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| case studies in patient safety: Case Studies in Patient Safety Julie K. Johnson, Helen W. Haskell, Paul R. Barach, 2015-02-05 This unique compendium of case studies on patient safety – told from the perspective of the patient and family – illustrates 24 stories of preventable health care errors that led to irreparable patient harm. The reader is guided through a structured analysis of the events, eliciting lessons learned and strategies for preventing similar events in the future. Learning objectives for each case facilitate the reader’s development of a set of core competencies related to improving safety and quality of health care. Students of the health professions including medicine, nursing, pharmacy, health administration, public health, as well as practicing professionals such as patient safety officers, chief quality officers, risk managers, and health service researchers will gain valuable insight into the real-world of medical errors and a better understanding of how they can be prevented through practical, actionable methods. |
| case studies in patient safety: New Horizons in Patient Safety: Understanding Communication Annegret Hannawa, Albert Wu, Robert Juhasz, 2017-03-20 This case studies book is a unique, practical, cutting-edge, and indispensable go-to resource for front-line practitioners and educators in medicine. Each case study (chapter) is framed by a set of introductory learning objectives, an evaluation section, thought-provoking discussion questions, and references to further readings. Furthermore, the book is conveniently organized along the continuum of medical care delivery, providing quick access to ad-hoc solutions in safety- and quality-compromised situations, illustrating how skillful communication can be the key to a more effective prevention, intervention, and response to “close calls” and adverse events. The case studies book is unique and innovative in its interdisciplinary integration of the contemporary literature in communication science with current “hot buttons” of patient safety. It manifests a valuable interdisciplinary collaboration by translating the basic tenets of human communication science for practitioners of medicine, providing a conceptual, evidence-based foundation for formulating communication-based practice guidelines to advance patient safety and quality of care. The case studies put communication theory into practice to facilitate experiential learning, granting insights into the breadth and diverse aspects of safe and high quality healthcare delivery. Thought-provoking discussion questions and references for further reading make this book a valuable reference for medical practitioners across the world. |
| case studies in patient safety: New Horizons in Patient Safety ANNEGRET. WU HANNAWA (ALBERT. JUHASZ, ROBERT.), Annegret F. Hannawa, Albert W. Wu, Robert S. Juhasz, 2017 This case studies book is a unique, practical, cutting-edge, and indispensable go-to resource for front-line practitioners and educators in medicine. Each case study (chapter) is framed by a set of introductory learning objectives, an evaluation section, thought-provoking discussion questions, and references to further readings. Furthermore, the book is conveniently organized along the continuum of medical care delivery, providing quick access to ad-hoc solutions in safety- and quality-compromised situations, illustrating how skillful communication can be the key to a more effective prevention, intervention, and response to close calls and adverse events. The case studies book is unique and innovative in its interdisciplinary integration of the contemporary literature in communication science with current hot buttons of patient safety. It manifests a valuable interdisciplinary collaboration by translating the basic tenets of human communication science for practitioners of medicine, providing a conceptual, evidence-based foundation for formulating communication-based practice guidelines to advance patient safety and quality of care. The case studies put communication theory into practice to facilitate experiential learning, granting insights into the breadth and diverse aspects of safe and high quality healthcare delivery. Thought-provoking discussion questions and references for further reading make this book a valuable reference for medical practitioners across the world. |
| case studies in patient safety: Safety of Health IT Abha Agrawal, 2016-08-01 This practical text provides an overview of the adverse consequences of health information technology (HIT) and its impact on patient safety. Specific cases of errors and risks related to various types of HIT are featured along with best practices for patient safety, workflows and organizational standards. The full impact of these challenges with meaningful solutions are openly examined. Written from a clinical perspective, healthcare professionals within multiple settings will find this timely book an invaluable resource to this essential and bourgeoning technology. |
| case studies in patient safety: New Horizons in Patient Safety: Safe Communication Annegret Hannawa, Anne Wendt, Lisa Day, 2017-12-18 This case studies book is an indispensable resource for educators, students, and practitioners of nursing. It is innovative in its application of lessons from the communication sciences to common challenges in the delivery of safe patient care. The authors apply basic tenets of human communication to the context of nursing to provide a foundation for practices that can advance the safety and quality of care. The cases, which describe close calls and adverse events, are organized along the continuum of healthcare delivery, providing quick access to solutions in commonly encountered care situations. Each case is accompanied by a discussion of how skillful communication can be key to preventing and recovering from errors and adverse events. Thought-provoking discussion questions and references for further reading make this book a valuable reference for nursing educators, students, and practitioners across the world. |
