Making Healthcare Safe : : The Story of the Patient Safety Movement.

• Author: Leape, Lucian L.
• Place / Publishing House: Cham : : Springer International Publishing AG,, 2021.; ©2021.
• Year of Publication: 2021
• Edition: 1st ed.
• Language: English
• Physical Description: 1 online resource (460 pages)

Table of Contents

Intro -- Foreword -- Preface -- Acknowledgments -- Contents -- About the Author -- Part I: In the Beginning -- Chapter 1: The Hidden Epidemic: The Harvard Medical Practice Study -- References -- Chapter 2: It's Not Bad People: Error in Medicine -- The Causes of Errors -- Application of Systems Thinking to Healthcare -- Error in Medicine -- Response to Error in Medicine -- References -- Chapter 3: Changing the System: The Adverse Drug Events Study -- BWH Center for Patient Safety Research and Practice -- References -- Chapter 4: Coming Together: The Annenberg Conference -- References -- Chapter 5: A Home of Our Own: The National Patient Safety Foundation -- References -- Part II: Institutional Responses -- Chapter 6: We Can Do This: The Institute for Healthcare Improvement Adverse Drug Events Collaborative -- What Is a Collaborative? -- How It Works -- The Reducing Adverse Drug Events Collaborative -- Results -- Lessons Learned -- Use of Collaboratives -- Subsequent IHI Initiatives -- Conclusion -- References -- Chapter 7: Who Will Lead? The Executive Session -- First Meeting, January 22-24, 1998 -- Second Meeting: June 25-27, 1998 -- Third Meeting: January 21-23, 1999 -- Fourth Meeting: June 17-19, 1999 -- Fifth Meeting: January 27-29, 2000 -- Lessons Learned -- Conclusion -- Appendix 7.1: Executive Session Members -- CEOs of Healthcare Delivery Organizations -- Leaders of Health-Related Organizations -- Others -- References -- Chapter 8: A Community of Concern: The Massachusetts Coalition for the Prevention of Medical Errors -- Medication Consensus Group -- Leadership Forum -- Regulatory Consensus Group -- Restraint Consensus Group -- DPH Project -- Surveys -- Implementing Best Practices -- The Reconciling Medications Project -- Communicating Critical Test Results -- Impact of the Coalition -- Appendix 8.1: Initial Coalition Member Organizations.

Appendix 8.2: Communicating Critical Test Results -- References -- Chapter 9: When the IOM Speaks: IOM Quality of Care Committee and Report -- To Err Is Human -- Postscript -- Appendix 9.1: Committee on Quality Of Health Care In America -- References -- Chapter 10: The Government Responds: The Agency for Healthcare Research and Quality -- Response to the IOM Report -- AHRQ Programs -- Impact of AHRQ Programs -- References -- Chapter 11: Setting Standards: The National Quality Forum -- Serious Reportable Events -- Safe Practices for Better Healthcare -- Performance Measures -- New Leadership -- Conflict of Interest Scandal -- Conclusion -- Appendix 11.1: Serious Reportable Events Steering Committee [11] -- Appendix 11.2: NQF Serious Reportable Events [11] -- Appendix 11.3: NQF Safe Practices [15] -- References -- Chapter 12: Enforcing Standards: The Joint Commission -- History of the Joint Commission [1] -- The Agenda for Change -- Changing Accreditation -- Focus on Patient Safety: Sentinel Events -- Sentinel Event Alerts -- Patient Safety Goals -- Core Measures -- Public Policy Initiative -- Accreditation Process Improvement -- Conclusion -- References -- Chapter 13: Partners in Progress: Patient Safety in the UK -- A National Commitment -- The Patient Safety Movement -- The National Patient Safety Agency (NPSA) -- Additional Safety Efforts -- Patient Safety in Scotland -- Reorganization -- Conclusion -- References -- Chapter 14: Going Global: The World Health Organization -- The World Alliance for Patient Safety -- Guidelines for Adverse Event Reporting and Learning Systems -- Patient and Consumer Involvement-Patients for Patient Safety (P4PS) -- Support of Patient Safety Research -- The Global Patient Safety Challenge -- Later Years -- Conclusion -- Appendix 14.1: The London Declaration -- References.

