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

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

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

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