| case studies in patient safety: Advances in Patient Safety Kerm Henriksen, 2005 v. 1. Research findings -- v. 2. Concepts and methodology -- v. 3. Implementation issues -- v. 4. Programs, tools and products. |
| case studies in patient safety: Patient Safety Abha Agrawal, 2013-10-04 Despite the evolution and growing awareness of patient safety, many medical professionals are not a part of this important conversation. Clinicians often believe they are too busy taking care of patients to adopt and implement patient safety initiatives and that acknowledging medical errors is an affront to their skills. Patient Safety provides clinicians with a better understanding of the prevalence, causes and solutions for medical errors; bringing best practice principles to the bedside. Written by experts from a variety of backgrounds, each chapter features an analysis of clinical cases based on the Root Cause Analysis (RCA) methodology, along with case-based discussions on various patient safety topics. The systems and processes outlined in the book are general and broadly applicable to institutions of all sizes and structures. The core ethic of medical professionals is to “do no harm”. Patient Safety is a comprehensive resource for physicians, nurses and students, as well as healthcare leaders and administrators for identifying, solving and preventing medical error. |
| case studies in patient safety: Case Studies in Patient Safety Julie K. Johnson, Helen Haskell, Paul Barach, 2016 Resource added for the Nursing-Associate Degree 105431, Practical Nursing 315431, and Nursing Assistant 305431 programs. |
| case studies in patient safety: Transforming Health Care Through Information Nancy M. Lorenzi, Joan S. Ash, Jonathan Einbinder, Wendy McPhee, Laura Einbinder, 2006-03-30 -Based on case studies, this book will be a great tool for students or professionals in medical informatics and health administration. -Released in 1995, the First Edition has sold 1,427 copies worldwide to date (1,110 US; 179 IC; 75 Bulk). |
| case studies in patient safety: Communication Pearls for Safe and High Quality Medicine Annegret Hannawa, Robert Juhasz, Albert Wu, Anne Wendt, 2018-01-15 This case studies book is a unique, practical, cutting-edge, indispensable go-to resource forprofessionals in nursing. Each case study is framed by learning objectives, an evaluation section, thought-provoking discussion questions and references to further readings. The book is conveniently organized along the continuum of medical care delivery, providing quick access to ad-hoc solutions in safety- and quality-compromised situations. |
| case studies in patient safety: Healthcare Quality Management Zachary Pruitt, PhD, MHA, CPH, Candace S. Smith, PhD, RN, NEA-BC, Eddie Perez-Ruberte, 2020-02-28 Healthcare Quality Management: A Case Study Approach is the first comprehensive case-based text combining essential quality management knowledge with real-world scenarios. With in-depth healthcare quality management case studies, tools, activities, and discussion questions, the text helps build the competencies needed to succeed in quality management. Written in an easy-to-read style, Part One of the textbook introduces students to the fundamentals of quality management, including history, culture, and different quality management philosophies, such as Lean and Six Sigma. Part One additionally explains the A3 problem-solving template used to follow the Plan-Do-Study-Act (PDSA) or Define, Measure, Analyze, Improve, and Control (DMAIC) cycles, that guides your completion of the problem-solving exercises found in Part Two. The bulk of the textbook includes realistic and engaging case studies featuring common quality management problems encountered in a variety of healthcare settings. The case studies feature engaging scenarios, descriptions, opinions, charts, and data, covering such contemporary topics as provider burnout, artificial intelligence, the opioid overdose epidemic, among many more. Serving as a powerful replacement to more theory-based quality management textbooks, Healthcare Quality Management provides context to challenging situations encountered by any healthcare manager, including the health administrator, nurse, physician, social worker, or allied health professional. KEY FEATURES: 25 Realistic Case Studies–Explore challenging Process Improvement, Patient Experience, Patient Safety, and Performance Improvement quality management scenarios set in various healthcare settings Diverse Author Team–Combines the expertise and knowledge of a health management educator, a Chief Nursing Officer at a large regional hospital, and a health system-based Certified Lean Expert Podcasts–Listen to quality management experts share stories and secrets on how to succeed, work in teams, and apply tools to solve problems Quality Management Tools–Grow your quality management skill set with 25 separate quality management tools and approaches tied to the real-world case studies Competency-Based Education Support–Match case studies to professional competencies, such as analytical skills, community collaboration, and interpersonal relations, using case-to-competency crosswalks for health administration, nursing, medicine, and the interprofessional team Comprehensive Instructor’s Packet–Includes PPTs, extensive Excel data files, an Instructor’s Manual with completed A3 problem-solving solutions for each Case Application Exercise, and more! Student ancillaries–Includes data files and A3 template |