Chapter 15: Just Do It: The Surgical Checklist -- Conclusion -- References -- Chapter 16: Spreading the Word: The Salzburg Seminar -- Appendix 16.1: History of the Salzburg Global Seminars -- Appendix 16.2: Participants in Salzburg Seminar 386 Patient Safety and Medical Error -- Reference -- Chapter 17: Publish or Perish: British Medical Journal Theme Issue, New England Journal of Medicine Series -- NEJM Series on Patient Safety -- Reporting of Adverse Events -- Patient Safety and Quality Journals -- Joint Commission Journal on Quality Improvement and Safety -- BMJ's Quality and Safety in Health Care -- The Journal of Patient Safety -- Conclusion -- References -- Part III: Getting to Work: Key Issues and How They were Dealt with -- Chapter 18: Sleepy Doctors: Work Hours and the Accreditation Council for Graduate Medical Education -- Residency Training -- Early History-What Happened After Zion -- 2003 ACGME Regulations -- The Duty Hours Debate -- What Happened: 2003-2008 -- The IOM Panel -- ACGME Duty Hour Task Force -- Harvard Conference on Duty Hours -- The ACGME Response -- CLER -- Milestones -- Duty Hours -- Conclusion -- References -- Chapter 19: A Conspiracy of Silence: Disclosure, Apology, and Restitution -- Malpractice -- The Contrarians -- Doing It Right -- When Things Go Wrong-The Disclosure Project -- When Things Go Wrong -- The Patient and Family Experience -- The Caregiver Experience -- Management of the Event -- Getting Support -- National Progress in Communication and Resolution -- Conclusion -- References -- Chapter 20: Who Can I Trust? Ensuring Physician Competence -- The System We Have -- What's the Problem? -- Why Doctors Fail -- Who Is Responsible for Ensuring Physician Competence and Safety? -- American Board of Medical Specialties -- Accreditation Council for Graduate Medical Education -- The Joint Commission.

State Licensing Boards -- Federation of State Medical Boards -- New York Cardiac Advisory Committee -- The Civil Justice System-Malpractice Litigation -- Hospital Responsibility for Physician Performance -- Multisource Feedback -- Support of Physicians with Problems -- How Should it Work? The Ideal System -- Nonregulatory Approaches to Improving Competence -- National Surgical Quality Improvement Program -- Analysis of Patient Complaints -- National Alliance for Physician Competence -- The Coalition for Physician Accountability -- Conclusion -- References -- Chapter 21: Everyone Counts: Building a Culture of Respect -- A Group of Leaders -- "Champions" -- The Problem -- A Culture of Respect -- A Culture of Respect, Part 1: The Nature and Causes of Disrespectful Behavior by Physicians [4] -- A Culture of Respect, Part 2: Creating a Culture of Respect [12] -- A Strange Twist -- Response -- References -- Part IV: Creating a Culture of Safety -- Chapter 22: Make No Little Plans: The Lucian Leape Institute -- Unmet Needs [4] -- Teaching Physicians to Provide Safe Patient Care -- Workshop Leaders: Dennis O'Leary and Lucian Leape -- Summary of Recommendations (Table 22.1) -- Progress -- Remaining Challenges -- Order from Chaos [5] -- Accelerating Care Integration -- Workshop Leaders: David Lawrence and Richard Bohmer -- Summary of Recommendations (Table 22.2) -- Progress -- Remaining Challenges -- Through the Eyes of the Workforce [6] -- Creating Joy, Meaning, and Safer Health Care -- Workshop Leaders: Julie Morath and Paul O'Neill -- Vulnerable Workplaces -- What Can Be Done? -- Developing Effective Organizations -- Summary of Recommendations (Table 22.3) -- Progress -- Remaining Challenges -- Safety Is Personal [7] -- Partnering with Patients and Families for the Safest Care -- Workshop Leaders: Susan Edgman-Levitan and James Conway.

Summary of Recommendations (Table 22.4) -- Progress -- Remaining Challenges -- Shining a Light [8] -- Safer Health Care Through Transparency -- Workshop Leaders: Gary Kaplan and Robert Wachter -- Summary of Recommendations (Table 22.5) -- Progress -- Remaining Challenges -- Transforming Health Care: A Compendium -- Members -- Later Work -- The "Must Do" List -- Financial Costs of Patient Safety -- Collaboration with American College of Healthcare Executives -- Conclusion -- References -- Chapter 23: Now the Hard Part: Creating a Culture of Safety -- What Is Culture? -- A Culture of Safety -- Characteristics of a Safe Culture -- A Just Culture -- High-Reliability Organizations -- The Problem -- Why Changing Culture Is so Hard to Do -- How to Do It -- Examples of Success -- Virginia Mason Medical Center -- Secrets of Success -- Cincinnati Children's Hospital -- Denver Health -- Safe and Reliable Health Care -- Making It Happen -- A Role for Government? -- A "Burning Platform"? -- References -- Correction to: Everyone Counts: Building a Culture of Respect -- Index.