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E-grāmata: Making Healthcare Safe: The Story of the Patient Safety Movement

  • Formāts: PDF+DRM
  • Izdošanas datums: 28-May-2021
  • Izdevniecība: Springer Nature Switzerland AG
  • Valoda: eng
  • ISBN-13: 9783030711238
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  • Formāts: PDF+DRM
  • Izdošanas datums: 28-May-2021
  • Izdevniecība: Springer Nature Switzerland AG
  • Valoda: eng
  • ISBN-13: 9783030711238

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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.


Part I In the Beginning
1 The Hidden Epidemic: The Harvard Medical Practice Study
3(14)
References
16(1)
2 It's Not Bad People: Error In Medicine
17(14)
The Causes of Errors
18(3)
Application of Systems Thinking to Healthcare
21(8)
Error in Medicine
22(3)
Response to Error in Medicine
25(4)
References
29(2)
3 Changing The System: The Adverse Drug Events Study
31(14)
BWH Center for Patient Safety Research and Practice
42(2)
References
44(1)
4 Coming Together: The Annenberg Conference
45(8)
References
51(2)
5 A Home Of Our Own: The National Patient Safety Foundation
53(16)
References
65(4)
Part II Institutional Responses
6 We Can Do This: The Institute For Healthcare Improvement Adverse Drug Events Collaborative
69(20)
What Is a Collaborative?
72(1)
How It Works
73(1)
The Reducing Adverse Drug Events Collaborative
74(3)
Results
77(1)
Lessons Learned
78(1)
Use of Collaborates
79(3)
Subsequent IHI Initiatives
82(3)
Conclusion
85(1)
References
85(4)
7 Who Will Lead? The Executive Session
89(16)
First Meeting, January 22--24, 1998
91(2)
Second Meeting: June 25--27, 1998
93(2)
Third Meeting: January 21--23, 1999
95(1)
Fourth Meeting: June 17--19, 1999
96(2)
Fifth Meeting: January 27--29, 2000
98(1)
Lessons Learned
98(2)
Conclusion
100(2)
Appendix: 7.1 Executive Session Members
102(2)
CEOs of Healthcare Delivery Organizations
102(1)
Leaders of Health-Related Organizations
102(1)
Others
103(1)
References
104(1)
8 A Community Of Concern: The Massachusetts Coalition For The Prevention Of Medical Errors
105(22)
Medication Consensus Group
109(1)
Leadership Forum
110(1)
Regulatory Consensus Group
110(1)
Restraint Consensus Group
111(2)
DPH Project
113(1)
Surveys
114(1)
Implementing Best Practices
115(1)
The Reconciling Medications Project
115(1)
Communicating Critical Test Results
116(4)
Impact of the Coalition
120(1)
Appendix 8.1 Initial Coalition Member Organizations
121(1)
Appendix 8.2 Communicating Critical Test Results
122(2)
References
124(3)
9 When The Iom Speaks: Iom Quality Of Care Committee And Report
127(16)
To Err Is Human
133(4)
Postscript
137(2)
Appendix 9.1 Committee On Quality Of Health Care In America
139(1)
References
140(3)
10 The Government Responds: The Agency For Healthcare Research And Quality
143(16)
Response to the IOM Report
146(3)
AHRQ Programs
149(6)
Impact of AHRQ Programs
155(2)
References
157(2)
11 Setting Standards: The National Quality Forum
159(26)
Serious Reportable Events
164(4)
Safe Practices for Better Healthcare
168(2)
Performance Measures
170(4)
New Leadership
171(3)
Conflict of Interest Scandal
174(1)
Conclusion
175(1)
Appendix 11.1 Serious Reportable Events Steering Committee
176(1)
Appendix 11.2 NQF Serious Reportable Events
177(4)
Appendix 11.3 NQF Safe Practices
181(2)
References
183(2)
12 Enforcing Standards: The Joint Commission
185(18)
History of the Joint Commission
185(3)
The Agenda for Change
188(2)
Changing Accreditation
190(1)
Focus on Patient Safety: Sentinel Events
191(3)
Sentinel Event Alerts
194(1)
Patient Safety Goals
195(2)
Core Measures
197(2)
Public Policy Initiative
199(1)
Accreditation Process Improvement
199(1)
Conclusion
200(1)
References
201(2)
13 Partners In Progress: Patient Safety In The Uk
203(12)
A National Commitment
204(1)
The Patient Safety Movement
205(2)
The National Patient Safety Agency (NPSA)
207(1)
Additional Safety Efforts
208(2)
Patient Safety in Scotland
210(1)
Reorganization
210(1)
Conclusion
211(1)
References
212(3)
14 Going Global: The World Health Organization
215(16)
The World Alliance for Patient Safety
216(1)
Guidelines for Adverse Event Reporting and Learning Systems
217(2)
Patient and Consumer Involvement---Patients for Patient Safety (P4PS)
219(2)
Support of Patient Safety Research
221(2)
The Global Patient Safety Challenge
223(2)
Later Years
225(1)
Conclusion
226(1)
Appendix 14.1 The London Declaration
227(1)
References
227(4)
15 Just Do It: The Surgical Checklist
231(12)
Conclusion
238(1)
References
239(4)
16 Spreading The Word: The Salzburg Seminar
243(10)
Appendix 16.1 History of the Salzburg Global Seminars
247(1)
Appendix 16.2 Participants in Salzburg Seminar 386 Patient Safety and Medical Error
248(2)
Reference
250(3)
17 Publish Or Perish: British Medical Journal Theme Issue, New England Journal Of Medicine Series
253(14)
NEJM Series on Patient Safety
255(3)
Reporting of Adverse Events
258(2)
Patient Safety and Quality Journals
260(1)
Joint Commission Journal on Quality Improvement and Safety
261(1)
BMJ's Quality and Safety in Health Care
261(1)
The Journal of Patient Safety
262(1)
Conclusion
262(1)
References
