Health Care Errors and Patient Safety E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 577

Veröffentlichungsjahr: 2011

Beschreibung

The detection, reporting, measurement, and minimization of medical errors and harms is now a core requirement in clinical organizations throughout developed societies. This book focuses on this major new area in health care. It explores the nature of medical error, its incidence in different health care settings, and strategies for minimizing errors and their harmful consequences to patients. Written by leading authorities, it discusses the practical issues involved in reducing errors in health care - for the clinician, the health policy adviser, and ethical and legal health professionals.

Leseprobe

Contents

List of contributors

Foreword

CHAPTER 1 Health care mistakes, violations and patient safetyBrian Hurwitz, Aziz Sheikh

Errors and mistakes

Violations

Learning from errors and violations

Erring and moral judgment

Multidisciplinary perspectives

Literary representations of medical mistakes and violations

Patient safety

Appendix 1.1: Glossary of key terms in health care safety

References

PART 1 Understanding patient safety

CHAPTER 2 When is an ‘error’ not an error?Dianne Parker, Tanya Claridge, Matthew Lawrie

Background

Use of rules

Compliance with rules: error or violation?

Error types

Violation types

Conclusion

References

CHAPTER 3 Intentionally harmful violations and patient safety: the example of Harold ShipmanRichard Baker, Brian Hurwitz

The Shipman story: a brief outline

Errors and violations

The latent failures

Discussion

References

CHAPTER 4 Patient safety and patient errorStephen Buetow, Glyn Elwyn

Patient errors

The context of patient errors

Mechanisms and types of error

Promotion of patients’ safety

Conclusion

Acknowledgments

References

CHAPTER 5 Health care safety and organisational changeRuth Boaden, Bernard Burnes

Schools of thought regarding organisational change

Planned change

Emergent change

A framework for change

Change and patient safety

Is there evidence about what works?

So what can be done?

Conclusion

References

CHAPTER 6 How does the law recognise and deal with medical errors?Alan F. Merry

The law, science, moral philosophy and medicine

Empirical scientific data on iatrogenic harm and medical error

Scientific theory: error, violation and intentional wrong doing

Some implications of legal action against medical error

Some basic concepts relevant to the legal response to medical error

Should medical error be tolerated?

The ideal legal response to medical errors that result in harm to patients

References

CHAPTER 7 The many advantages and some disadvantages of a no-blame culture regarding medical errorsMavis Maclean

No-fault schemes

References

PART 2 Threats to patient safety

CHAPTER 8 Diagnostic errors: psychological theories and research implicationsOlga Kostopoulou

Psychological theories of diagnosis

Hypothesis generation and associated errors

Hypothesis testing and associated errors

Knowledge base: content and structure

A synthesis of the literature

The role of decision support systems in reducing diagnostic errors

Research implications

References

CHAPTER 9 ‘Mince’ or ‘mice’? Clinical miscommunications and patient safety in a linguistically diverse communityCelia Roberts

Misunderstandings in interaction

Misunderstandings caused by patients

Misunderstandings caused by doctors

Conclusion

Appendix 9.1: Transcription conventions

References

CHAPTER 10 Clinical transitions: implications for patient safetyAlan Forster

Adverse events due to transition to hospital

Adverse events due to transitions between hospital services

Adverse events due to transition from hospital

Adverse events due to transitions between providers

Conclusion

References

CHAPTER 11 Medicines managementRachel L. Howard, Anthony J. Avery

Prescribing decision

Generating and signing prescriptions

Information provision and patient counselling

Dispensing medication

Patient administration

Monitoring medication

Repeat prescribing

Conclusion

References

CHAPTER 12 The patient’s role in preventing errors and promoting safetyJo Ellins, Angela Coulter

Why is patient involvement important?

Recent initiatives

Opportunities for patient involvement in patient safety

Conclusion

References

PART 3 Responses to health care errors and violations

CHAPTER 13 Aftermath of error for patients and health care staffCharles Vincent, Lesley Page

Psychological responses to medical injury

Experiences of injured patients and their relatives

Principles for helping patients and their families

Impact on staff

Supporting staff

Conclusion

References

CHAPTER 14 Significant event auditing and root cause analysisMike Pringle

Background

Inception of significant event auditing to the present day

What is significant event auditing?

Models of significant event auditing

Process of significant event auditing

Root cause analysis

Conclusion

References

CHAPTER 15 Patient safety—epidemiological considerationsRichard Thomson, Alison Pryce

Definitions

How big are these problems and how preventable are they?

