High reliability
"High reliability organizations are organizations that operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures. The concept of high reliability is attractive for health care, due to the complexity of operations and the risk of significant and even potentially catastrophic consequences when failures occur in health care."
Read more on "High reliability" on the AHRQ's Patient Safety Network site.
Failure mode and effect analysis (FMEA)
"Failure mode and effect analysis (FMEA) is a common approach to prospectively determine error risk within a particular process. FMEA begins by identifying all the steps that must be taken for a given process to occur ("process mapping") and then how each step can go wrong (i.e., failure modes), the probability that each error will be detected before causing harm, and the impact of the error if it actually occurs. The estimated likelihood of a particular process failure, the chance of detecting such failure, and its impact are combined numerically to produce a criticality index, which provides a rough estimate of the magnitude of hazard posed by each step in a high-risk process. Steps ranked at the top (those with the highest criticality indices) should be prioritized for error proofing."
Read more on "FMEA" and detection of safety hazards on AHRQ's Patient Safety Network site.
Human Factors Engineering
"Human factors engineering is...the discipline that takes into account human strengths and limitations in the design of interactive systems that involve people, tools and technology, and work environments to ensure safety, effectiveness, and ease of use."
Read more on "Human factors engineering" on AHRQ's Patient Safety Network site.
Patient Safety Ebooks
Medical Quality Management by
This comprehensive medical textbook is a compendium of the latest information on healthcare quality. The text provides knowledge about the theory and practical applications for each of the core areas that comprise the field of medical quality management as well as insight and essential briefings on the impact of new healthcare technologies and innovations on medical quality and improvement. The third edition provides significant new content related to medical quality management and quality improvement, a user-friendly format, case studies, and updated learning objectives. This textbook also serves as source material for the American Board of Medical Quality in the development of its core curriculum and certification examinations. Each chapter is designed for a review of the essential background, precepts, and exemplary practices within the topical area: Basics of Quality Improvement Data Analytics for the Improvement of Healthcare Quality Utilization Management, Case Management, and Care Coordination Economics and Finance in Medical Quality Management External Quality Improvement -- Accreditation, Certification, and Education The Interface Between Quality Improvement and Law Ethics and Quality Improvement With the new edition of Medical Quality Management: Theory and Practice, the American College of Medical Quality presents the experience and expertise of its contributors to provide the background necessary for healthcare professionals to assume the responsibilities of medical quality management in healthcare institutions, provide physicians in all medical specialties with a core body of knowledge related to medical quality management, and serve as a necessary guide for healthcare administrators and executives, academics, directors, medical and nursing students and residents, and physicians and other health practitioners.
ISBN: 9783030480790Publication Date: 2020-09-01
Understanding Patient Safety, Third Edition by
Publisher's Note: Products purchased from Third Party sellers are not guaranteed by the publisher for quality, authenticity, or access to any online entitlements included with the product. Now revised and updated--the landmark patient safety primer written by the world's leading authorities Medical errors are the unfortunate byproduct of an increasingly complex healthcare system. Now more than ever, keeping patients safe takes well-trained caregivers, relevant insights from a range of industries, additional investment--and a groundbreaking text like Understanding Patient Safety. Understanding Patient Safety is "must read" for those seeking to master the clinical, organizational, and systems issues of patient safety. In this bestselling primer, patient safety pioneer Robert Wachter and Kiran Gupta put all the essential tools and principles at your fingertips. Engaging and accessible, the book is filled with high-yield cases, analyses, tables, graphics, along with key points and references--all designed to help you optimize quality and safety. Understanding Patient Safety begins with an introduction to patient safety and medical errors. Its second section surveys specific types of medical errors, including those related to surgery, medications, diagnosis, transition and handoff, and infections. The third section covers proven solutions, from establishing reporting systems, to creating a culture of safety. The third edition reflects pivotal new developments in the field, including major updates in diagnostic errors, information technology and patient safety, ambulatory safety, and clinician burnout. Features: *Coverage of human factors and errors at the person-machine interface *Review of workplace issues, including supporting caregivers after major errors *How to organize an effective safety program *Coordination of patient education and training *Overview of the malpractice system *Discussion of the patient's role
ISBN: 9781259860249Publication Date: 2017-11-23
Understanding Healthcare Delivery Science by
