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Practical Patient Safety [Pehme köide]

, (Consultant Physician and Clinical Pharmacologist, J), (Consultant Urological Surgeon, Department of Urology, Churchill Hospital, Oxford; Honorary Consultant Urologist to the National Spinal Injuries Centre, Stoke Mandeville Hospital, UK)
  • Formaat: Paperback / softback, 318 pages, kõrgus x laius x paksus: 233x156x18 mm, kaal: 478 g, 19 black and white illustrations
  • Ilmumisaeg: 19-Mar-2009
  • Kirjastus: Oxford University Press
  • ISBN-10: 0199239932
  • ISBN-13: 9780199239931
  • Formaat: Paperback / softback, 318 pages, kõrgus x laius x paksus: 233x156x18 mm, kaal: 478 g, 19 black and white illustrations
  • Ilmumisaeg: 19-Mar-2009
  • Kirjastus: Oxford University Press
  • ISBN-10: 0199239932
  • ISBN-13: 9780199239931
Following recent high profile cases of surgical error in the UK and USA, patient safety has become a key issue in healthcare, now placed at heart of junior doctor's training. Errors made by doctors are very similar to those made in other high risk organisations, such as aviation, nuclear and petrochemical industries. Practical Patient Safety aims to demonstrate how core principles of safety from these industries can be applied in surgical and medical practice, in particular through training for health care professionals and healthcare managers.

Whilst theoretical aspects of risk management form the backdrop, the book focuses on key techniques and principles of patient safety in a practical way, giving the reader practical advice on how to avoid personal errors, and more importantly how to start patient safety training within his or her department or hospital.

Arvustused

The authors' last paragraph says 'Be brave. The fact that you have bought this book means you are in the vanguard of change'. Those bringing up the rear, who have not bought it, should borrow a copy from their more enlightened colleagues. * British Journal of Hospital Medicine * This excellent volume delivers crucial information and advice, elegantly presented in a practical and trim format. Its 345 grams sit easily in the pocket of a white coat and to adapt a metaphor to recognise the importance of hand function, it punches well above its weight. * Journal of Surg Eng *