Developing an overarching surveillance and monitoring system: the Patient Safety Observatory model

Conclusion

References

CHAPTER 16 Analysis of health care error reportsAdrian Cook, Sarah Scobie

The role of analysis in learning from patient safety incidents

The Billings model and patient safety systems

Selecting reports for secondary analysis

Secondary analysis: analysing incident descriptions

Identifying hazards and prioritising issues for local or national action

Conclusion

Acknowledgements

References

CHAPTER 17 Patient safety education and curriculum designMarshall F. Gilula, Paul R. Barach

Innovation in the medical school environment

Stand-alone course or interwoven curricular elements?

Examples of patient safety courses

Legislative interest in patient safety training

Patient safety practices in state and national health care

Case study: the Florida experience

Conclusion

Appendix 17.1: Matrix of patient safety training domains for health care students

References

CHAPTER 18 Teaching and learning about patient safetyJohn Sandars

What should be learned?

How should it be taught?

How should the learning be assessed?

How can a strategy be developed?

Conclusion

Appendix 18.1: Sources of educational resources

Appendix 18.2: Examples of patient safety curricula

Appendix 18.3: Critical factors for teaching and learning patient safety in medical school (after Aron & Headrick [14])

Appendix 18.4: National Patient Safety Education Framework: learning areas and topics (after Lyons et al. [15])

Appendix 18.5: Key messages of the Royal College of General Practitioners Curriculum Statement 3.2, Patient Safety

References

CHAPTER 19 Health care errors, patient safety and the mediaGeoff Watts

References

Index

Dedication

For Ruth and Sangeeta, with love

Epigraph

But there exists a black kingdom which the eyes of man avoid because its landscape fails signally to flatter them. This darkness, which he imagines he can dispense with in describing the light, is error with its unknown characteristics, error which demands that a person contemplate it for its own sake before rewarding him with the evidence about fugitive reality that it alone could give. . . . Error is certainty’s constant companion. Error is the corollary of evidence. And anything said about truth may equally well be said about error: the delusion will be no greater. . . . Light is meaningful only in relation to darkness, and truth presupposes error. It is these mingled opposites which people our life, which make it pungent, intoxicating. [Louis Aragon, Préfaceàune mythologie moderne. In: Louis Aragon. Le Paysan de Paris. Paris: Gallimard, 1926, 11–15. Transaltion by Simon Watson in Paris Peasant. London: Jonathan Cape, 1971, 20–24.]

This edition first published 2009, © by Blackwell Publishing Ltd

BMJ Books is an imprint of BMJ Publishing Group Limited, used under licence by Blackwell Publishing which was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing programme has been merged with Wiley’s global Scientific, Technical and Medical business to form Wiley-Blackwell.

Registered office: John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK

The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

111 River Street, Hoboken, NJ 07030–5774, USA

For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell

The right of the author to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

Library of Congress Cataloging-in-Publication Data

Health care errors and patient safety/edited by Brian Hurwitz and Aziz Sheikh.

p.; cm.

Includes bibliographical references.

ISBN 978-1-4051-4643-2

1. Medical errors. 2. Hospital care—Safety measures. I. Hurwitz, Brian. II. Sheikh, Aziz.

[DNLM: 1. Medical Errors. 2. Safety Management. WB 100 H434 2009]