263(4)
Part III Getting to Work: Key Issues and How They were Dealt with
18 Sleepy Doctors: Work Hours And The Accreditation Council For Graduate Medical Education
267(26)
Residency Training
268(1)
Early History---What Happened After Zion
269(2)
2003 ACGME Regulations
271(1)
The Duty Hours Debate
272(3)
What Happened: 2003--2008
275(1)
The IOM Panel
276(1)
ACGME Duty Hour Task Force
277(1)
Harvard Conference on Duty Hours
278(2)
The ACGME Response
280(2)
CLER
282(1)
Milestones
283(3)
Duty Hours
286(1)
Conclusion
287(1)
References
288(5)
19 A Conspiracy Of Silence: Disclosure, Apology, And Restitution
293(26)
Malpractice
296(2)
The Contrarians
298(2)
Doing It Right
300(3)
When Things Go Wrong---The Disclosure Project
303(3)
When Things Go Wrong
306(4)
The Patient and Family Experience
306(1)
The Caregiver Experience
306(1)
Management of the Event
307(1)
Getting Support
308(2)
National Progress in Communication and Resolution
310(4)
Conclusion
314(1)
References
315(4)
20 Who Can I Trust? Ensuring Physician Competence
319(36)
The System We Have
320(1)
What's the Problem?
321(1)
Why Doctors Fail
322(1)
Who Is Responsible for Ensuring Physician Competence and Safety?
323(1)
American Board of Medical Specialties
324(3)
Accreditation Council for Graduate Medical Education
327(1)
The Joint Commission
328(1)
State Licensing Boards
328(2)
Federation of State Medical Boards
330(2)
New York Cardiac Advisory Committee
332(1)
The Civil Justice System---Malpractice Litigation
333(2)
Hospital Responsibility for Physician Performance
335(1)
Multisource Feedback
336(1)
Support of Physicians with Problems
337(1)
How Should it Work? The Ideal System
338(1)
Nonregulatory Approaches to Improving Competence
339(1)
National Surgical Quality Improvement Program
339(3)
Analysis of Patient Complaints
342(2)
National Alliance for Physician Competence
344(4)
The Coalition for Physician Accountability
348(1)
Conclusion
349(1)
References
350(5)
21 Everyone Counts: Building A Culture Of Respect
355(16)
A Group of Leaders
356(2)
"Champions"
358(2)
The Problem
360(1)
A Culture of Respect
361(3)
A Culture of Respect, Part 1 The Nature and Causes of Disrespectful Behavior by Physicians
362(1)
A Culture of Respect, Part 2 Creating a Culture of Respect
363(1)
A Strange Twist
364(1)
Response
365(1)
References
366(5)
Part IV Creating a Culture of Safety
22 Make No Little Plans: The Lucian Leape Institute
371(30)
Unmet Needs
374(3)
Teaching Physicians to Provide Safe Patient Care
374(3)
Order from Chaos
377(4)
Accelerating Care Integration
377(4)
Through the Eyes of the Workforce
381(4)
Creating Joy, Meaning, and Safer Health Care
381(4)
Safety Is Personal
385(3)
Partnering with Patients and Families for the Safest Care
385(3)
Shining a Light
388(5)
Safer Health Care Through Transparency
388(5)
Members
393(3)
Later Work
396(3)
The "Must Do" List
396(1)
Financial Costs of Patient Safety
397(1)
Collaboration with American College of Healthcare Executives
398(1)
Conclusion
399(1)
References
399(2)
23 Now The Hard Part: Creating A Culture Of Safety
401(1)
What Is Culture?
402(3)
A Culture of Safety
405(1)
Characteristics of a Safe Culture
406(1)
A Just Culture
407(1)
High-Reliability Organizations
408(1)
The Problem
409(1)
Why Changing Culture Is so Hard to Do
410(3)
How to Do It
413(4)
Examples of Success
417(1)
Virginia Mason Medical Center
417(6)
Secrets of Success
423(1)
Cincinnati Children's Hospital
424(5)
Denver Health
429(1)
Safe and Reliable Health Care
430(2)
Making It Happen
432(1)
A Role for Government?
433(2)
A "Burning Platform"?
435(1)
References
436(2)
Correction to: Everyone Counts: Building a Culture of Respect 1(438)
Index 439
Lucian L. Leape, MD

Immediate Past Chair, Lucian Leape Institute for Healthcare Improvement

Adjunct Professor of Health Policy

Harvard T.H. Chan School of Public Health

Boston, MA 

USA







Lucian Leape, MD is a physician and professor at Harvard School of Public Health, who has been active in trying to improve the medical system to reduce medical error. In 1994 he had an article, "Error in Medicine," published in JAMA. In 1997, he testified before a subcommittee of the US Senate with his recommendations for improving medical safety.

Leape is known as the father of the patient safety movement has spent the last 30 years of his working life campaigning for change in the American healthcare system. He travels the world to give talks and lectures, influencing many of the world's brightest medics.

Leape is the Chair of the Lucian Leape Institute at the National Patient Safety Foundation. The Institute, founded in 2007, is charged with defining strategic paths and calls to action for the field of patient safety, offering vision and context for the many efforts underway within health care, and providing the leverage necessary for change at the system level. Its members comprise national thought leaders with a common interest in patient safety whose expertise and influence are brought to bear as the Institute calls for the innovation necessary to expedite the work and create significant, sustainable improvements in culture, process, and outcomes critical to safer health care.