An accessible new title focused on the science of healthcare delivery, from the acclaimed Understanding series "... a landmark text that will shape the field and inform our dialog for years to come---and it should be part of the required curriculum at medical and nursing schools around the world. Excellence in healthcare delivery science should become a core competency of the modern physician. Howell and Stevens have given medicine an important gift that may enable just that." - Sachin H. Jain, MD, MBA, FACP; President and CEO, CareMore and Aspire Health; Co-Founder and Co-Editor-in-Chief, Healthcare: The Journal of Delivery Science and Innovation "You hold in your hands 35 years of investigation and learning, condensed into understandable principles and applications. It is a guidebook for effective care delivery leadership, practice, and success." - Brent C. James, MD, MStat, Clinical Professor, Stanford University School of Medicine "...a must-read for anyone who, like me, is frustrated with the pace of our progress and is committed to creating a learning health system for all." - Lisa Simpson MB, BCh, MPH, FAAP, President and CEO, AcademyHealth "... will quickly become the go-to, must-read resource for practitioners looking to have an impact as innovators in healthcare delivery." - David H. Roberts, MD, Steven P. Simcox, Patrick A. Clifford, and James H. Higby Associate Professor of Medicine, Harvard Medical School Today's healthcare system is profoundly complicated, but we persist in trying to roll out breakthroughs as if the healthcare system were still just the straightforward "physician's workshop" of the early 20th century. Only rarely do we employ research-quality analytics to assess how well our care delivery innovations really work in the practice. And shockingly, the US healthcare delivery system spends only 0.1% of revenue on R&D in how we actually deliver care. Small wonder that we find ourselves faced with the current medical paradox: Treatments that seemed miraculous at the beginning of our lifetimes are routine today, but low-quality care and medical errors harm millions of people worldwide even as spiraling healthcare costs bankrupt an unacceptable number of American families every year. Healthcare delivery science bridges this gap between scientific research and complex, real-world healthcare delivery and operations. With its engaging, clinically relevant style, Understanding Healthcare Delivery Science is the perfect introduction to this emerging field. This reader-friendly text pairs a thorough discussion of commonly available healthcare improvement tools and top-tier research methods with numerous case studies that put the content into a clinically relevant framework, making this text a valuable tool for administrators, researchers, and clinicians alike.
ISBN: 9781260026481Publication Date: 2019-12-17
Handbook of Human Factors and Ergonomics in Health Care and Patient Safety by
The first edition of Handbook of Human Factors and Ergonomics in Health Care and Patient Safety took the medical and ergonomics communities by storm with in-depth coverage of human factors and ergonomics research, concepts, theories, models, methods, and interventions and how they can be applied in health care. Other books focus on particular human factors and ergonomics issues such as human error or design of medical devices or a specific application such as emergency medicine. This book draws on both areas to provide a compendium of human factors and ergonomics issues relevant to health care and patient safety. The second edition takes a more practical approach with coverage of methods, interventions, and applications and a greater range of domains such as medication safety, surgery, anesthesia, and infection prevention. New topics include: work schedules error recovery telemedicine workflow analysis simulation health information technology development and design patient safety management Reflecting developments and advances in the five years since the first edition, the book explores medical technology and telemedicine and puts a special emphasis on the contributions of human factors and ergonomics to the improvement of patient safety and quality of care. In order to take patient safety to the next level, collaboration between human factors professionals and health care providers must occur. This book brings both groups closer to achieving that goal.
ISBN: 9781439830338Publication Date: 2011-11-09
To Err Is Human by
Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDS--three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequence--but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agenda--with state and local implications--for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errors--which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health care--it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocates--as well as patients themselves. "First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine"
ISBN: 9780309261746Publication Date: 2000-04-01
Crossing the Quality Chasm by
Second in a series of publications from the Institute of Medicine's Quality of Health Care in America project Today's health care providers have more research findings and more technology available to them than ever before. Yet recent reports have raised serious doubts about the quality of health care in America. Crossing the Quality Chasm makes an urgent call for fundamental change to close the quality gap. This book recommends a sweeping redesign of the American health care system and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others. In this comprehensive volume the committee offers: A set of performance expectations for the 21st century health care system. A set of 10 new rules to guide patient-clinician relationships. A suggested organizing framework to better align the incentives inherent in payment and accountability with improvements in quality. Key steps to promote evidence-based practice and strengthen clinical information systems. Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change.