R729.8.H43 2009

610—dc22

2008045731

List of contributors

Anthony J. Avery

Professor

Division of Primary Care

Medical School

Queens Medical Centre

Nottingham NG7 2UH, UK

Richard Baker

Professor

Department of Health Sciences

University of Leicester

Leicester LE1 6TP, UK

Paul Barach

Associate Professor

Department of Anesthesiology

University of Miami Medical School

Miami, FL 33136, USA

Ruth Boaden

Professor of Service Operations

Management

Manchester Business School

University of Manchester

Manchester M15 6PB, UK

Stephen Buetow

Associate Professor and Director of Research

Department of General Practice and Primary

School of Population Health

University of Auckland

Auckland, New Zealand

Bernard Burnes

Professor of Organisational Change

Manchester Business School

University of Manchester

Manchester M15 6PB, UK

Tanya Claridge

Heaton Norris Health Centre

Heaton Norris

Stockport SK4 JXE, UK

Adrian Cook

National Patient Safety Agency

London W1T 5HD, UK

Angela Coulter

Chief Executive

Picker Institute Europe

King’s Mead House

Oxford OX1 1RX, UK

Jo Ellins

Research Fellow

Health Services Management Centre

University of Birmingham

Birmingham B15 2RT, UK

Glyn Elwyn

Professor of Primary Care Medicine

Department of General Practice

Centre for Health Sciences Research

Cardiff University

Cardiff CF14 4YS, UK

Alan Forster

The Ottawa Hospital

Civic Campus

Ottawa

Ontario K1Y 4E9, Canada

Marshall F. Gilula

Director

Life Energies Research Institute

2510 Inagua Avenue

Miami, FL 33136, USA

Rachel L. Howard

Lecturer in Pharmacy Practice

Department of Pharmacy Practice

School of Pharmacy

University of Reading

Reading RG6 6AP, UK

Brian Hurwitz

Professor of Medicine and the Arts

Department of English Language and Literature

Schools of Humanities and Medicine King’s College

London WC2R 2LS, UK

Olga Kostopoulou

National Primary Care Postdoctural Fellow

Department of Primary Care and General Practice

Primary Care Clinical Sciences Building

University of Birmingham

Birmingham B15 2TT, UK

Matthew Lawrie

School of Psychological Sciences

Coupland One

University of Manchester

Manchester M13 9PL, UK

Mavis Maclean

Joint Director

Oxford Centre for Family Law and Policy

Oxford OX1 2ER, UK

Alan F. Merry

Professor and Head of Department

Department of Anaesthesiology

University of Auckland

Auckland, New Zealand

Lesley Page

Visiting Professor in Midwifery

Nightingale School of Nursing and Midwifery

King’s College London

London, UK

Dianne Parker

Head of Division of Psychology

School of Psychological Sciences

Coupland One

University of Manchester

Manchester M13 9PL, UK

Mike Pringle

Head of School of Community Health Sciences Division of Primary Care

University of Nottingham

Nottingham NG7 2RD, UK

Alison Pryce

Senior Statistician

National Patient Safety Agency

London W1T 5HD, UK

Celia Roberts

Department of Education and Professional Studies

Professor of Applied Linguistics

King’s College London

Franklin Wilkins Building

Waterloo Bridge Annexe

London SE1 9NN, UK

John Sandars

Senior Lecturer in Community Based Education

Medical Education Unit

University of Leeds

Leeds LS2 9JT, UK

Sarah Scobie

Head of Observatory

The National Patient Safety Agency

London W1T 5HD, UK

Aziz Sheikh

Professor of Primary Care

Research and Development

Centre of Population Health Sciences

University of Edinburgh

Edinburgh EH8 9DX, UK

Richard Thomson

Professor of Epidemiology and Public Health

Institute of Health and Society

Medical School

Newcastle upon Tyne NE2 4HH

Charles Vincent

Professor of Clinical Safety Research

Department of Biosurgery and Technology

10th Floor QEQM Building

St Mary’s Hospital

London W2 1NY, UK

Geoff Watts

Science and medicine writer and broadcaster

London NW3 1LS, UK

Foreword

Healthcare professionals dedicate their working lives to improving the lives of others. It is a privilege to be in a position to cure, treat and support patients and their families, whether living or dying with disease. It is also a noble endeavour, driven by compassion and humanity. Yet the phrase ‘only human’ expresses a truth long understood in general but only relatively recently taken seriously within medicine: all human undertakings involve error. Despite the good intentions of motivated and caring healthcare professionals, one in three hundred hospital visits result in a death due to medical error. Patient safety has been most extensively studied in the secondary care setting, but is not limited to this field: it is universal.

This is by no means cause for despair. Although some error is inevitable, the rate can be reduced, and measures can be taken to prevent errors from being translated into harm to patients. If we learn effectively, the same errors need never recur. Opportunities to learn exist not only for individuals, but also for organisations.

Patient safety is rapidly evolving. Modern research provides new insights and solutions to increasingly recognised issues. Transmitting this information to all those who can benefit is now a major challenge. Gilula and Barach raise the important issue of patient safety education and curriculum design, and this is echoed by the work of the World Health Organization’s World Alliance for Patient Safety to develop a curricular guide for medical students.

This book provides a theoretical groundwork on patient safety, but also practical advice for all those involved in healthcare: patients and their families, healthcare workers and institutions. I have long championed the involvement of patients and their families, and am delighted that their participation in patient safety is promoted here.

Avedis Donabedian famously said: ‘Ultimately, the secret of quality is love… If you have love, you can then work backward to monitor and improve the system’. It is time that we channelled the real care and compassion of healthcare workers into frameworks which allow them to monitor, analyse, improve and re-evaluate systems to make care safer for patients.

To all those looking for an insight into recent developments in patient safety, thought-provoking discussions and advice on making care safer for patients: read on.

Sir Liam Donaldson

Chief Medical Officer

Department of Health