| case studies in patient safety: To Err Is Human Institute of Medicine, Committee on Quality of Health Care in America, 2000-03-01 Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€with state and local implicationsâ€for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€which begs the question, How can we learn from our mistakes? Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine |
| case studies in patient safety: Surgical Patient Safety: A Case-Based Approach Philip F. Stahel, 2017-10-06 Put patient safety at the center of your surgical protocol—with this essential case-based guide Despite many advances in the practice of surgery, surgical complications continue to cause significant patient morbidity and mortality. Now more than ever, it is the responsibility of every surgeon to take the lead in understanding and mitigating complications and adverse events. Surgical Patient Safety: A Case-based Approach is your blueprint for putting this goal within reach. This timely resource gives you all the insights needed to effectively manage patient safety, covering everything from sharpening communication skills to establishing shared decision-making with patients and their families. Supplementing this important content are numerous case-based examples and exercises, supported by color illustrations, tables, figures, radiographs, and algorithms. Taken as a whole, this new textbook represents a one-stop, hands-on patient safety primer that no other sourcebook can match. Surgical Patient Safety represents a vital call to action—one designed to inspire a physician-driven initiative fostering a global culture of patient safety. Features • The latest practical patient safety tools for surgeons in training, including surgical safety checklists, intraoperative “rescue” strategies, and the global implementation of new regulatory compliance guidelines • Case-based scenarios examining technical challenges and bail-out options in the operating room • Bulleted “pearls and pitfalls” that take you through the decision-making process for diagnostic work up and revision of specific complications • Insights from renowned experts that explain how to handle malpractice lawsuits; navigate the modern dangers of electronic health records; apply the pragmatic “IKEA approach” for patient advocacy; and much more • A must-read for all practicing surgeons, independent of the surgical subspecialty |
| case studies in patient safety: Cases in Hospital Medicine Zahir Kanjee, Joshua M. Liao, 2019-10-16 Written by authors who are hospitalists and clinician-educators, Cases in Hospital Medicine uses practical case studies and current medical evidence to guide you expertly through the types of cases seen most often by practicing hospital-based clinicians. This engaging handbook covers the wide range of both broad and specific knowledge required in the hospital environment, while focusing on highly relevant questions and today’s best practices. You’ll find real-world guidance on essential topics, including commentary on research studies and clinical guidelines.\ |
| case studies in patient safety: Patient Safety in Developing Countries Yaser Al-Worafi, 2023-09 Understanding the various aspects of patient safety education, practice, and research in developing countries is vital in preparing a plan to overcome the challenges of improving patient safety. This unique volume discusses patient safety in developing countries, and the achievements and challenges faced in those places when trying to improve patient safety education and practice. This book includes a compilation of over 100 case studies surrounding patient safety in all aspects of health care. Both real and simulated scenarios are provided to help medical students and professionals apply their knowledge to solve the cases and prepare for real practice-- |
| case studies in patient safety: New Horizons in Patient Safety Annegret F. Hannawa, Anne L. Wendt, Lisa J. Day, 2018 |
| case studies in patient safety: Applying Lean in Healthcare Joe Aherne, John Whelton, 2010-04-21 Typically entrenched and systemic, healthcare problems require the sort of comprehensive solutions that can only be addressed by a change in culture and a shift in thinking. Applying Lean in Healthcare: A Collection of International Case Studies demonstrates how honest appraisal, intelligent planning, and vigilant follow-up have led to dramatic imp |
| case studies in patient safety: Patient Safety Handbook Barbara J. Youngberg, 2013 Examines the newest scientific advances in the science of safety. |
| case studies in patient safety: Understanding Patient Safety, Second Edition Robert Wachter, 2012-05-23 Complete coverage of the core principles of patient safety Understanding Patient Safety, 2e is the essential text for anyone wishing to learn the key clinical, organizational, and systems issues in patient safety.The book is filled with valuable cases and analyses, as well as up-to-date tables, graphics, references, and tools -- all designed to introduce the patient safety field to medical trainees, and be the go-to book for experienced clinicians and non-clinicians alike. Features NEW chapter on the critically important role of checklists in medical practice NEW case examples throughout Expanded coverage of the role of computers in patient safety and outcomes Expanded coverage of new patient initiatives from the Joint Commission |
