From newborns switched in the nursery to medication mix-ups and hospital-acquired infections, we are all familiar with the horror stories about hospital safety, and unfortunately, the statistics say we aren't exaggerating. The safety issue in U.S. hospitals has become so profound and embedded, that we cannot hope to fix it without a paradigm shift
Rezensionen / Stimmen
Not only is this an excellent work and a valuable addition to the field, it is also very timely in light of revelations about woefully inadequate or absent procedures in the present crisis. We have always needed a 'systems' approach, and this book should be required reading for all decision makers.-Richard Fellows, MD
Sprache
Verlagsort
Verlagsgruppe
Zielgruppe
Für Beruf und Forschung
Senior level managers in hospitals and healthcare organizations, physicians and nurses, lawyers, policymakers and government agencies such as AHRA, the Joint Commission, and Medicare.
Illustrationen
23 s/w Abbildungen, 18 s/w Tabellen
23 b/w images and 18 tables
Dateigröße
ISBN-13
978-1-4398-2103-9 (9781439821039)
Copyright in bibliographic data and cover images is held by Nielsen Book Services Limited or by the publishers or by their respective licensors: all rights reserved.
Schweitzer Klassifikation
The Etiologies of Unsafe Healthcare Failure Is Not an Option An Unconventional Way to Manage Risks Defining Unsafe Work How Unsafe Work Propagates Unknowingly How Does Unsafe Work Originate? So, Why Do We Unknowingly Sustain Unsafe Work? Using Best Practices Is Insufficient There Is Hope The Lessons Learned Sufficient Understanding Is a Prerequisite to Safe Care Insufficient Understanding of System Vulnerability Insufficient Understanding of What Is Preventable Insufficient Understanding from Myopia Insufficient Understanding of Oversights and Omissions Insufficient Understanding of Variation Some Remedies Preventing "Indifferencity" to Enhance Patient Safety Performance without Passion Not Learning from Mistakes Inattention to the Voice of the Patient Making Premature Judgments without Critical Thinking Lack of Teamwork Lack of Feedback and Follow-Up Performance without Due Concern Lack of Accountability Encouraging Substandard Work Reacting to Unsafe Incidences Instead of Proactively Seeking Them Inattention to Clinical Systems Difference in Mindset between Management and Employees Poor Risk Management Performance Diligently Done in a Substandard Manner Continuing to Do Substandard Work, Knowing It Is Substandard Ignoring Bad Behavior Inattention to Quality Continuous Innovation Is Better Than Continuous Improvement Why Continuous Innovation? Types of Innovations Marginal Innovation Incremental Innovation Radical Innovation Disruptive Innovation Accidental Innovation Strategic Innovation Diffusion Innovation Translocation Innovation The Foundation for the Innovation Culture Choice of Innovation Encouraging Creativity Structure for Sustaining Innovation Innovations Should Start with Incidence Reports The Purpose and Scope of Incidence Reports What to Do with Incidence Reports? A Sample Incidence Reporting Procedure A Sample Incidence Report Form Ideas for Innovative Solutions Doing More with Less Is Innovation Be Lean, Don't Be Mean Eliminate Waste, Don't Eliminate Value Do It Right the First Time-Excellence Does Matter Add More Right Work to Save Time and Money Attack Complacency Create a Sense of Urgency Establish Evidence between Lean Strategies and Patient Satisfaction Ideas for Lean Innovation Reinvent Quality Management A Recipe for Success Redefine Quality Conduct Negative Requirements Analysis Develop Strategic Plan Based on SWOT Analysis Consciously Manage Quality at All the Levels of an Organization Quality at Conformance Level Quality at Process Level Quality of Kind at Organization Level Architect a Patient-Centric Quality System Validate Interactions and Dependencies Frequently Incorporate Feedback Loops Reinvent Risk Management Identify Risks Failure Mode and Effects Analysis (FMEA) Fault Tree Analysis (FTA) Operations and Support Hazard Analysis More Safety Analysis Techniques Mitigate Risks Orchestrate Risks Create a Sound Structure Integrate the Support Staff Conduct Risk Management Rehearsals Aim at High Return on Investment without Compromising Safety Human Errors May Be Unpreventable; Preventing Harm Is an Innovation Principles of Human Factors Engineering Principles of Human Factors Engineering (HFE) Harm Prevention Methodologies Crew Resource Management (CRM) Management Oversight and Risk Tree (MORT) Change Analysis Swiss Cheese Model for Error Trapping Mistake Proofing Managing Safety: Lessons from Aerospace Where Does US Healthcare Stand on System Safety? System Safety Theory of Accidents System Safety in Emergency Medicine Aerospace Hazard Analysis Techniques The Paradigm Pioneers Johns Hopkins Hospital Allegheny General Hospital Geisinger Health System VA Hospitals Seattle Children's Hospital Ideas for Future Paradigm Pioneers Protect Patients from Dangers in Medical Devices The Nature of Dangers Hazard Mitigation for Existing Devices Potential Dangers in New Devices and Technologies Hazard Mitigation for New Devices and Technologies Can We Use This Knowledge in Bedside Intelligence? Heuristics for Continuous Innovation Heuristics for Medicine Other Heuristics for Medicine Heuristics for Frontline Processes Stop Working on Wrong Things, and You Will Automatically Work on Right Things Learn to Say "No" to Yes Men "No Action" Is an Action No Control Is the Best Control Heuristics for Management If You Don't Know Where You Are Going, Any Road Will Get You There Convert Bad News into Good News As Quality Goes up, the Costs Go Down That Which Gets Measured, Is What Gets Done % of Causes Are Responsible For % of Effects Aequanimitas-The Best-Known Strategy for Safe Care Aequanimitas Explained Why Aequanimitas Is the Best-Known Strategy for Safe Care? The Practice of Aequanimitas Modern Variations of Aequanimitas Emotional Intelligence (EI) The Beginner's Mind Ray Brown's Senses Appendix A: Swiss Cheese Model for Error Trapping Index Each chapter includes an Introduction, Summary, & References
