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E-raamat: Patient Safety: A Human Factors Approach

(Griffith University, Mt Gravatt, Australia)
  • Formaat: 262 pages
  • Ilmumisaeg: 19-Apr-2016
  • Kirjastus: CRC Press Inc
  • Keel: eng
  • ISBN-13: 9781040063576
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  • Formaat: 262 pages
  • Ilmumisaeg: 19-Apr-2016
  • Kirjastus: CRC Press Inc
  • Keel: eng
  • ISBN-13: 9781040063576

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Increased concern for patient safety has put the issue at the top of the agenda of practitioners, hospitals, and even governments. The risks to patients are many and diverse, and the complexity of the healthcare system that delivers them is huge. Yet the discourse is often oversimplified and underdeveloped. Written from a scientific, human factors perspective, Patient Safety: A Human Factors Approach delineates a method that can enlighten and clarify this discourse as well as put us on a better path to correcting the issues.

People often think, understandably, that safety lies mainly in the hands through which care ultimately flows to the patientthose who are closest to the patient, whose decisions can mean the difference between life and death, between health and morbidity. The human factors approach refuses to lay the responsibility for safety and risk solely at the feet of people at the sharp end. That is where we should intervene to make things safer, to tighten practice, to focus attention, to remind people to be careful, to impose rules and guidelines. The book defines an approach that looks relentlessly for sources of safety and risk everywhere in the systemthe designs of devices; the teamwork and coordination between different practitioners; their communication across hierarchical and gender boundaries; the cognitive processes of individuals; the organization that surrounds, constrains, and empowers them; the economic and human resources offered; the technology available; the political landscape; and even the culture of the place.

The breadth of the human factors approach is itself testimony to the realization that there are no easy answers or silver bullets for resolving the issues in patient safety. A user-friendly introduction to the approach, this book takes the complexity of health care seriously and doesnt over simplify the problem. It demonstrates what the approach does do, that is offer the substance and guidance to consider the issues in all their nuance and complexity.

Arvustused

"User-friendly and well written, this book takes the complex nature of healthcare seriously and pulls no punches. It demonstrates what the human factors approach can and does do, providing excellent examples to tease out the subtleties of this fascinating subject." The RoSPA Occupational Safety & Health Journal, June 2012