Preface vii
Acknowledgements xiii
1 Clinical error: the scale of the problem 1
The Harvard Medical Practice Study 1984
2
The Quality in Australian Healthcare Study 1992
3
The University College London Study 2001
4
Danish, New Zealand, Canadian, and French studies
4
The frequency and costs of adverse drug events
4
Accuracy of retrospective studies
6
Error rates revealed in retrospective studies are of the same order of magnitude as those found in observational studies
7
Error rates according to type of clinical activity
7
Deaths from adverse events
9
Extra bed days as a consequence of error
10
Criminal prosecutions for medical errors
12
Reliability: other industries
12
Reliability: healthcare
12
References
13
2 Clinical errors: What are they? 15
Sources of error in primary care and office practice
15
Sources of error along the patient pathway in hospital care and potential methods of error prevention
16
Errors in dealing with referral letters
16
Errors of identification
17
Errors in note keeping
26
Errors with medical records in general
26
Other slips in letters that you have dictated
27
Errors as a consequence of patients failing to attend appointments for investigations or for outpatient consultations
28
Washing your hands between patients and attention to infection control
28
Admission to hospital
32
Diagnostic errors in general
32
Errors in drug prescribing and administration
36
Reducing errors in blood transfusion
45
Intravenous drug administration
46
Errors in the operating theatre
47
The use of diathermy
48
Harm related to patient positioning
49
Leg supports that give way
52
Generic safety checks prior to any surgical procedure
52
Failure to give DVT prophylaxis
53
Failure to give antibiotic prophylaxis
53
Errors in the postoperative period
54
Shared care
55
Medical devices
55
References
62
3 Safety culture in high reliability organizations 65
High reliability organizations: background
65
High reliability organizations: common features
68
The consequences of failure
69
'Convergent evolution' and its implication for healthcare
71
Learning from accidents: overview of basic high reliability organizational culture
72
Elements of the safety culture
72
Counter-intuitive aspects of high reliability organization safety culture
78
References
83
4 Case studies 85
Case study 1: wrong patient
87
Case study 2: wrong blood
88
Case study 3: wrong side nephrectomy
89
Case study 4: another wrong side nephrectomy
90
Case study 5: yet another wrong side nephrectomy case
93
Case study 6: medication error—wrong route (intrathecal vincristine)
94
Case study 7: another medication error—wrong route (intrathecal vincristine)
97
Case study 8: medication error—wrong route (intrathecal vincristine)
98
Case study 9: medication error—miscalculation of dose
100
Case study 10: medication error—frequency of administration mis-prescribed as 'daily' instead of 'weekly'
101
Case study 11: medication error—wrong drug
102
Case study 12: miscommunication of path lab result
103
Case study 13: biopsy results for two patients mixed up
105
Case study 14: penicillin allergy death
107
Case study 15: missing X-ray report
107
Case study 16: medication not given
108
Case study 17: oesophageal intubation
109
Case study 18: tiredness error
109
Case study 19: inadequate training
110
Case study 20: patient fatality—anaesthetist fell asleep
112
References
113
5 Error management 115
How accidents happen: the person approach versus the systems approach
115
Error chains
117
System failures
119
'Catalyst events'
121
Human error
123
Error classification
124
How experts and novices solve problems
126
Three error management opportunities
130
Detecting and reversing incipient adverse events in real time: 'Red flags'
134
Red flags: the symptoms and signs of evolving error chains
135
Speaking up protocols
141
Error management using accident and incident data
144
References
148
6 Communication failure 149
The prevalence of communication failures in adverse events in healthcare
150
Communication failure categories
153
Whose fault: message sender or receiver?
165
Safety-critical communications (SCC) protocols
166
How to prevent communication errors in specific healthcare situations
180
Composing an 'abnormal' (non-routine) safety-critical message
191
Written communication/documentation communication failures
197
References
198
7 Situation awareness 201
Situation awareness: definitions
202
Three levels of situation awareness
202
Catastrophic loss of situation awareness and the associated syndrome: 'mind lock'
203
Understanding loss of situation awareness
207
Cognitive failures: the role of mental models/the psychology of mistakes
207
Mental models: the problems
208
Ensuring high situation awareness
213
Two special cases involving loss of situation awareness
220
References
244
8 Professional culture 247
Similarities between two professions
247
Negative aspects of professional cultures
248
Steep hierarchy
248
Changing the pilots' professional culture
250
Team resource management/non-technical skills
256
References
262
9 When carers deliberately cause harm 263
References
265
10 Patient safety toolbox 267
Practical ways to enhance the safety of your patients
267
11 Conclusions 271
Glossary 275
Appendices 285
Appendix 1: Initiating a safety-critical (verbal) communication (STAR) 285
Appendix 2: I-SBAR—to describe a (deteriorating) patient's condition 286
Appendix 3: General patient safety tools 287
Appendix 4: Red flags (the symptoms and signs of an impending error) 289
Index 291
John Reynard is a consultant urological surgeon in the Nuffield Department of Surgery in Oxford and an honorary consultant urologist to the National Spinal Injury Centre at Stoke Mandeville Hospital. He read physiological sciences at Lady Margaret Hall in Oxford and competed his clinical studies at the London Hospital Medical College, qualifying in 1987. After basic surgical training in London and research at the Bristol Urological Institute he specialized in urology at St Bartholomew's and The Royal London Hospitals, completing his training in Christchurch in New Zealand before returning to Oxford. Along with Peter Stevenson he has delivered Patients Safety Training to medical students and junior doctors in Oxford since 2003, and is member of the Clinical Human Factors Group - an organisation consisting of airline patients, human factors experts, and doctors dedicated to the promotion of human factors training in healthcare.

John Reynolds studied medicine at Downing College Cambridge and St Catherine's College Oxford, and qualified in 1981. He was Clinical Lecturer in Clinical Pharmacology at Oxford University from 1990 to 1997 and obtained his DPhil in neuropharmacology in 1996. In 1997 he was appointed as a consultant physician and clinical pharmacologist at the John Radcliffe Hospital in Oxford. As a practicing general physician he has a full time clinical commitment to acute general medicine at the John Radcliffe Hospital. He has also been very actively involved in local prescribing both in a management role and in post-graduate education. He is a member of the Oxfordshire Area Prescribing Committee, the local Cancer Therapeutics Committee, Antimicrobial Prescribing Committee, and the Oxfordshire Priorities Forum, and he chairs the Oxford Radcliffe Hospitals Medicines Advisory Committee.

Peter Stevenson is a commercial pilot flying wide-body airliners on long-haul routes for a major British airline. In the early 1990s he developed and presented Crew Resource Management (CRM) training courses for pilots in his airline. These courses were based around learning the lessons from dozens of air disasters in the 1970s and 1980s. In 2000 he helped the Post Graduate Medical Education Centres of two NHS hospitals to create a healthcare version of the CRM course. He has prepared and delivered a programme of Patient Safety Training for medical students at the Nuffield Department of Surgery at the University of Oxford from 2003 onwards.