Error Reduction in Health Care

Error Reduction in Health Care: A Systems Approach to Improving Patient Safety, 2nd Edition

Completely revised and updated this book offers a step-by-step guide for implementing the Institute of Medicine guidelines to reduce the frequency of errors in health care services and mitigate the impact of those errors that do occur. It explores the fundamental concepts and tools of error reduction, and shows how to design an effective error reduction initiative. The book pinpoints how to reduce and eliminate medical mistakes that threaten the health and safety of patients and teaches how to identify the root cause of medical errors, implement strategies for improvement, and monitor the effectiveness of these new approaches.

Figures, Tables, and Exhibits v

Foreword ix
Lucian L. Leape

Preface xi

The Editor xvii

The Authors xix

PART ONE: The Basics of Patient Safety

Chapter 1 A Formula for Errors: Good People + Bad Systems 3
Susan McClanahan, Susan T. Goodwin, and Jonathan B. Perlin

Chapter 2 The Human Side of Medical Mistakes 21
Sven Ternov

Chapter 3 High Reliability and Patient Safety 35
Yosef D. Dlugacz and Patrice L. Spath

PART TWO: Measure and Evaluate Patient Safety

Chapter 4 Measuring Patient Safety Performance 59
Karen Ferraco and Patrice L. Spath

Chapter 5 Analyzing Patient Safety Performance 103
Karen Ferraco and Patrice L. Spath

Chapter 6 Using Performance Data to Prioritize Safety Improvement Projects 119
Robert Latino

PART THREE: Reactive and Proactive Safety Investigations

Chapter 7 Accident Investigation and Anticipatory Failure Analysis 143
Sanford E. Feldman and Douglas W. Roblin

Chapter 8 MTO and DEB Analysis Can Find System Breakdowns 157
Sven Ternov

Chapter 9 Using Deductive Analysis to Examine Adverse Events 171
Robert Latino

PART FOUR: How to Make Health Care Processes Safer

Chapter 10 Proactively Error-Proofing Health Care Processes 197
Richard J. Croteau and Paul M. Schyve

Chapter 11 Reducing Errors Through Work System Improvements 217
Patrice L. Spath

Chapter 12 Improve Patient Safety with Lean Techniques 245
Danielle Lavallee

PART FIVE: Focused Patient Safety Initiatives

Chapter 13 How Information Technology Can Improve Patient Safety 269
Donna J. Slovensky and Nir Menachemi

Chapter 14 A Structured Teamwork System to Reduce Clinical Errors 297
Daniel T. Risser, Robert Simon, Matthew M. Rice, Mary L. Salisbury, and John C. Morey

Chapter 15 Medication Safety Improvement 335
Yosef D. Dlugacz

Glossary 369

Index 383

Patrice L. Spath, MA, RHIT, is president of Brown-Spath & Associates and assistant professor in the Department of Health Services Administration at the University of Alabama in Birmingham. She serves on the advisory board for WebM&M, an online case-based journal and forum on patient safety and health care quality sponsored by the Agency for Healthcare Research and Quality. Spath has authored numerous books and journal articles on health care performance improvement and patient safety.

Completely revised and updated, this second edition of Error Reduction in Health Care offers a step-by-step guide for implementing the recommendations of the Institute of Medicine to reduce the frequency of errors in health care services and to mitigate the impact of errors when they do occur.

With contributions from noted leaders in health safety, Error Reduction in Health Care provides information on analyzing accidents and shows how systematic methods can be used to understand hazards before accidents occur. In the chapters, authors explore how to prioritize risks to accurately focus efforts in a systems redesign, including performance measures and human factors.

This expanded edition covers contemporary material on innovative patient safety topics such as applying Lean principles to reduce mistakes, opportunity analysis, deductive adverse event investigation, improving safety through collaboration with patients and families, using technology for patient safety improvements, medication safety, and high reliability organizations.

Praise for the prior edition:

"The content exceeds the reader's expectations and the text is a worthy reference in a climate of growing national attention. Its scope constitutes mandatory reading for executive and middle managers, as well as quality assurance and risk management professionals and physician leaders. The distinguished contributors bring unsurpassed expertise from a variety of sources, both inside and outside of health care. This publication provides not only a theoretical framework to gain an understanding of the nature of error, but also outlines useful, practical, proven strategies for beginning a patient safety initiative in any health care organization. This is one of the first comprehensive references available since the subject has gained national attention."
—Doody's Publishing, five-star review