error rates according to type of clinical activity

  • Deaths from adverse events

  • Extra bed days as a consequence of error

  • Criminal prosecutions for medical errors

  • Reliability: other industries

  • Reliability: healthcare

  • References

2. Clinical Errors: What Are They?

  • Sources of error in primary care and office practice

  • Sources of error along the patient pathway in hospital care

  • Errors in dealing with referral letters

  • Errors of identification

  • Errors in note keeping

  • Errors with medical records in general

  • Slips in dictated letters

  • Errors from patients failing to attend appointments

  • Infection control and hand hygiene

  • Admission to hospital

  • Diagnostic errors

  • Errors in drug prescribing and administration

  • Reducing errors in blood transfusion

  • Intravenous drug administration

  • Errors in the operating theatre

  • Use of diathermy

  • Patient positioning and support failures

  • Generic safety checks in surgery

  • Failure to give DVT and antibiotic prophylaxis

  • Postoperative errors

  • Shared care

  • Medical devices

  • References

3. Safety Culture in High Reliability Organizations

  • Background and definition

  • Common features

  • Consequences of failure

  • Convergent evolution and healthcare implications

  • Learning from accidents

  • Elements of a safety culture

  • Counter-intuitive aspects of safety culture

  • References

4. Case Studies

  • Case 1: Wrong patient

  • Case 2: Wrong blood

  • Case 3: Wrong side nephrectomy

  • Case 4–5: Additional wrong side nephrectomy cases

  • Cases 6–8: Medication errors—wrong route (intrathecal vincristine)

  • Case 9: Miscalculation of dose

  • Case 10: Mis-prescribed frequency

  • Case 11: Wrong drug

  • Case 12: Miscommunication of pathology result

  • Case 13: Mixed-up biopsy results

  • Case 14: Penicillin allergy death

  • Case 15: Missing X-ray report

  • Case 16: Medication not given

  • Case 17: Oesophageal intubation

  • Case 18: Tiredness error

  • Case 19: Inadequate training

  • Case 20: Fatality—anaesthetist fell asleep

  • References

5. Error Management

  • Person vs systems approach

  • Error chains and system failures

  • Catalyst events

  • Human error and classification

  • Problem-solving by experts vs novices

  • Error management opportunities

  • Detecting and reversing error chains

  • Red flags and symptoms of incipient failure

  • Speaking up protocols

  • Using accident and incident data

  • References

6. Communication Failure

  • Prevalence in adverse events

  • Categories of communication failure

  • Responsibility: sender or receiver?

  • Safety-critical communication (SCC) protocols

  • Preventing errors in healthcare settings

  • Crafting abnormal or non-routine SCC messages

  • Failures in written/documented communication

  • References

7. Situation Awareness

  • Definitions and three levels

  • Catastrophic loss: “mind lock” syndrome

  • Understanding and preventing loss

  • Role of mental models in cognitive failure

  • Ensuring high situation awareness

  • Special cases

  • References

8. Professional Culture

  • Comparisons between professions

  • Negative cultural traits

  • Hierarchical structures

  • Changing professional cultures

  • Team resource management and non-technical skills

  • References

9. When Carers Deliberately Cause Harm

  • References

10. Patient Safety Toolbox

  • Practical strategies to improve patient safety

11. Conclusions

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Tags: John Reynard, John Reynolds, Peter Stevenson, Practical Patient