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Cham : Springer International Publishing AG, 2020

1 online resource (493 pages)

ISBN 9783030594039 (electronic bk.)

ISBN 9783030594022

Print version: Donaldson, Liam Textbook of Patient Safety and Clinical Risk Management Cham : Springer International Publishing AG,c2020 ISBN 9783030594022

4: Looking to the Future -- 4.1 Introduction -- 4.2 The Vision for the Future -- 4.3 The Challenges to Overcome to Facilitate Safety.

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.

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 ---

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 ---

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 ---

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 ---

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 ---

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 ---

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.

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.

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.

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 ---

14.14 Training Future Leaders in Patient 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 ---

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 ---

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(OCoLC)1235593884