| case studies in patient safety: Patient Safety and Quality Ronda Hughes, 2008 Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043). - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/ |
| case studies in patient safety: Case Studies in Public Health Theodore H. Tulchinsky, 2018-03-12 Case Studies in Public Health contains selected case studies of some of the most important and influential moments in medicine and epidemiology. The cases chosen for this collection represent a wide array of public health issues that go into the makeup of what can be termed the New Public Health (NPH), which includes traditional public health, such as sanitation, hygiene and infectious disease control, but widens its perspective to include the organization, financing and quality of health care services in a much broader sense. Each case study is presented in a systematic fashion to facilitate learning, with the case, background, current relevance, economic issues, ethical issues, conclusions, recommendation and references discussed for each case. The book is a valuable resource for advanced students and researchers with specialized knowledge who need further information on the general background and history of public health and important scientific discoveries within the field. It is an ideal resource for students in public health, epidemiology, medicine, anthropology, and sociology, and for those interested in how to apply lessons from the past to present and future research. - Explores the history of public health through important scientific events and flashpoints - Presents case studies in a clear, direct style that is easy to follow - Uses a systematic approach to help learn lessons from the past and apply them to the present |
| case studies in patient safety: Making Healthcare Safe Lucian L. Leape, 2021-05-28 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. |
| case studies in patient safety: The Value of Close Calls in Improving Patient Safety Joint Commission Resources, Inc, 2011 Because close calls, often termed near misses, don't raise the same concerns about malpractice liability and may be less emotionally charged than errors that cause serious harm, they are a unique source of learning for individuals and organizations striving to keep patients safe. This book tells how to take advantage of these lessons to prevent today's close call from turning into tomorrow's catastrophic event. Special Features: * Foreword by human error expert James Reason, Ph.D. * Authoritative tutorials on what the literature tells us about the concept of close calls and their identification, relationship with errors, and use in assessing and improving the safety and reliability of health care. * 15 detailed case studies from a variety of clinical disciplines and specialties to show how health care organizations use close calls to identify and solve patient safety problems |
| case studies in patient safety: Textbook of Patient Safety and Clinical Risk Management Liam Donaldson, Walter Ricciardi, Susan Sheridan, Riccardo Tartaglia, 2020-12-14 Implementing safety practices in healthcare saves lives and improves the quality of care: it is therefore vital to apply good clinical practices, such as the WHO surgical checklist, to adopt the most appropriate measures for the prevention of assistance-related risks, and to identify the potential ones using tools such as reporting & learning systems. The culture of safety in the care environment and of human factors influencing it should be developed from the beginning of medical studies and in the first years of professional practice, in order to have the maximum impact on clinicians' and nurses' behavior. Medical errors tend to vary with the level of proficiency and experience, and this must be taken into account in adverse events prevention. Human factors assume a decisive importance in resilient organizations, and an understanding of risk control and containment is fundamental for all medical and surgical specialties. This open access book offers recommendations and examples of how to improve patient safety by changing practices, introducing organizational and technological innovations, and creating effective, patient-centered, timely, efficient, and equitable care systems, in order to spread the quality and patient safety culture among the new generation of healthcare professionals, and is intended for residents and young professionals in different clinical specialties. |
| case studies in patient safety: Patient Safety and Hospital Accreditation Sharon Ann Myers, 2011-12-20 Print+CourseSmart |
| case studies in patient safety: Building Safer Healthcare Systems Peter Spurgeon, Mark-Alexander Sujan, Stephen Cross, Hugh Flanagan, 2019-08-21 This book offers a new, practical approach to healthcare reform. Departing from the priorities applied in traditional approaches, it instead assesses – both theoretically and practically – the successful lessons learned in other safety-critical industries, and applies them to healthcare settings. The authors focus on the importance of human factors and performance measures to establish proactive, systematic methods for healthcare system design. This approach helps to identify potential hazards before accidents occur, enhancing patient safety. In addition, the book details the new approach on the basis of real-world applications in the NHS and insights from NHS staff. Case studies and results are presented, demonstrating the significant improvements that can be achieved in risk reduction and safety culture. Lastly, the book outlines what steps healthcare organisations need to take in order to successfully adopt this new approach. The approach and experiential learning is brought together through the development of a new holistic patient safety education syllabus. |
