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
• Language: English
• Physical Description: 1 online resource (460 pages)

This unique and engaging open access title provides a compelling and ground-breaking account of the patient safety movement in the United States, told from the perspective of one of its most prominent leaders, and arguably the movement’s founder, Lucian L. Leape, MD. Covering the growth of the field from the late 1980s to 2015, Dr. Leape details the developments, actors, organizations, research, and policy-making activities that marked the evolution and major advances of patient safety in this time span. In addition, and perhaps most importantly, this book not only comprehensively details how and why human and systems errors too often occur in the process of providing health care, it also promotes an in-depth understanding of the principles and practices of patient safety, including how they were influenced by today’s modern safety sciences and systems theory and design. Indeed, the book emphasizes how the growing awareness of systems-design thinking and the self-education and commitment to improving patient safety, by not only Dr. Leape but a wide range of other clinicians and health executives from both the private and public sectors, all converged to drive forward the patient safety movement in the US. Making Healthcare Safe is divided into four parts: I. In the Beginning describes the research and theory that defined patient safety and the early initiatives to enhance it. II. Institutional Responses tells the stories of the efforts of the major organizations that began to apply the new concepts and make patient safety a reality. Most of these stories have not been previously told, so this account becomes their histories as well. III. Getting to Work provides in-depth analyses of four key issues that cut across disciplinary lines impacting patient safety which required special attention. IV. Creating a Culture of Safety looks to the future, marshalling the best thinking about what it will take to achieve the safe care we all deserve. Captivatingly written with an “insider’s” tone and a major contribution to the clinical literature, this title will be of immense value to health care professionals, to students in a range of academic disciplines, to medical trainees, to health administrators, to policymakers and even to lay readers with an interest in patient safety and in the critical quest to create safe care.

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.