ISBN: 0309072808Publication Date: 2001-08-19
Teaming by
New breakthrough thinking in organizational learning, leadership, and change Continuous improvement, understanding complex systems, and promoting innovation are all part of the landscape of learning challenges today's companies face. Amy Edmondson shows that organizations thrive, or fail to thrive, based on how well the small groups within those organizations work. In most organizations, the work that produces value for customers is carried out by teams, and increasingly, by flexible team-like entities. The pace of change and the fluidity of most work structures means that it's not really about creating effective teams anymore, but instead about leading effective teaming. Teaming shows that organizations learn when the flexible, fluid collaborations they encompass are able to learn. The problem is teams, and other dynamic groups, don't learn naturally. Edmondson outlines the factors that prevent them from doing so, such as interpersonal fear, irrational beliefs about failure, groupthink, problematic power dynamics, and information hoarding. With Teaming, leaders can shape these factors by encouraging reflection, creating psychological safety, and overcoming defensive interpersonal dynamics that inhibit the sharing of ideas. Further, they can use practical management strategies to help organizations realize the benefits inherent in both success and failure. Presents a clear explanation of practical management concepts for increasing learning capability for business results Introduces a framework that clarifies how learning processes must be altered for different kinds of work Explains how Collaborative Learning works, and gives tips for how to do it well Includes case-study research on Intermountain healthcare, Prudential, GM, Toyota, IDEO, the IRS, and both Cincinnati and Minneapolis Children's Hospitals, among others Based on years of research, this book shows how leaders can make organizational learning happen by building teams that learn.
ISBN: 078797093XPublication Date: 2012-04-03
The Human Contribution by
This book explores the human contribution to the reliability and resilience of complex, well-defended systems. Usually the human is considered a hazard - a system component whose unsafe acts are implicated in the majority of catastrophic breakdowns. However there is another perspective that has been relatively little studied in its own right - the human as hero, whose adaptations and compensations bring troubled systems back from the brink of disaster time and again. What, if anything, did these situations have in common? Can these human abilities be 'bottled' and passed on to others? The Human Contribution is vital reading for all professionals in high-consequence environments and for managers of any complex system. The book draws its illustrative material from a wide variety of hazardous domains, with the emphasis on healthcare reflecting the author's focus on patient safety over the last decade. All students of human factors - however seasoned - will also find it an invaluable and thought-provoking read.
ISBN: 9781351888110Publication Date: 2017-03-02
Achieving Safe and Reliable Healthcare by
Every healthcare organization must address the issue of medical error or face the negative response of the public, the media, and regulatory bodies. This practical resource will provide you with a comprehensive blueprint for building and supporting a culture of patient safety. It includes contributions from experts in leading organizations including the renowned Institute for Healthcare Improvement.
ISBN: 9781417555260Publication Date: 2004-01-01
Drift into Failure by
What does the collapse of sub-prime lending have in common with a broken jackscrew in an airliner's tailplane? Or the oil spill disaster in the Gulf of Mexico with the burn-up of Space Shuttle Columbia? These were systems that drifted into failure. While pursuing success in a dynamic, complex environment with limited resources and multiple goal conflicts, a succession of small, everyday decisions eventually produced breakdowns on a massive scale. We have trouble grasping the complexity and normality that gives rise to such large events. We hunt for broken parts, fixable properties, people we can hold accountable. Our analyses of complex system breakdowns remain depressingly linear, depressingly componential - imprisoned in the space of ideas once defined by Newton and Descartes. The growth of complexity in society has outpaced our understanding of how complex systems work and fail. Our technologies have gotten ahead of our theories. We are able to build things - deep-sea oil rigs, jackscrews, collateralized debt obligations - whose properties we understand in isolation. But in competitive, regulated societies, their connections proliferate, their interactions and interdependencies multiply, their complexities mushroom. This book explores complexity theory and systems thinking to understand better how complex systems drift into failure. It studies sensitive dependence on initial conditions, unruly technology, tipping points, diversity - and finds that failure emerges opportunistically, non-randomly, from the very webs of relationships that breed success and that are supposed to protect organizations from disaster. It develops a vocabulary that allows us to harness complexity and find new ways of managing drift.
ISBN: 9781409422228Publication Date: 2011-02-28
The House of God by
By turns heartbreaking, hilarious, and utterly human, The House of God is a mesmerizing and provocative novel about what it really takes to become a doctor. "The raunchy, troubling, and hilarious novel that turned into a cult phenomenon. Singularly compelling...brutally honest."--The New York Times Struggling with grueling hours and sudden life-and-death responsibilities, Basch and his colleagues, under the leadership of their rule-breaking senior resident known only as the Fat Man, must learn not only how to be fine doctors but, eventually, good human beings. A phenomenon ever since it was published, The House of God was the first unvarnished, unglorified, and uncensored portrait of what training to become a doctor is truly like, in all its terror, exhaustion and black comedy. With more than two million copies sold worldwide, it has been hailed as one of the most important medical novels ever written. With an introduction by John Updike
ISBN: 9780425238097Publication Date: 2010-09-07
