Textbook of Patient Safety and Clinical Risk Management.

• Author: Donaldson, Liam.
• TeilnehmendeR: Ricciardi, Walter.; Sheridan, Susan.; Tartaglia, Riccardo.
• Place / Publishing House: Cham : : Springer International Publishing AG,, 2020.; ©2021.
• Year of Publication: 2020
• Edition: 1st ed.
• Language: English
• Physical Description: 1 online resource (493 pages)

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.