Acknowledgments ix
Preface xi
Chapter 1 Medical Competence and Patient Safety
1(32)
Competence as Individual Virtue or Systems Issue?
2(3)
Why the Difference in Competence Assumptions?
5(2)
Good Doctoring and the Pursuit of Perfection
7(8)
From Sacred Status to Contractual Duty
8(2)
The Symbolic Importance of Medical Competence to This Day
10(5)
Standardization and the Fear of Scientific-Bureaucratic Medicine
15(7)
Getting the Job Done Despite the Organization
18(3)
Standardization: Yes or No?
21(1)
The Expectation of Perfection versus the Inevitability of Mistake
22(6)
Infallibility, Error, and Technical Advances in Medicine
26(2)
Key Points
28(1)
References
29(4)
Chapter 2 The Problem of "Human Error" in Healthcare
33(32)
Numbers Are Strong
33(3)
The Human Factors Approach
36(8)
Error and Expertise Are Two Sides of the Same Coin
43(1)
Human Error as Attribution and Starting Point
44(2)
"I Knew This Could Happen!"
46(9)
The Hindsight Bias
46(3)
Counterfactual Reasoning
49(2)
The Outcome Bias
51(1)
Why Are These Biases So Pervasive?
52(1)
Judging Instead of Explaining
53(2)
The Local Rationality Principle
55(5)
Human Error as a Rational Choice
56(1)
Error as the By-Product of Normal Work
57(2)
The Accountability Backlash
59(1)
Key Points
60(1)
References
61(4)
Chapter 3 Cognitive Factors of Healthcare Work
65(18)
Attentional Dynamics
66(5)
Cognitive Fixation and Vagabonding
66(2)
Escalation and Dynamic Fault Management
68(1)
Multitasking and Prospective Memory
69(2)
Knowledge Factors
71(6)
Buggy Mental Models, Heuristics, and Oversimplifications
72(4)
Knowledge and Diagnosis
76(1)
Strategic Factors
77(3)
Key Points
80(1)
References
80(3)
Chapter 4 New Technology, Automation, and Patient Safety
83(16)
The Substitution Myth
83(6)
The Transformative Effects of Technology
85(3)
New Technology beyond Task-Specific Devices
88(1)
Data Overload
89(1)
Automation Surprises
90(2)
Evaluating and Testing Medical Technology
92(4)
The Envisioned World Problem
94(2)
Key Points
96(1)
References
97(2)
Chapter 5 Safety Culture and Organizational Risk
99(40)
Safety Culture and Drifting into Failure
100(2)
Risk as Energy to Be Contained
102(8)
Man-Made Disaster Theory
102(5)
How to Avoid Man-Made Disasters
107(1)
The Swiss Cheese Model
108(2)
Risk as Complexity
110(5)
Risk as the Gradual Acceptance of the Abnormal
115(13)
The Normalization of Deviance
115(5)
How to Prevent the Normalization of Deviance
120(2)
Structural Secrecy and Practical Drift
122(3)
Clinical Guidelines and Patient Safety
125(3)
Risk as a Managerial or Control Problem
128(8)
Control Theory
128(5)
High-Reliability Theory
133(3)
Key Points
136(1)
References
137(2)
Chapter 6 Practical Tools for Creating Safety
139(48)
Safety Reporting and Organizational Learning
139(12)
What Is Organizational Learning?
139(1)
Effective Reporting Systems: Nonpunitive, Protected, Voluntary
140(3)
Narratives or Indexing?
143(3)
Getting People to Report and Keeping Up the Reporting Rate
146(2)
Root Causes and Responsibilities
148(1)
How Should Your Safely Department Look?
148(3)
Adverse Event Investigations
151(14)
First and Second Stories
151(2)
Managing the Hindsight Bias
153(2)
Reconstructing the Human Contribution to an Adverse Event
155(10)
Human Factors and Resource Management Training
165(12)
Communication and Coordination Breakdowns
166(6)
The Fallacy of Social Redundancy
172(2)
Diversity
174(3)
Briefings and Checklists
177(6)
What Does a Checklist Do?
178(2)
How Should a Checklist Look?
180(3)
Key Points
183(1)
References
184(3)
Chapter 7 Accountability and Learning from Failure
187(26)
Learning and Accountability---Just Culture
187(10)
Just Assign Behavior to the Right Category (Right?)
188(1)
Assigning Behavior to Categories Is about Power, Production, and Protection
189(3)
Achieving Organizational Justice
192(2)
Reporting versus Disclosure
194(1)
A Discretionary Space for Accountability
195(1)
Accountability Free Is Not Blame Free
196(1)
Criminalization of Medical Error: A Growing Problem?
197(8)
Crimes as Inherently Real or as Constructed Phenomena
197(6)
Criminalizing Professional Error in Healthcare: Why a Concern?
203(2)
The Second Victim
205(2)
Peer and Employee Assistance
206(1)
Key Points
207(1)
References
208(5)
Chapter 8 New Frontiers in Patient Safety: Complexity and Systems Thinking
213(28)
Complicated versus Complex
214(8)
Obstetrics, Intervention Decisions, and New Technology
215(1)
Signal Detection in Obstetrics
216(2)
Complexity and Signal Detection
218(2)
Complexity and Technological or Managerial Interventions
220(1)
Complexity, Workarounds, and Compliance
221(1)
Newton, Components, and Complexity
222(3)
The Cartesian-Newtonian Worldview and Adverse Events
225(10)
Newtonian Responses to Failure in Complex Systems
228(1)
Complexity and Its Implications for Understanding Adverse Events
229(2)
A Post-Newtonian Analysis of Adverse Events
231(4)
Key Points
235(1)
References
236(5)
Index 241
About the author: Sidney Dekker (PhD, The Ohio State University, 1996) is Professor and Director of the Key Centre for Ethics, Law, Justice and Governance at Griffith University, Brisbane, Australia. He was previously Professor and Director of the Leonardo da Vinci Center for Complexity and Systems Thinking at Lund University, Sweden, and Professor of Community Health Science at the Faculty of Medicine, University of Manitoba, Canada. He has been Visiting Professor at the Alfred Hospital in Melbourne, Australia. He recently became active as airline pilot, flying the Boeing 737.