| case studies in patient safety: Principles of Risk Management and Patient Safety Barbara J. Youngberg, 2010-08-10 Principles of Risk Management and Patient Safety identifies changes in the industry and describes how these changes have influenced the functions of risk management in all aspects of healthcare. The book is divided into four sections. The first section describes the current state of the healthcare industry and looks at the importance of risk management and the emergence of patient safety. It also explores the importance of working with other sectors of the health care industry such as the pharmaceutical and device manufacturers. Important Notice: The digital edition of this book is missing some of the images or content found in the physical edition. |
| case studies in patient safety: Patient Safety Institute of Medicine, Board on Health Care Services, Committee on Data Standards for Patient Safety, 2003-12-20 Americans should be able to count on receiving health care that is safe. To achieve this, a new health care delivery system is needed †a system that both prevents errors from occurring, and learns from them when they do occur. The development of such a system requires a commitment by all stakeholders to a culture of safety and to the development of improved information systems for the delivery of health care. This national health information infrastructure is needed to provide immediate access to complete patient information and decision-support tools for clinicians and their patients. In addition, this infrastructure must capture patient safety information as a by-product of care and use this information to design even safer delivery systems. Health data standards are both a critical and time-sensitive building block of the national health information infrastructure. Building on the Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm, Patient Safety puts forward a road map for the development and adoption of key health care data standards to support both information exchange and the reporting and analysis of patient safety data. |
| case studies in patient safety: Respiratory Disease Robert L Wilkins, James R Dexter, Philip M Gold, 2006-09-22 Now edited by a pulmonologist, the 3rd edition is still one of the most well-written texts for students learning to understand the assessment and treatment of patients with respiratory disease. Each chapter begins with a background of selected disorders, followed by a case study with questions and answers designed to stimulate critical thinking skills. |
| case studies in patient safety: Zero Harm: How to Achieve Patient and Workforce Safety in Healthcare Craig Clapper, James Merlino, Carole Stockmeier, 2018-11-09 From the nation’s leading experts in healthcare safety—the first comprehensive guide to delivering care that ensures the safety of patients and staff alike.One of the primary tenets among healthcare professionals is, “First, do no harm.” Achieving this goal means ensuring the safety of both patient and caregiver. Every year in the United States alone, an estimated 4.8 million hospital patients suffer serious harm that is preventable. To address this industry-wide problem—and provide evidence-based solutions—a team of award-winning safety specialists from Press Ganey/Healthcare Performance Improvement have applied their decades of experience and research to the subject of patient and workforce safety. Their mission is to achieve zero harm in the healthcare industry, a lofty goal that some hospitals have already accomplished—which you can, too.Combining the latest advances in safety science, data technology, and high reliability solutions, this step-by-step guide shows you how to implement 6 simple principles in your workplace. 1. Commit to the goal of zero harm.2. Become more patient-centric.3. Recognize the interdependency of safety, quality, and patient-centricity.4. Adopt good data and analytics.5. Transform culture and leadership.6. Focus on accountability and execution.In Zero Harm, the world’s leading safety experts share practical, day-to-day solutions that combine the latest tools and technologies in healthcare today with the best safety practices from high-risk, yet high-reliability industries, such as aviation, nuclear power, and the United States military. Using these field-tested methods, you can develop new leadership initiatives, educate workers on the universal skills that can save lives, organize and train safety action teams, implement reliability management systems, and create long-term, transformational change. You’ll read case studies and success stories from your industry colleagues—and discover the most effective ways to utilize patient data, information sharing, and other up-to-the-minute technologies. It’s a complete workplace-ready program that’s proven to reduce preventable errors and produce measurable results—by putting the patient, and safety, first. |
| case studies in patient safety: Patient Safety Russell Kelsey, 2023-08-28 The second edition of this well-received book, the first to provide detailed guidance on how to conduct incident investigations in primary care, has been thoroughly revised and updated throughout to reflect the current nomenclature for different aspects of the investigatory process in the UK and the latest format for incident reporting. Key features: Explains how to recognise a serious clinical incident, how to conduct a root cause analysis (RCA) investigation, and how and when duty of candour applies Covers the technical aspects of serious incident recognition and report writing Includes a wealth of practical advice and 'top tips', including how to manage the common pitfalls in writing reports Offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow Explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. At a time of increasing regulatory scrutiny and medico-legal risk, in which failure to manage appropriately can have serious consequences both for service organisations and for individuals involved, this concise and convenient book continues to provide a master class for anyone performing RCA and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices, 'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical incidents are investigated and managed. |
| case studies in patient safety: Cases in Health Services Management Jonathon S. Rakich, Beaufort B. Longest, Kurt Darr, 1987 |
| case studies in patient safety: Clinical Case Studies on Medication Safety Yaser Mohammed Al-Worafi, 2023-01-19 Clinical Case Studies on Medication Safety provides real and simulated scenarios about safety issues related to medication, including Adverse Drug Reactions (ADRs), medication errors, and Drug Related Problems (DRPs). The book explains real-life case management, including details about adverse drug reactions, mistakes during drug administration, drug avoidance, and drug-drug interactions with a goal of improving patient care. With over 150 case studies, including cases from alternative medicine and traditional medicine, this book will help medical and health sciences educators, students, healthcare professionals, and other readers apply their knowledge and skills to solve cases for better patient care. - Includes real and simulated case studies about drug safety issues - Aids medical students and practitioners to improve their case solving skills - Contains more than 150 case studies with questions and key answers |
| case studies in patient safety: Pediatric Nursing Gannon Tagher, Lisa Knapp, 2019-08-29 Immerse Yourself in the Role of a Pediatric Nurse Develop the clinical judgment and critical thinking skills needed to excel in pediatric nursing with this innovative, case-based text. Pediatric Nursing: A Case-Based Approach brings the realities of practice to life and helps you master essential information on growth and development, body systems, and pharmacologic therapy as you apply your understanding to fictional scenarios based on real clinical cases throughout the pediatric nursing experience. Accompanying units leverage these patient stories to enrich your understanding of key concepts and reinforce their clinical relevance, giving you unparalleled preparation for the challenges you’ll face in your nursing career. Powerfully written case-based patient scenarios instill a clinically relevant understanding of essential concepts to prepare you for clinicals. Nurse’s Point of View sections in Unit 1 help you recognize the nursing considerations and challenges related to patient-based scenarios. Unfolding Patient Stories, written by the National League for Nursing, foster meaningful reflection on commonly encountered clinical scenarios. Let’s Compare boxes outline the differences between adult and pediatric anatomy and physiology. Growth and Development Check features alert you to age and developmental stage considerations for nursing care. The Pharmacy sections organize medications by problem for convenient reference. Whose Job is it Anyway? features reinforce the individual responsibilities of different members of the healthcare team. Analyze the Evidence boxes compare conflicting research findings to strengthen your clinical judgment capabilities. How Much Does It Hurt? boxes clarify the principles of pediatric pain relevant to specific problems. Hospital Help sections alert you to specific considerations for the hospitalization of pediatric patients. Priority Care Concepts help you confidently assess patients and prioritize care appropriately. Patient Teaching boxes guide you through effective patient and parent education approaches. Patient Safety alerts help you quickly recognize and address potential safety concerns. Interactive learning resources, including Practice & Learn Case Studies and Watch & Learn Videos, reinforce skills and challenge you to apply what you have learned. Learning Objectives and bolded Key Terms help you maximize your study time. Think Critically questions instill the clinical reasoning and analytical skills essential to safe patient-centered practice. Suggested Readings point you to further research for more information and clinical guidance. |
| case studies in patient safety: Improving Diagnosis in Health Care National Academies of Sciences, Engineering, and Medicine, Institute of Medicine, Board on Health Care Services, Committee on Diagnostic Error in Health Care, 2015-12-29 Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety. |
| case studies in patient safety: Patient Safety Culture Dr Patrick Waterson, 2014-11-28 How safe are hospitals? Why do some hospitals have higher rates of accident and errors involving patients? How can we accurately measure and assess staff attitudes towards safety? How can hospitals and other healthcare environments improve their safety culture and minimize harm to patients? These and other questions have been the focus of research within the area of Patient Safety Culture (PSC) in the last decade. More and more hospitals and healthcare managers are trying to understand the nature of the culture within their organisations and implement strategies for improving patient safety. The main purpose of this book is to provide researchers, healthcare managers and human factors practitioners with details of the latest developments within the theory and application of PSC within healthcare. It brings together contributions from the most prominent researchers and practitioners in the field of PSC and covers the background to work on safety culture (e.g. measuring safety culture in industries such as aviation and the nuclear industry), the dominant theories and concepts within PSC, examples of PSC tools, methods of assessment and their application, and details of the most prominent challenges for the future in the area. Patient Safety Culture: Theory, Methods and Application is essential reading for all of the professional groups involved in patient safety and healthcare quality improvement, filling an important gap in the current market. |
| case studies in patient safety: Keeping Patients Safe Institute of Medicine, Board on Health Care Services, Committee on the Work Environment for Nurses and Patient Safety, 2004-03-27 Building on the revolutionary Institute of Medicine reports To Err is Human and Crossing the Quality Chasm, Keeping Patients Safe lays out guidelines for improving patient safety by changing nurses' working conditions and demands. Licensed nurses and unlicensed nursing assistants are critical participants in our national effort to protect patients from health care errors. The nature of the activities nurses typically perform †monitoring patients, educating home caretakers, performing treatments, and rescuing patients who are in crisis †provides an indispensable resource in detecting and remedying error-producing defects in the U.S. health care system. During the past two decades, substantial changes have been made in the organization and delivery of health care †and consequently in the job description and work environment of nurses. As patients are increasingly cared for as outpatients, nurses in hospitals and nursing homes deal with greater severity of illness. Problems in management practices, employee deployment, work and workspace design, and the basic safety culture of health care organizations place patients at further risk. This newest edition in the groundbreaking Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety. |
| case studies in patient safety: Quality and Safety in Nursing Gwen Sherwood, Jane Barnsteiner, 2017-04-17 Drawing on the universal values in health care, the second edition of Quality and Safety in Nursing continues to devote itself to the nursing community and explores their role in improving quality of care and patient safety. Edited by key members of the Quality and Safety Education for Nursing (QSEN) steering team, Quality and Safety in Nursing is divided into three sections. Itfirst looks at the national initiative for quality and safety and links it to its origins in the IOM report. The second section defines each of the six QSEN competencies as well as providing teaching and clinical application strategies, resources and current references. The final section now features redesigned chapters on implementing quality and safety across settings. New to this edition includes: Instructional and practice approaches including narrative pedagogy and integrating the competencies in simulation A new chapter exploring the application of clinical learning and the critical nature of inter-professional teamwork A revised chapter on the mirror of education and practice to better understand teaching approaches This ground-breaking unique text addresses the challenges of preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the health care system in which they practice. |
| case studies in patient safety: The Learning Healthcare System Institute of Medicine, Roundtable on Evidence-Based Medicine, 2007-06-01 As our nation enters a new era of medical science that offers the real prospect of personalized health care, we will be confronted by an increasingly complex array of health care options and decisions. The Learning Healthcare System considers how health care is structured to develop and to apply evidence-from health profession training and infrastructure development to advances in research methodology, patient engagement, payment schemes, and measurement-and highlights opportunities for the creation of a sustainable learning health care system that gets the right care to people when they need it and then captures the results for improvement. This book will be of primary interest to hospital and insurance industry administrators, health care providers, those who train and educate health workers, researchers, and policymakers. The Learning Healthcare System is the first in a series that will focus on issues important to improving the development and application of evidence in health care decision making. The Roundtable on Evidence-Based Medicine serves as a neutral venue for cooperative work among key stakeholders on several dimensions: to help transform the availability and use of the best evidence for the collaborative health care choices of each patient and provider; to drive the process of discovery as a natural outgrowth of patient care; and, ultimately, to ensure innovation, quality, safety, and value in health care. |
| case studies in patient safety: A Visual Reference for Evidence-based Design Jain Malkin, 2008 |
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